How to manage a cough in a patient with a tracheostomy, considering potential underlying conditions such as chronic obstructive pulmonary disease (COPD) or pneumonia?

Management of Cough in Tracheostomy Patients

The primary management of cough in tracheostomy patients centers on optimizing humidification with heat moisture exchangers (HMEs) with viral filters, implementing closed-circuit suctioning to manage secretions, and ensuring proper tube patency—while avoiding saline instillation which paradoxically worsens coughing. 1

Immediate Assessment and Airway Patency

Before addressing the cough itself, you must first verify that the tracheostomy tube is patent and properly positioned:

• Remove any obstructing attachments including speaking valves, decannulation caps, or humidifying devices that may have become blocked with secretions 1, 2
• Inspect and clean the inner cannula immediately, as this is a common site of obstruction from secretion buildup 1, 3
• Verify tube patency using waveform capnography and passage of a suction catheter, as tube displacement or obstruction accounts for 50% of airway-related deaths in critical care 2

This step is critical because tracheostomy tube occlusion from mucus plugging is one of the most common reasons for airway rapid response activation, particularly in patients with thick tenacious secretions. 4

Secretion Management

Use closed-circuit suctioning with inline suction catheters rather than open suctioning to minimize aerosolization risk while effectively managing secretions. 1, 5

Avoid saline instillation before suctioning—this practice increases coughing risk, provides minimal benefit, and potentially increases aerosolization of pathogens. 1, 5

For patients requiring frequent suctioning, ensure bedside equipment includes a functional suctioning system, oxygen source, manual resuscitation bag, and complete tracheostomy kit. 3

Humidification Strategy

Prioritize heat moisture exchangers (HMEs) with viral filters over heated humidification or nebulized treatments to reduce both coughing episodes and secretion buildup. 1, 5

• Select HMEs with filtration efficiency >99.9% and bidirectional design 1
• Inspect HME filters daily and whenever ventilation deteriorates 1
• For mechanically ventilated patients requiring inhaled medications, use vibrating mesh nebulizers that don't require circuit disconnection rather than jet nebulizers which can aerosolize particles up to 80cm 4

The rationale here is that jet nebulizers significantly increase aerosolization and coughing, while HMEs provide adequate humidification with a closed system. 4

Cuff Management

Maintain proper cuff inflation at 20-30 cmH₂O for air-filled cuffs to ensure ventilation system integrity while preventing tracheal injury. 1, 5

A critical pitfall: prolonged overzealous cuff inflation—often done to minimize leak—can cause tracheal dilation, tracheomalacia, and long-term complications including tracheal stenosis. 4

Cough Effectiveness and Underlying Conditions

For COPD or Pneumonia Patients

Patients with COPD and airways obstruction have impaired mucociliary clearance due to excessive secretions, making cough a necessary adjunct to clearance mechanisms. 4

Monitor closely for complications including pneumonia, atelectasis, and respiratory failure in patients with ineffective cough. 4

For Neuromuscular Weakness

Implement mechanical insufflation-exsufflation (MI-E) in addition to standard physiotherapy when cough is ineffective and sputum retention occurs. 4, 1

Consider mini-tracheostomy to facilitate secretion clearance in patients with weak cough, though this requires patient cooperation and a skilled operator. 4, 1

The evidence shows that only modest increases in intrathoracic pressure are needed for effective cough, so patients with mild-to-moderate respiratory muscle weakness may still cough effectively. However, severe weakness limits both inspiratory volume and intrathoracic pressure generation, rendering cough ineffective. 4

Procedural Cough Suppression

For tube changes or procedures that trigger coughing, spray airways with 4% lidocaine to decrease cough reflex, being mindful of proper dosing especially in pediatric populations. 1

Avoid medications with sedative properties that could compromise respiratory function in tracheostomy patients. 5

Special Considerations for COVID-19 or High Secretion States

Patients with unusually thick and tenacious secretions face amplified risks of tube occlusion. 4

• Use disposable inner cannulas to avoid risks from cleaning and handling reusable cannulas 4
• Consider Xeroform dressings or custom tubes with stoma seals to improve seal and decrease aerosolization 4
• Change dressings only when soiled to minimize tube manipulation and cough stimulation 4

Critical Pitfalls to Avoid

Do not perform tracheostomy solely to improve cough effectiveness—patients with endotracheal tubes can produce effective cough through huffing maneuvers with an open glottis, so tracheostomy offers no advantage for cough improvement alone. 4

Do not use jet nebulizers in tracheostomy patients due to excessive aerosolization; use spacers for metered-dose inhalers in non-ventilated patients instead. 4

Do not assume the problem is purely related to underlying disease without first verifying tube patency, as mechanical obstruction is frequently overlooked. 2