Which nursing interventions are important for the patient who is unable to cough up thick secretions?

Effective (or controlled) coughing has just enough force to loosen and carry mucus through the airways without causing them to narrow and collapse. For people with chronic obstructive pulmonary disease (COPD), this saves energy.

Inhaltsverzeichnis Show

What should I know about controlled coughing?
Controlled coughing technique
Mucus clearing devices
More health news + info
Removing mucus from trach tube without suctioning
When to suction
How to suction
What intervention can the nurse provide to decrease the viscosity of secretions?
Which interventions can help patients expectorate sputum?
What is the nursing intervention for cough?
What are nursing interventions for ineffective airway clearance?

What should I know about controlled coughing?

COPD can cause your lungs to produce excess mucus, leading to frequent coughing. Not all coughs are effective in clearing excess mucus from the lungs. Explosive or uncontrolled coughing causes airways to collapse and spasm, trapping mucus.

The effective, or controlled, cough comes from deep within the lungs and has just enough force to loosen and carry mucus through the airways without causing them to narrow and collapse. Controlled coughing saves energy and therefore, oxygen.

Controlled coughing technique

To cough effectively:

Sit on a chair or on the edge of your bed, with both feet on the floor. Lean slightly forward. Relax.
Fold your arms across your abdomen and breathe in slowly through your nose. (The power of the cough comes from moving air.)
To exhale: lean forward, pressing your arms against your abdomen. Cough 2-3* times through a slightly open mouth. Coughs should be short and sharp. The first cough loosens the mucus and moves it through the airways. The second and third cough enables you to cough the mucus up and out.
Breathe in again by "sniffing" slowly and gently through your nose. This gentle breath helps prevent mucus from moving back down your airways.
Rest
Perform again if needed.

Tips

Avoid breathing in quickly and deeply through your mouth after coughing. Quick breaths can interfere with the movement of mucus up and out of the lungs, and can cause uncontrolled coughing.
Drink 6 to 8 glasses of fluid per day unless your doctor has told you to limit your fluid intake. When mucus is thin, coughing is easier.
Use the controlled coughing technique after you use your bronchodilator medication or any time you feel mucus (congestion) in the airways.

Mucus clearing devices

If you have trouble coughing up secretions, your physician may prescribe a hand-held mucus clearing device. These devices include the Flutter device, the Acapella® (known as the ‘pickle’), the RC Cornet®, Lung Flute (lungflute®), and the Aerobika®.

To use these devices, place a mouthpiece in your mouth, seal your lips around it, and take a deep breath using your diaphragm. Breathe out slowly with a moderate force through the device for as long as you can. The increased pressure in the airways and the oscillations created by the device will give you the feeling to cough. When you feel the urge to cough, take a deep breath in, hold for 1-3 seconds and cough to loosen the mucus.

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Tracheostomy
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Faculty and Staff
Frequently Asked Questions
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Overview: Living with a Tracheostomy
Tracheostomy Complications
Difficulty Inserting the New Tracheostomy Tube
Suctioning
Stoma Care
Tracheostomy Equipment
Cleaning and Caring for Tracheostomy Equipment
Eating with a Tracheostomy
Speech with a Tracheostomy
Tracheostomy and a Passy-Muir Valve
Swimming with a Tracheostomy
Traveling with a Tracheostomy
Tracheostomy Humidification
Decannulation

In This Section

The upper airway warms, cleans and moistens the air we breathe. The trach tube bypasses these mechanisms, so that the air moving through the tube is cooler, dryer and not as clean. In response to these changes, the body produces more mucus. Suctioning clears mucus from the tracheostomy tube and is essential for proper breathing. Also, secretions left in the tube could become contaminated and a chest infection could develop. Avoid suctioning too frequently as this could lead to more secretion buildup.

Removing mucus from trach tube without suctioning

Bend forward and cough. Catch the mucus from the tube, not from the nose and mouth.
Squirt sterile normal saline solutions (approximately 5cc) into the trach tube to help clear the mucus and cough again.
Remove the inner tube (cannula).
Suction.
Call 911 if breathing is still not normal after doing all of the above steps.
Remove the entire trach tube and try to place the spare tube.
Continue trying to cough, instill saline, and suction until breathing is normal or help arrives.

When to suction

Suctioning is important to prevent a mucus plug from blocking the tube and stopping the patient's breathing. Suctioning should be considered

Any time the patient feels or hears mucus rattling in the tube or airway
In the morning when the patient first wakes up
When there is an increased respiratory rate (working hard to breathe)
Before meals
Before going outdoors
Before going to sleep

The secretions should be white or clear. If they start to change color, (e.g. yellow, brown or green) this may be a sign of infection. If the changed color persists for more than three days or if it is difficult to keep the tracheostomy tube intact, call your surgeon's office. If there is blood in the secretions (it may look more pink than red), you should initially increase humidity and suction more gently. A Swedish or artificial nose (HME), which is a cap that can be attached to the tracheostomy tube, may help to maintain humidity. The cap contains a filter to prevent particles from entering the airway and maintains the patient's own humidity. Putting the patient in the bathroom with the door closed and shower on will increase the humidity immediately. If the patient coughs up or has bright red blood mucus suctioned, or if the patient develops a fever, call your surgeon's office immediately.

How to suction

Equipment
Clean suction catheter (Make sure you have the correct size)
Distilled or sterile water
Normal saline
Suction machine in working order
Suction connection tubing
Jar to soak inner cannula (if applicable)
Tracheostomy brushes (to clean tracheostomy tube)
Extra tracheostomy tube

Wash your hands.
Turn on the suction machine and connect the suction connection tubing to the machine.
Use a clean suction catheter when suctioning the patient. Whenever the suction catheter is to be reused, place the catheter in a container of distilled/sterile water and apply suction for approximately 30 seconds to clear secretions from the inside. Next, rinse the catheter with running water for a few minutes then soak in a solution of one part vinegar and one part distilled/sterile water for 15 minutes. Stir the solution frequently. Rinse the catheters in cool water and air-dry. Allow the catheters to dry in a clear container. Do not reuse catheters if they become stiff or cracked.
Connect the catheter to the suction connection tubing.
Lay the patient flat on his/her back with a small towel/blanket rolled under the shoulders. Some patients may prefer a sitting position which can also be tried.
Wet the catheter with sterile/distilled water for lubrication and to test the suction machine and circuit.
Remove the inner cannula from the tracheostomy tube (if applicable). The patient may not have an inner cannula. If that is the case, skip this step and go to number 8.
a. There are different types of inner cannulas, so caregivers will need to learn the specific manner to remove their patient's. Usually rotating the inner cannula in a specific direction will remove it.
b. Be careful not to accidentally remove the entire tracheostomy tube while removing the inner cannula. Often by securing one hand on the tracheostomy tube?s flange (neck plate) one can/ will prevent?accidental removal.
c. Place the inner cannula in a jar for soaking (if it is disposable, then throw it out).
Carefully insert the catheter into the tracheostomy tube. Allow the catheter to follow the natural curvature of the tracheostomy tube. The distance to the location of catheter becomes easier to determine with experience. The least traumatic technique is to pre-measure the length of the tracheostomy tube then introduce the catheter only to that length. For example if the patient?s tracheostomy tube is 4 cm long, place the catheter 4 cm into the tracheostomy tube. Often, there will be instances when this technique of suctioning (called tip suctioning) will not clear the patient?s secretions. For those situations, the catheter may need to be inserted several mm beyond the end of the tracheostomy tube (called deep suctioning). With experience, caregivers will be able to judge the distance to insert the tracheostomy tube without measuring.
Place your thumb over the suction vent (side of the catheter) intermittently while you remove the catheter. Do not leave the catheter in the tracheostomy tube for more than 5-10 seconds since the patient will not be able to breathe well with the catheter in place.
Allow the patient to recover from the suctioning and to catch his/her breath. Wait for at least 10 seconds.
Suction a small amount of distilled/sterile water with the suction catheter to clear any residual debris/secretions.
Insert the inner cannula from extra tracheostomy tube (if applicable).
Turn off suction machine and discard catheter (clean according to step 3 if to be reused).
Clean inner cannula (if applicable).

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What intervention can the nurse provide to decrease the viscosity of secretions?

Increasing the humidity will decrease the viscosity of secretions.

Which interventions can help patients expectorate sputum?

Breathing techniques, such as active cycle of breathing, body positioning and manual techniques, including percussion, shaking and vibrations, can also be used to loosen secretions and thus facilitate expectoration.