What is the best management approach for a patient with a tracheostomy (trach) experiencing increased secretions?

Management of Increased Secretions in Tracheostomy Patients

Immediate Assessment and Suctioning

The cornerstone of managing increased secretions in tracheostomy patients is proper suctioning technique combined with adequate humidification to prevent secretion thickening and tube obstruction. 1

Suctioning Technique

• Use the largest catheter that fits inside the tracheostomy tube rather than the traditionally recommended half-diameter size, as larger catheters remove secretions more efficiently and reduce suctioning time, thereby minimizing atelectasis risk 1
• Perform an initial pass to clear visible or audible secretions before delivering any hyperinflation or hyperoxygenation breaths, as delivering breaths when secretions are present forces them into distal airways 1
• Use pre-marked catheters and twirl the catheter between fingertips during suctioning to optimize secretion removal 1
• Decontaminate hands before and after contact with respiratory secretions or devices, whether or not gloves are worn 1

Critical Pitfall: Saline Instillation

• Do not routinely instill normal saline, as this practice decreases oxygen saturation, fails to thin mucus effectively, and may contaminate lower airways with unsterile solution 1
• Proper humidification is far more effective than saline instillation for maintaining thin secretions 1

Humidification Strategy

Primary Prevention

Adequate humidification is the single most important preventive measure for managing secretions, as tracheostomy bypasses the upper airway's natural warming and moisturizing mechanisms 1, 2

• Target inspired gas temperature of 32-34°C with humidity of 36-40 mg/L to replicate normal upper airway conditions 1
• Use heat and moisture exchangers (HMEs), particularly hygroscopic condenser humidifier filters (HCHFs), as first-line humidification for active patients due to superior convenience and efficacy 1
• Consider heated humidification systems during sleep or for inactive patients, as they may provide better humidification despite reduced convenience 1
• Hygroscopic condenser humidifiers significantly improve secretion viscosity, reduce bacterial colonization, and decrease suctioning frequency compared to no humidification 3
• Heated high-flow humidification is superior to cold-air nebulization, resulting in significantly fewer required suctioning procedures (median 3 vs 5 times daily) and improved ciliary beat frequency 4

Equipment Considerations

• Avoid bubble bottles for humidification, as they provide no clinical benefit and pose infection risk 2
• For patients requiring speaking valves, passive humidifiers will not function properly as no moisture is captured for the next inspiration 1

Mucolytic Therapy

Acetylcysteine Administration

When secretions remain thick despite adequate humidification, acetylcysteine is FDA-approved specifically for tracheostomy care and abnormal viscid secretions 5

Dosing for tracheostomy patients:

• Instill 1-2 mL of 10-20% solution every 1-4 hours directly into the tracheostomy for routine care 5
• For severe secretion problems, may use 1-2 mL of 20% solution or 2-4 mL of 10% solution every 1-4 hours 5
• Remove inner cannula before administration and clean it thoroughly 6
• After administration, ensure proper suctioning to remove liquefied secretions, as increased volume of liquified secretions will occur 5, 6

Critical Warning

• When cough is inadequate after acetylcysteine administration, maintain the airway by mechanical suction to prevent aspiration of liquified secretions 5
• Watch asthmatic patients carefully, as bronchospasm may occur; discontinue immediately if bronchospasm progresses 5

Emergency Management of Tube Obstruction

Recognition

High-pitched wheezing over the trachea in an unresponsive patient indicates mucus plugging causing tube obstruction—an immediately life-threatening emergency 6

Immediate Intervention Algorithm

1. Remove all external attachments and inner cannula immediately 6
2. Attempt aggressive suctioning with the largest appropriate catheter 1, 6
3. If suctioning fails, perform emergency tracheostomy tube change without delay—this is life-saving and cannot be postponed 6
4. Have emergency equipment at bedside including smaller tube sizes for immediate access 6

High-Risk Populations

• Neurologically impaired or unresponsive patients with reduced cough effectiveness 6
• Patients with COVID-19 or neurological injuries who develop unusually thick, tenacious secretions 6
• Pediatric patients or those with narrow tube lumens 6

Ongoing Monitoring and Prevention

• Assess suctioning needs regularly based on secretion characteristics rather than fixed schedules 1
• Inspect the peristomal area daily, keeping skin clean and dry to prevent infection that worsens secretion management 1
• Ensure pulse oximetry monitoring to detect early obstruction 6
• Consider disposable inner cannulas in patients with persistently thick secretions to reduce blockage risk 6
• Maintain emergency supplies at bedside at all times, including complete tracheostomy kit, suction equipment, oxygen source, and manual resuscitation bag 7