What is the pulmonary regimen for managing copious secretions?

From the Guidelines

A pulmonary regimen for managing copious secretions should prioritize airway clearance techniques, including manually assisted cough and mechanical insufflation-exsufflation devices (MI-E), as recommended by the most recent guidelines 1.

Key Components of the Regimen

• Airway clearance techniques:
  • Manually assisted cough
  • Mechanical insufflation-exsufflation devices (MI-E) for patients with significantly impaired cough
  • Breath stacking and lung volume recruitment (LVR) for inspiration
• Adequate hydration: 2-3 liters of fluid daily to thin secretions
• Medications:
  • Mucolytics such as N-acetylcysteine (NAC) or guaifenesin to break down mucus
  • Bronchodilators like albuterol to open airways before airway clearance
  • Hypertonic saline nebulization (3-7%) for patients with bronchiectasis or cystic fibrosis
• Proper positioning: head elevation at 30-45 degrees to prevent pooling of secretions
• Deep breathing exercises and effective coughing techniques: performed hourly while awake

Considerations for Specific Patient Groups

• Patients with Duchenne muscular dystrophy: referral to a specialist respiratory service for consideration of airway clearance support if there are concerns about cough strength or ability to manage chest secretions 1
• Patients with compromised respiratory function (FVC <80%): low threshold for antibiotic treatment and individual care plan to advise on antibiotic use 1
• Patients with significant learning and behavioral issues: lower threshold for referral to respiratory specialists and consideration of engagement with learning disability and palliative care teams 1

From the FDA Drug Label

Acetylcysteine solution, USP is indicated as adjuvant therapy for patients with abnormal, viscid, or inspissated mucous secretions in such conditions as: Chronic bronchopulmonary disease (chronic emphysema, emphysema with bronchitis, chronic asthmatic bronchitis, tuberculosis, bronchiectasis and primary amyloidosis of the lung) After proper administration of acetylcysteine, an increased volume of liquified bronchial secretions may occur. When cough is inadequate, the open airway must be maintained open by mechanical suction if necessary. The mucolytic action of acetylcysteine is related to the sulfhydryl group in the molecule This group probably “opens” disulfide linkages in mucus thereby lowering the viscosity.

The pulmonary regimen for copious secretions involves the use of acetylcysteine as an adjuvant therapy to help loosen and clear abnormal, viscid, or inspissated mucous secretions. Key points to consider:

• Mechanical suction may be necessary to maintain an open airway if cough is inadequate.
• Bronchodilators may be used to quickly relieve bronchospasm.
• The medication should be discontinued immediately if bronchospasm progresses 2, 2, 2.

From the Research

Pulmonary Regimen for Copious Secretions

The management of airway secretions is a crucial aspect of pulmonary care, particularly for patients with chronic respiratory diseases. Several techniques and therapies have been developed to address this issue, including non-invasive ventilation (NIV), mucoactive agents, and airway clearance techniques.

• Non-Invasive Ventilation (NIV): NIV is a mainstay of management for chronic respiratory failure in many disorders, including those with abnormal airway secretion clearance 3. However, there is a lack of guidance on secretion handling during NIV use and the role of NIV in secretion management.
• Mucoactive Agents: Mucoactive agents are used to manage airway secretions in mechanically ventilated patients, but the current treatment strategies are primarily based on anecdotal experiences rather than statistical evidence 4. There is a need for evidence-based recommendations on the use of mucoactive agents in critically ill patients.
• Airway Clearance Techniques: Airway clearance techniques, such as intrapulmonary percussive ventilation (IPV), are used to clear excessive lung secretions in patients with chronic obstructive airway diseases 5. However, the systematic use of IPV as an airway clearance technique is not supported by strong evidence, and its effectiveness in improving lung function and other parameters is limited.
• Secretion Clearance Techniques: A comprehensive review of secretion clearance techniques found that there is a lack of high-level evidence to support any secretion clearance technique, despite clinical observations that retained secretions are detrimental to respiratory function 6.
• Treatment of Airway Mucus Hypersecretion: Airway mucus hypersecretion is a key pathophysiological feature in many patients with asthma, chronic obstructive pulmonary disease (COPD), and cystic fibrosis 7. Conventional therapies have variable efficacy in inhibiting airway mucus hypersecretion, and novel pharmacotherapeutic targets are being investigated to develop more effective treatments.