Management of Tracheostomy Secretions
Anticholinergic medications, particularly glycopyrrolate and scopolamine, are the primary pharmacologic agents recommended to reduce excessive tracheostomy secretions, with glycopyrrolate preferred due to its lower risk of delirium. 1
Anticholinergic Agents for Secretion Management
First-Line Medications
Glycopyrrolate is the preferred anticholinergic agent for managing excessive tracheostomy secretions because it does not effectively cross the blood-brain barrier, making it less likely to cause delirium compared to other anticholinergic options, though it can still produce peripheral anticholinergic side effects. 1
Alternative anticholinergic options include scopolamine, atropine, and hyoscyamine, all of which effectively reduce secretions but carry higher risks of central nervous system effects including delirium. 1
Scopolamine Administration Considerations
- Subcutaneous or transdermal routes are available for scopolamine administration 1
- Critical timing caveat: Transdermal scopolamine patches have an onset of benefit of approximately 12 hours, making them inappropriate for patients requiring immediate secretion control 1
- For acute management: A subcutaneous injection of scopolamine can be administered when the patch is applied or if secretion management remains inadequate 1
Nebulized Anticholinergics
Nebulized ipratropium bromide (250-500 mcg) has demonstrated efficacy in reducing airway secretions during bronchoscopic procedures and may be beneficial for tracheostomy patients, though this represents off-label use extrapolated from bronchoscopy data. 2 The study showed significant reduction in airway secretions and patient discomfort when administered 20-40 minutes before procedures. 2
Important Safety Consideration for Nebulized Medications
Avoid jet nebulizers in tracheostomy patients as they can aerosolize particles up to 80 cm, creating infection control concerns. 3 For mechanically ventilated patients requiring inhaled medications, vibrating mesh nebulizers are recommended as they do not require disconnection of closed-circuit systems. 3 For non-mechanically ventilated patients, use a spacer for delivery of metered-dose inhaled medications via the tracheostomy tube. 3
Normal Saline for Secretion Management
Normal saline (0.9% sodium chloride, 5 mL every 6 hours) may be tried to loosen tenacious secretions, though there is currently no supporting scientific evidence for this practice. 4 This represents a common clinical practice based on theoretical benefit rather than proven efficacy.
Critical Secretion Management Practices
Suctioning Protocols
Frequent suctioning is essential to prevent mucus plugging, which is one of the most common reasons for airway rapid response activation in tracheostomy patients. 3 However, suctioning must be performed carefully as it generates negative pressure of 100-200 cmH2O and can increase aerosolization risk. 3
Use closed-circuit suctioning systems for all tracheostomy patients when possible:
- For mechanically ventilated patients: inline suction catheter via closed circuit 3
- For non-ventilated patients: inline suction catheter using a T-connector or Kelley Circuit 3
Avoid saline instillation before suctioning due to increased risk of coughing and aerosolization with little evidence of benefit. 3
Humidification
While not a medication per se, adequate humidification through heat moisture exchange (HME) devices with viral filters is recommended for non-mechanically ventilated tracheostomy patients to help maintain secretion consistency. 3
Common Pitfalls to Avoid
- Do not use transdermal scopolamine for acute secretion management due to 12-hour onset delay 1
- Avoid jet nebulizers in tracheostomy patients due to aerosolization risks 3
- Do not instill saline before suctioning as this increases coughing without proven benefit 3
- Be aware of anticholinergic side effects, particularly delirium with scopolamine, atropine, and hyoscyamine 1
- Avoid unnecessary tracheostomy tube manipulation and dressing changes to minimize secretion stimulation 3
Medications NOT Recommended for Secretion Management
Nebulized opioids are sometimes used for breathlessness palliation but have conflicting evidence and are not indicated for secretion management. 4 Nebulized corticosteroids lack scientific evidence for managing tracheostomy secretions. 4