How should increased airway secretions be managed, including both pharmacologic and non‑pharmacologic measures?

Management of Increased Airway Secretions

Begin with non-pharmacologic airway clearance techniques as first-line therapy, reserving pharmacologic agents for patients who fail initial measures or have severe bronchospasm complicating secretion clearance. 1

Initial Assessment and Problem Identification

Before selecting interventions, identify the underlying mechanism reducing airway clearance 1:

• Assess cough effectiveness: Determine if the patient can generate adequate inspiratory volume and expiratory flow to clear secretions 1
• Evaluate secretion burden: Quantify volume (>30 mL/day typically requires intervention) and viscosity 2
• Identify respiratory muscle weakness: Patients with neuromuscular disease, post-operative states, or critical illness may have impaired cough mechanics 1
• Check for bronchospasm: Wheezing or increased airway resistance indicates need for bronchodilators before clearance techniques 3

Non-Pharmacologic Airway Clearance (First-Line)

For Non-Intubated Patients with Adequate Muscle Strength

Interventions to increase inspiratory volume should be used if reduced inspiratory volume is contributing to ineffective forced expiration 1:

• Active cycle of breathing techniques (ACBT): Combines breathing control, thoracic expansion exercises, and forced expiratory technique (huffing) 3
• Directed coughing techniques: Teach huffing (forced expiration with open glottis) as an adjunct to other clearance methods 1
• Gravity-assisted positioning (postural drainage): Use gravity dependency to augment secretion movement toward central airways where cough is more effective 1, 3

For Patients with Respiratory Muscle Weakness

Manually assisted cough techniques and/or mechanical insufflation-exsufflation should be applied in patients with retained secretions secondary to respiratory muscle weakness 1:

• Air stacking: Deliver multiple positive-pressure breaths without exhalation to increase lung volume before cough, which can increase peak cough flows by 80% 1
• Manually assisted cough: Apply thoracic or abdominal compression synchronized with patient's expiratory effort 1
• Mechanical insufflation-exsufflation devices: Can increase peak cough flows by more than four-fold and are recommended to prevent respiratory complications in neuromuscular disease 1

Critical caveat: In patients with COPD or expiratory airflow obstruction, manually assisted cough may be detrimental and should not be used 1

For Intubated and Mechanically Ventilated Patients

• Body positioning and mobilization: Optimize ventilation-perfusion matching and use gravity to enhance secretion clearance 1
• Manual hyperinflation or ventilator hyperinflation: Prevent atelectasis, re-expand collapsed alveoli, and facilitate secretion movement 1
• Airway suctioning: Perform regularly under sterile technique, preferably under direct vision in deeply anesthetized patients to avoid laryngospasm 1

Oro-nasal suctioning should be used only when other methods fail to clear secretions 1, and nasal suctioning requires extreme caution in patients with anticoagulation, facial trauma, or recent upper airway surgery 1

Pharmacologic Management (Adjunctive or When Non-Pharmacologic Fails)

Bronchodilators (Primary Pharmacologic Intervention)

Short-acting β2-agonists and anticholinergics are the initial medications to reduce bronchospasm and facilitate secretion clearance 3:

• Aerosolized albuterol: 2.5 mg in 3 mL saline via nebulizer 1, 3
• Ipratropium bromide: 0.5 mg via nebulizer 1, 3
• Combination therapy: In severe cases with marked bronchospasm, combined albuterol and ipratropium provides superior outcomes 1, 3

The European Respiratory Society supports inhaled ipratropium bromide specifically for cough suppression and secretion management in URI or chronic bronchitis 1, though evidence for anticholinergics is somewhat inconsistent across different respiratory conditions 1

Corticosteroids (For Severe Bronchospasm)

Intravenous methylprednisolone 125 mg three times daily combined with bronchodilators may provide added value in severe airway congestion with noncardiogenic pulmonary edema 1

Mucoactive Agents (Consider in Severe Cases)

• Hypertonic saline: Can be added when secretions remain refractory to bronchodilators and clearance techniques 3
• Adequate hydration: Encourage fluid intake to reduce secretion viscosity 3

Important limitation: The ACCP evidence review found inconsistent efficacy for mucolytic agents, with expectorants unlikely to alter mucus volume without also affecting consistency 1

Treatment Algorithm by Severity

Mild-Moderate Secretions

1. Institute directed coughing and breathing techniques 3
2. Apply gravity-assisted positioning if tolerated 3
3. Administer bronchodilators (β2-agonists and/or anticholinergics) 3
4. Encourage adequate fluid intake 3

Severe Secretions

1. Intensify bronchodilator therapy (combination albuterol + ipratropium) 3
2. Add mucoactive agents (hypertonic saline) 3
3. Consider mechanical cough assist devices if muscle weakness present 1
4. Provide supplemental oxygen to maintain SpO2 >90% if hypoxemic 3

COPD Exacerbations with Secretions

The primary goals are to remove excess secretions, increase maximum airflow, and improve respiratory muscle strength 1:

• Antibiotics: Administer when increased sputum volume and purulence are present 3, 4
• Bronchodilators: Initiate, increase dose, or combine β2-agonists and anticholinergics 4
• Controlled oxygen: Target SpO2 88-92% to avoid worsening hypercapnia 3, 4

Critical Pitfalls to Avoid

• Never use manually assisted cough in COPD patients with airflow obstruction, as it may worsen air trapping and cause barotrauma 1
• Avoid excessive oxygen administration in COPD, which can suppress respiratory drive and worsen hypercapnia; target SpO2 88-92% rather than normalization 3, 4
• Do not rely solely on suctioning when other clearance techniques could be effective, as suctioning is traumatic and should be reserved for failure of other methods 1
• Avoid sedatives and hypnotics in patients with excessive secretions, as these suppress the cough reflex 3
• Ensure adequate inspiratory volume before attempting forced expiratory techniques, as all cough maneuvers require sufficient lung inflation to be effective 1
• Verify endotracheal tube security frequently in intubated patients with copious secretions, as excessive oral secretions and perspiration can dislodge tubes; nasal intubation may be preferred 1

Special Populations

Critically Ill Patients

• Active or passive mobilization and muscle training should be instituted early to prevent deconditioning and optimize secretion clearance 1
• Regular airway aspiration by sterile technique starting soon after intubation 1
• Pressure-controlled mandatory ventilation with 100% oxygen and PEEP for adequate minute volume 1

Neuromuscular Disease

• Mechanical cough assist devices are recommended to prevent respiratory complications when assisted peak cough flows decrease to <270 L/min 1
• Noninvasive positive-pressure ventilation combined with manually and mechanically assisted coughing reduces hospitalization rates 1

Dying Patients

Respiratory tract secretions develop in approximately 49% of dying patients, with median time from onset to death of 16 hours 5. While hyoscine hydrobromide is commonly used, only 30.5% respond within four hours, and increasing doses for nonresponders shows no significant benefit 5. Focus on positioning and gentle suctioning when appropriate rather than aggressive pharmacologic intervention in this population.