What is the best management approach for a tracheostomized patient experiencing a cough, considering their complex medical history and potential for respiratory complications?

Management of Cough in Tracheostomized Patients

For tracheostomized patients experiencing cough, prioritize proper humidification with heat-moisture exchangers (HMEs), closed-circuit suctioning to clear secretions, and immediate assessment for tube displacement or obstruction, as these are the most common causes of respiratory distress in this population. 1

Immediate Assessment Protocol

When a tracheostomized patient presents with cough, perform the following systematic evaluation:

• Look, listen, and feel for airflow at both the tracheostomy stoma and the upper airway (mouth/nose), applying high-flow oxygen to both sites simultaneously if available 2
• Pass a suction catheter through the tracheostomy tube to confirm patency along its entire length and perform therapeutic suctioning if secretions are present 2
• Use waveform capnography when available to confirm adequate ventilation and airway patency 3, 2
• Remove any attachments to the tracheostomy tube that could cause obstruction, including speaking valves, caps, or humidifying devices blocked with secretions 1
• Inspect and clean the inner cannula if present, as secretion buildup is a common cause of tube occlusion 1, 4

Critical caveat: Never use stiff introducers or bougies to assess patency, as these can create false passages if the tube is partially displaced 3, 2

Primary Management Strategies

Humidification Management

The loss of natural upper airway humidification is the fundamental physiological change causing excessive cough and secretions in tracheostomized patients:

• Use HMEs with viral filters (filtration efficiency >99.9%) as the preferred humidification method rather than heated humidification or nebulized treatments 3, 1
• The tracheostomy bypasses natural humidification mechanisms, exposing lower airways to cold, dry air and eliminating approximately 150 mL of anatomical dead space 3
• Inspect HME filters daily and whenever there is deterioration in ventilation, as inadequate humidification leads to mucus plugging—the most common cause of airway emergencies 3, 1

Secretion Management

• Perform closed-circuit suctioning with inline suction catheters to manage secretions while minimizing aerosolization risk 5, 1
• Avoid saline instillation before suctioning, as it increases coughing risk and provides little benefit while potentially increasing aerosolization 1
• For routine nursing care, 1-2 mL of 10-20% acetylcysteine solution may be instilled every 1-4 hours directly into the tracheostomy to help liquefy thick secretions 6
• When using acetylcysteine, monitor closely as increased volume of liquified secretions may occur, requiring mechanical suction if cough is inadequate 6

Cough Suppression When Appropriate

• Consider spraying airways with 4% lidocaine before tube changes or procedures to decrease coughing, being mindful of proper dosing especially in pediatric populations 1
• For patients with neuromuscular disease and ineffective cough, mechanical insufflation-exsufflation should be used in addition to standard physiotherapy techniques 1

Emergency Management Algorithm

If the patient deteriorates despite initial interventions or if subcutaneous emphysema develops:

1. Remove the tracheostomy tube immediately, even with concerns about difficult airways 2
2. Reassess both airways (upper and stoma) and apply oxygen to both face and stoma 2
3. Emergency oxygenation options include via oro-nasal route or via tracheostomy stoma using a pediatric facemask or laryngeal mask airway applied to the skin 2
4. If the patient fails to improve, oral intubation may be possible using a long tube advanced beyond the stoma, or attempt intubation of the stoma with a smaller tracheostomy tube 2

Critical warning: Excessive coughing during tracheostomy care can cause serious complications including tube displacement (particularly in patients with full necks or obesity) or, in rare cases, diaphragmatic rupture 7, 8

Prevention of Complications

• Maintain cuff pressure at 20-30 cmH2O for air-filled cuffs to ensure ventilation system integrity while preventing tracheal injury 1
• Ensure bedside availability of humidification equipment, suction with appropriate catheters, spare tracheostomy tubes, sterile water, water-soluble lubricant, and PPE 1, 4
• Monitor continuously for respiratory rate, oxygen saturation, work of breathing, and secretion characteristics 3
• For patients with thick secretions despite HME use, consider acetylcysteine nebulization: 3-5 mL of 20% solution or 6-10 mL of 10% solution 3-4 times daily via nebulization 6

Special Considerations for Bronchospasm

• Watch asthmatics carefully when using acetylcysteine, as bronchospasm can occur 6
• Most patients with bronchospasm are quickly relieved by bronchodilator given by nebulization 6
• If bronchospasm progresses, discontinue acetylcysteine immediately 6

Long-term Monitoring

• Perform regular assessment to identify potential complications early, including tracheomalacia (related to cuff over-inflation) and tracheal stenosis (related to prolonged intubation, large tube size, diabetes, and excessive cuff pressure) 3
• Never delay tube removal in a deteriorating patient—remove immediately and reassess both upper airway and stoma 3