How to manage high secretions in intubated (inserted tube into the airway) ICU (Intensive Care Unit) patients to prevent pneumonia or tube blockade?

Managing High Secretions in Intubated ICU Patients

Suction only when clinically indicated based on assessment findings rather than on a fixed schedule, using proper technique with hyperoxygenation before and after each pass, and maintain cuff pressures at 20-30 cm H₂O to prevent microaspiration while ensuring adequate humidification to reduce secretion viscosity. 1

Assessment-Based Suctioning Strategy

When to Suction

• Perform endotracheal suctioning only when necessary based on clinical assessment rather than routine fixed intervals, as this approach reduces complications while maintaining adequate airway clearance 2, 3, 4
• Assess for suctioning needs by monitoring for: absence or change in capnograph waveform, reduced chest wall movement, increasing airway pressures, reducing tidal volumes, or inability to pass a suction catheter 1
• Auscultate breath sounds to identify secretions requiring removal, as nurses trained in assessment skills achieve better patient outcomes than those using routine 2-hourly suctioning 2

Oropharyngeal Secretion Management

• Suction oropharyngeal secretions at minimum every 4 hours to prevent aspiration of secretions pooling above the endotracheal tube cuff, which is a major risk factor for ventilator-associated pneumonia 5
• Some patients accumulate significantly more secretions (>11 mL at 2 hours) and require more frequent oropharyngeal suctioning 5
• Use deep suction catheters for oropharyngeal clearance, typically requiring 3 passes over approximately 48 seconds to adequately clear secretions 5

Proper Suctioning Technique

Equipment and Catheter Selection

• Use a suction catheter that occludes less than half the lumen of the endotracheal tube to minimize airway obstruction during the procedure 3
• Either open or closed suction systems are acceptable; closed systems do not decrease ventilator-associated pneumonia incidence but may be preferred in specific high-risk situations 1, 3
• Minimally invasive suctioning (29 cm catheter depth) causes fewer adverse events than routine deep suctioning (49 cm) without compromising outcomes 4

Suctioning Protocol

• Insert the catheter no further than the carina to avoid traumatic injury to the tracheal mucosa 3
• Apply the lowest effective suction pressure and limit suctioning duration to no longer than 15 seconds per pass 3
• Use continuous rather than intermittent suctioning technique during catheter withdrawal 3
• Provide hyperoxygenation before and after each suction pass to prevent desaturation, using 100% FiO₂ for 30-60 seconds 3, 1
• Always use aseptic technique with appropriate personal protective equipment to minimize infection risk 3

Avoid Routine Saline Instillation

• Do not routinely instill normal saline before suctioning, as this practice has potential adverse effects on oxygen saturation and cardiovascular stability with variable effectiveness for secretion removal 1, 3

Airway Maintenance and Monitoring

Endotracheal Tube Management

• Maintain cuff pressure at 20-30 cm H₂O and check pressure each shift to prevent both microaspiration (if too low) and tracheal mucosal injury (if too high) 1, 6
• Document tracheal tube insertion depth on the bedside chart and verify each shift or with any respiratory deterioration 1
• Ensure tubes are well secured, though optimal securing method remains uncertain; experienced vigilant staff are crucial 1

Humidification and Secretion Management

• Provide adequate humidification and regular tracheal suction to reduce avoidable tube blockage, as this is a common cause of critical incidents after initial intubation 1, 6
• Use heat and moisture exchange (HME) filters between the catheter mount and breathing circuit 1
• Consider nebulized N-acetylcysteine for patients with abnormal, viscid, or inspissated mucous secretions that are difficult to clear with standard suctioning 7

Pharmacologic Adjuncts for Thick Secretions

• N-acetylcysteine 3-5 mL of 20% solution (or 6-10 mL of 10% solution) can be nebulized 3-4 times daily for patients with thick, tenacious secretions 7
• For tracheostomy patients, 1-2 mL of 10-20% N-acetylcysteine solution may be instilled every 1-4 hours directly into the tracheostomy 7
• Monitor carefully for bronchospasm when using N-acetylcysteine in asthmatic patients; discontinue immediately if bronchospasm progresses despite bronchodilator use 7
• When cough is inadequate after N-acetylcysteine administration, maintain the open airway by mechanical suction as the increased volume of liquified secretions may accumulate 7

Monitoring and Red Flags

Continuous Monitoring Requirements

• Waveform capnography is mandatory for all intubated ICU patients, as it detects 95% of critical incidents and is the single most important change to prevent airway-related deaths 1
• Monitor for airway red flags indicating potential tube displacement or blockage: absence or change in capnograph waveform, reduced chest movement, increasing airway pressure, reducing tidal volume, inability to pass suction catheter, obvious air leak, or vocalization with cuffed tube inflated 1

Positioning to Reduce Secretions and Edema

• Maintain 35-degree head-up positioning to reduce airway swelling and decrease aspiration risk 1, 6
• Body positioning and mobilization enhance airway secretion clearance in intubated patients 1

Prevention of Complications

Reducing Airway Edema

• Administer intravenous corticosteroids for at least 12 hours in high-risk patients to reduce airway edema, post-extubation stridor, and reintubation rates 1, 6
• Avoid unnecessary positive fluid balances that can worsen airway edema 1
• Consider antibiotics if upper airway infection is suspected as a contributor to increased secretions 1, 6

High-Risk Procedures

• During patient turns, physiotherapy, transfers, or procedures near the airway, nominate an experienced team member solely to safeguard the airway in high-risk patients 1
• Interventions such as position changes and physiotherapy can cause airway displacement, particularly in prone positioning which worsens airway edema 1

Common Pitfalls to Avoid

• Never suction on a fixed routine schedule (e.g., every 2 hours) without clinical indication, as this increases complications without improving outcomes 2, 3, 4
• Do not use hand bulbs for nebulization as their output is too small and particle size is suboptimal 7
• Avoid instilling saline routinely before suctioning despite this being a common practice, as evidence shows potential harm 1, 3
• Do not ignore oropharyngeal suctioning—only 48% of institutional policies address oral care despite its importance in preventing ventilator-associated pneumonia 8
• Never delay suctioning when clinical assessment indicates need, as secretion accumulation can rapidly progress to tube obstruction 1