Ineffective Airway Clearance

Ineffective Airway Clearance can be an acute (e.g., postoperative recovery) or chronic (e.g., CVA or spinal cord injury) problem. High-risk for ineffective airway clearance are the aged individuals who have an increased incidence of emphysema and a higher prevalence of chronic cough or sputum production.
There is a wide range of airway clearance interventions that nurses can choose from when they are teaching the patients and family members the strategies of secretion removal. In general, these interventions are done to maintain a patent airway, improve comfort and ease of breathing, improve pulmonary ventilation and oxygenation, and to prevent risks associated with oxygenation problems.
Related Factors
Here are some factors that may be related to Ineffective Airway Clearance:
  • Airway spasm/asthma
  • Copious and tenacious tracheobronchial secretions
  • Decreased energy and fatigue
  • Impaired respiratory muscle function
  • Neuromuscular function
  • Presence of artificial airway
  • Tracheobronchial infection
  • Tracheobronchial obstruction (foreign body aspiration)
Possibly evidenced by
  • Abnormal arterial blood gasses.
  • Adventitious lung sounds (Wheezes, Rhonchi).
  • Changes in respiratory rate and rhythm.
  • Chest tightness.
  • Cough.
  • Cyanosis.
  • Dyspnea;orthopnea.
  • Retained secretions.
Desired Outcomes
  • Patient will maintain clear, open airways as evidence by normal breath sounds, normal rate and depth of respirations, and ability to effectively cough up secretions after treatments and deep breaths.
  • Patient will demonstrate increased air exchange.
  • Patient will classify methods to enhance secretion removal.
  • Patient will recognize the significance of changes in sputum to include color, character, amount, and odor.
  • Patient will identify and avoid specific factors that inhibit effective airway clearance.
Nursing Assessment
  • Assess airway for patency.
  • Rationale:⇒ Maintaining patent airway is always the first priority, especially in cases like trauma, acute neurological decompensation, or cardiac arrest.
  • Rates and Depths of Respiration
  • Note presence of sputum; evaluate its quality, color, amount, odor, and consistency.
  • Use pulse oximetry to monitor oxygen saturation; assess arterial blood gases (ABGs)
  • Auscultate lungs for presence of normal or adventitious breath sounds.
Decreased or absent breath sounds:: These may indicate presence of a mucous plug or other major obstruction.
Wheezing:: This may indicate partial airway obstruction or resistance.
Coarse crackles::This may indicate presence of secretions along larger airways.
Rationale:⇒ Abnormal breath sounds can be heard as fluid and mucus accumulate. This may indicate airway is obstructed.
Nursing Interventions
  • Teach the patient the proper ways of coughing and breathing. (e.g., take a deep breath, hold for 2 seconds, and cough two or three times in succession). Rationale:⇒ The most convenient way to remove most secretions is coughing. So it is necessary to assist the patient during this activity. Deep breathing, on the other hand, promotes oxygenation before controlled coughing.
  • Educate the patient in the following:
  1. Optimal positioning (sitting position)
  2. Use of pillow or hand splints when coughing
  3. Use of abdominal muscles for more forceful cough
  4. Use of quad and huff techniques
  5. Use of incentive spirometry
  6. Importance of ambulation and frequent position changes
  • Rationale:⇒ The proper sitting position and splinting of the abdomen promote effective coughing by increasing abdominal pressure and upward diaphragmatic movement. Controlled coughing methods help mobilize secretions from smaller airways to larger airways because the coughing is done at varying times. Ambulation promotes lung expansion, mobilizes secretions, and lessens atelectasis.
  • Position the patient upright if tolerated. Regularly check the patient’s position to prevent sliding down in bed.  Rationale:⇒ Upright position limits abdominal contents from pushing upward and inhibiting lung expansion. This position promotes better lung expansion and improved air exchange.
  • Perform nasotracheal suctioning as necessary, especially if cough is ineffective.  Rationale:⇒ Suctioning is needed when patients are unable to cough out secretions properly due to weakness, thick mucus plugs, or excessive or tenacious mucus production.
  • Encourage patient to increase fluid intake to 3 liters per day within the limits of cardiac reserve and renal function. Rationale:⇒ Fluids help minimize mucosal drying and maximize ciliary action to move secretions.
  • Give medications as prescribed, such as antibiotics, mucolytic agents, bronchodilators, expectorants, noting effectiveness and side effects. Rationale:⇒ A variety of medications are prepared to manage specific problems. Most promote clearance of airway secretions and may reduce airway resistance.
  • Coordinate with a respiratory therapist for chest physiotherapy and nebulizer management as indicated.  Rationale:⇒ Chest physiotherapy includes the techniques of postural drainage and chest percussion to mobilize secretions from smaller airways that cannot be eliminated by means of coughing or suctioning.
  • Provide postural drainage, percussion, and vibration as ordered. Rationale:⇒ Chest physical therapy helps mobilize bronchial secretions; it should be used only when prescribed because it can cause harm if patient has underlying conditions such as cardiac disease or increased intracranial pressure.
  • If secretions cannot be cleared, consider the need for an intubation. Rationale:⇒  Readiness for an emergency helps prevent further complications. Intubation may be needed to facilitate removal of tenacious and copious amounts of secretions and provide source for augmenting oxygenation.
  • Educate patient on coughing, deep breathing, and splinting techniques.
  • Rationale:⇒ Patient will understand the underlying principle and proper techniques to keep the airway clear of secretions.
  • Provide patient understanding about the proper use of prescribed medications and inhalers. Rationale:⇒ Understanding prescriptions promote safe and effective medication administration.
  • Instruct patient about the need for adequate fluid intake even after hospital discharge.  Rationale:⇒ Hydration facilitates easy elimination of secretions.
  • Consider verbalization of feelings. Rationale:⇒ Recognize reality of situation. Anxiety adds to oxygen demand, and hypoxemia potentiates respiratory distress or cardiac symptoms, which in turn increases anxiety.
  • Explain further the effects of smoking, including secondhand smoke.  Rationale:⇒ Chemical irritants and allergens can increase mucus production and bronchospasm.
  • Refer to the pulmonary clinical nurse specialist, home health nurse, or respiratory therapist as indicated. Rationale:⇒ Consultants may be helpful in ensuring that proper treatments are met.
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