Should a patient with a tracheostomy and increased secretions receive breathing treatments?

Management of Breathing Treatments for Tracheostomy Patients with Increased Secretions

Yes, you should provide breathing treatments (nebulized bronchodilators or mucolytics) to tracheostomy patients with increased secretions, as these treatments are specifically indicated for tracheostomy care and help mobilize viscid secretions that can lead to life-threatening tube obstruction. 1

Primary Indication for Breathing Treatments

Nebulized acetylcysteine is FDA-approved specifically for tracheostomy care and is indicated as adjuvant therapy for patients with abnormal, viscid, or inspissated mucous secretions. 1 The medication works by liquefying thick secretions that accumulate in tracheostomy patients due to bypassed upper airway humidification mechanisms. 2

Dosing and Administration via Tracheostomy

• Administer 1-2 mL of 10-20% acetylcysteine solution every 1-4 hours by direct instillation into the tracheostomy for routine nursing care of tracheostomy patients. 1
• Alternatively, nebulize 1-10 mL of 20% solution or 2-20 mL of 10% solution every 2-6 hours when using face mask, mouthpiece, or tracheostomy delivery. 1
• The recommended dose for most patients is 3-5 mL of 20% solution or 6-10 mL of 10% solution administered 3-4 times daily. 1

Critical Safety Considerations

After administering acetylcysteine, an increased volume of liquified secretions will occur, requiring aggressive suctioning to prevent airway obstruction. 1 This is not optional—failure to adequately suction after treatment can lead to respiratory compromise.

Mandatory Post-Treatment Protocol

• Ensure functional suctioning equipment is immediately available before administering any breathing treatment. 3, 4
• Remove all external attachments and inner cannula before administration, then clean the inner cannula thoroughly. 5
• Perform aggressive suctioning after treatment using the largest catheter that fits inside the tracheostomy tube to remove liquified secretions efficiently and minimize atelectasis risk. 2
• If cough is inadequate, maintain the open airway by mechanical suction. 1

When Breathing Treatments Are Most Critical

Breathing treatments become essential when secretions are thick, tenacious, or causing audible wheezing over the trachea, which indicates impending tube obstruction—a life-threatening emergency. 5

High-Risk Scenarios Requiring Treatment

• Patients with COVID-19 or neurological injuries who develop unusually thick and tenacious secretions. 5
• Unresponsive or neurologically impaired patients with reduced cough effectiveness. 5
• Patients with narrow tube lumens (pediatric or smaller adult tubes) at higher risk for mucus plugging. 5
• Any patient with high-pitched wheezing audible over the trachea, indicating partial tube obstruction. 5

Bronchodilator Considerations

If the patient has bronchospasm or underlying reactive airway disease, nebulized bronchodilators should be administered using oxygen as the driving gas at 6-8 L/min flow rate. 3 However, watch asthmatics carefully during acetylcysteine treatment, as bronchospasm can occur. 1

Delivery Technique for Bronchodilators

• Use oxygen-driven nebulizers at 6-8 L/min for patients at risk of hypoxemia. 3
• For patients with COPD or risk of hypercapnic respiratory failure, consider air-driven nebulizers with supplemental oxygen by nasal cannula at 2-6 L/min to avoid excessive oxygen delivery. 3
• Discontinue treatment immediately if bronchospasm progresses despite bronchodilator use. 1

Essential Humidification Strategy

Adequate humidification is the single most important preventive measure for managing secretions and should be optimized before and alongside breathing treatments. 2

Humidification Requirements

• Target inspired gas temperature of 32-34°C with humidity of 36-40 mg/L to replicate normal upper airway conditions. 2
• Use heat and moisture exchangers (HMEs), particularly hygroscopic condenser humidifier filters, as first-line humidification for active patients. 2
• All supplemental oxygen delivered to tracheostomized patients must be humidified to maintain patent tracheostomy tubes and reduce secretion buildup. 3

Emergency Management Algorithm

If breathing treatments and suctioning fail to clear obstruction, follow this sequence:

1. Remove all external attachments and inner cannula immediately. 3, 5
2. Attempt aggressive suctioning with the largest appropriate catheter. 2, 5
3. If suctioning fails, perform emergency tracheostomy tube change without delay—this is life-saving and cannot be postponed. 2
4. Ensure emergency equipment (spare tubes one size smaller and same size) is at bedside before initiating any breathing treatment. 3

Common Pitfalls to Avoid

• Never instill normal saline routinely, as this decreases oxygen saturation, fails to thin mucus effectively, and may contaminate lower airways with unsterile solution. 2
• Do not use anticholinergic agents like scopolamine patches in tracheostomy patients with secretion problems, as they worsen management by thickening mucus. 2
• Avoid using bubble bottles for humidification—they are ineffective and contraindicated. 3
• Never deliver hyperinflation or hyperoxygenation breaths when visible secretions are present, as this forces secretions into distal airways. 2

Monitoring Requirements

• Maintain pulse oximetry monitoring to detect early tube obstruction. 3, 5
• Assess suctioning needs regularly based on secretion characteristics rather than fixed schedules. 2
• Inspect the peristomal area daily, keeping skin clean and dry to prevent infection that worsens secretion management. 2