Airway Clearance, Ineffective
Sue Galanes, RN,
NANDA: A state in which an individual is unable to clear secretions
or obstructions from the respiratory tract to maintain airway patency
Maintaining a patent airway is vital to life. Coughing is the main
mechanism for clearing the airway. However the cough may be ineffective in both
normal and disease states secondary to factors such as pain from surgical
incisions/trauma, respiratory muscle fatigue, or neuromuscular weakness. Other
mechanisms that exist in the lower bronchioles and alveoli to maintain the
airway include the mucociliary system, macrophages, and the lymphatics. Factors
such as anesthesia and dehydration can affect function of the mucociliary
system. Likewise, conditions that cause increased production of secretions
(pneumonia, bronchitis, chemical irritants) can overtax these mechanisms.
Ineffective airway clearance can be an acute (e.g., postoperative recovery) or
chronic (e.g., from cerebrovascular accident [CVA] or spinal cord injury)
problem. The elderly who have an increased incidence of emphysema and a higher
prevalence of chronic cough or sputum production are at high risk.
- Decreased energy and fatigue
- Ineffective cough
- Tracheobronchial infection
- Tracheobronchial obstruction (including foreign body aspiration)
- Copious tracheobronchial secretions
- Perceptual/cognitive impairment
- Impaired respiratory muscle function
- Abnormal breath sounds (crackles, rhonchi, wheezes)
- Changes in respiratory rate or depth
- Chest wheezing
Patient's secretions are mobilized and airway is maintained free of
secretions, as evidenced by clear lung sounds, eupnea, and ability to
effectively cough up secretions after treatments and deep breaths.
Ongoing Assessment Actions/Interventions/Rationale
- (i) independent
- (i) Assess airway for patency.
- Maintaining the airway is always the first priority,
especially in cases of trauma, acute neurological decompensation, or cardiac
- (i) Auscultate lungs for presence of normal
or adventitious breath sounds, as in the following:
- Decreased or absent breath sounds
- May indicate presence of mucous plug or other major
- May indicate increasing airway resistance.
- Coarse sounds
- May indicate presence of fluid along larger
- (i) Assess respirations; note quality, rate,
pattern, depth, flaring of nostrils, dyspnea on exertion, evidence of
splinting, use of accessory muscles, position for breathing.
- Abnormality indicates respiratory compromise.
- (i) Assess changes in mental status.
- Increasing lethargy, confusion, restlessness, and/or
irritability can be early signs of cerebral hypoxia.
- (i) Assess changes in vital signs and
- Tachycardia and hypertension may be related to increased work
of breathing. Fever may develop in response to retained
- (i) Assess cough for effectiveness and
- Consider possible causes for ineffective cough: respiratory
muscle fatigue, severe bronchospasm, thick tenacious secretions, and
- (i) Note presence of sputum; assess quality,
color, amount, odor, and consistency.
- May be a result of infection, bronchitis, chronic smoking,
and others. A sign of infection is discolored sputum (no longer clear or
white); an odor may be present.
- Send a sputum specimen for culture and sensitivity as
- Respiratory infections increase the work of breathing;
antibiotic treatment is indicated.
- (c) Monitor arterial blood gases (ABGs).
- Increasing PaCO2 and decreasing PaO2 are signs of respiratory failure.
- (i) Assess for pain.
- Postoperative pain can result in shallow breathing and an
- (c) If patient is on mechanical ventilation,
monitor for peak airway pressures and airway resistance.
- Increases in these parameters signal accumulation of
secretions/fluid and possibility for ineffective ventilation.
- (i) Assess patient's knowledge of disease
- Patient education will vary depending on the acute or chronic
disease state as well as the patient's cognitive level.
- (i) independent
- (i) Assist patient in performing coughing and
- To improve productivity of the cough.
- (i) Instruct patient in the following:
- Optimal positioning (sitting position)
- Use of pillow or hand splints when coughing
- Use of abdominal muscles for more forceful cough
- Use of quad and huff techniques
- Use of incentive spirometry
- Importance of ambulation and frequent position changes.
- These methods help maintain adequate lung expansion thus
preventing buildup of secretions and atelectasis.
- (i) Use positioning
(if tolerated, head of
bed at 45 degrees; sitting in chair, ambulation).
- To facilitate clearing of secretions
These promote better
lung expansion and improved air exchange.
- (i) If bedridden, routinely check the
patient's position so he or she does not slide down in bed.
- This may cause the abdomen to compress the diaphragm, which
would cause respiratory embarrassment.
- (c) If cough is ineffective, use
nasotracheal suctioning as needed
- To remove sputum and mucous plugs.
- Explain procedure to patient.
- Use soft rubber catheters
- To prevent trauma to mucous membranes.
- Use curved-tip catheters and head positioning (if not
- To facilitate secretion removal from a specific side
(right versus left lung).
- Instruct the patient to take several deep breaths before and
after each nasotracheal suctioning procedure and use supplemental O2 as appropriate
- To prevent suction-related hypoxia.
- Stop suctioning and provide supplemental O2 (assisted breaths by ambu bag as needed) if
the patient experiences bradycardia, an increase in ventricular ectopy, and/or
- Use universal precautions: gloves, goggles, and mask as
- If sputum is purulent, precautions should be instituted
before receiving the culture and sensitivity report.
- (c) Institute appropriate isolation precautions
for positive cultures (e.g., methicillin-resistant Staphylococcus
aureus [MRSA], tuberculosis, and others).
- (i) Use humidity (humidified O2 or humidifier at bedside).
- To loosen secretions
- (i) Encourage oral intake of fluids within
the limits of cardiac reserve
- To prevent drying of secretions.
- (c) Administer medications (e.g.,
antibiotics, mucolytic agents, bronchodilators, expectorants) as ordered,
noting effectiveness and side effects.
- (c) For patients with chronic problems with
bronchoconstriction, instruct in use of meter dose inhaler (MDI) or nebulizer
- (c) Consult respiratory therapist for chest
physiotherapy and nebulizer treatments as indicated (hospital and home
care/rehabilitation environments). Coordinate optimal time for postural
drainage and percussion, that is, at least 1 hour after eating
- To prevent aspiration.
- (i) For patients with reduced energy, pace
Maintain planned rest periods. Promote energy conservation
- To prevent fatigue.
- (c) For acute problem, assist with
- To obtain lavage samples for culture and sensitivity, and to
remove mucous plugs.
- (c) If secretions cannot be cleared,
anticipate the need for an artificial airway (intubation). After intubation:
- Institute suctioning of airway as determined by presence of
- Use sterile saline instillations during suctioning
- To help facilitate removal of tenacious sputum.
- (c) For patients with complete airway
obstruction, institute cardiopulmonary resuscitation (CPR) maneuvers.
Education/Continuity of Care
- (i) independent
- (i) Demonstrate and teach coughing, deep
breathing, and splinting techniques
- So patient will understand the rationale and appropriate
techniques to keep the airway clear of secretions.
- (i) Instruct patient on indications for,
frequency, and side effects of medications.
- (i) Instruct patient how to use prescribed
inhalers, as appropriate.
- (i) In home setting, instruct caregivers
regarding cough enhancement techniques and need for humidification.
- (i) Instruct caregivers in suctioning
techniques. Provide opportunity for return demonstration. Adapt technique for
- (i) For patients with debilitating disease
being cared for at home (CVA, neuromuscular impairment, and others), instruct
caregiver in chest physiotherapy as appropriate.
- This may also be useful for the patient with bronchiectasis,
who is ambulatory but requires chest physiotherapy because of the volume of
secretions and the inability to adequately clear them.
- (i) Teach patient about environmental
factors that can precipitate respiratory problems.
- (i) Explain effects of smoking, including
- (i) Refer patient and/or significant others
to smoking-cessation group, as appropriate, and discuss potential use of
smoking-cessation aids (e.g., Nicorette Gum, Nicoderm, or Habitrol) to wean off
the effects of nicotine.
- (i) Instruct patient on warning signs of
pending or recurring pulmonary problems.
- (c) Refer to pulmonary clinical nurse
specialist, home health nurse, or respiratory therapist as indicated.
Cough Enhancement; Airway Management; Airway
- See also:
- Tracheostomy, Chapter 5, p. 533
- Tuberculosis, Chapter 5, p. 539
- Pneumonia, Chapter 5, p. 493
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