What interventions can the nurse implement to prevent respiratory complications?

Ineffective airway clearance is the inability to clear secretions or obstructions from the respiratory tract. This can be detrimental to breathing and create complications. Secretions can be problematic as a result of a condition such as cystic fibrosis or related to an inability to clear secretions such as with a stroke deficit or the presence of a tracheostomy.

Nurses understand the most important aspects of care include maintaining the airway, breathing, and circulation (ABCs). Nurses must be vigilant in assessing for airway obstruction and implementing interventions to prevent worsening secretions.

Causes of Ineffective Airway Clearance (Related to) 

• Smoking/smoke inhalation 
• Chronic obstructive pulmonary disease (COPD) 
• Asthma 
• Infection
• Sedation from anesthesia 
• Paralysis from stroke or spinal cord injury 
• Obstructed airway from retained secretions, excessive mucus, obstructed airway, or artificial airway 
• Neuromuscular disorders

Signs and Symptoms (As evidenced by) 

Subjective: (Patient reports) 

• Dyspnea  

Objective: (Nurse assesses) 

• Adventitious breath sounds 
• Abnormal respiratory rate, rhythm, and depth 
• Declining oxygen saturation 
• Ineffective or absent cough reflex 
• Copious mucus production 
• Hypoxemia 
• Restlessness  
• Change in level of consciousness 
• Orthopnea 
• Cyanosis

Expected Outcomes

• Patient will maintain a patent airway as evidenced by clear breath sounds, oxygen saturation within normal limits, and the ability to cough to clear secretions 
• Patient will avoid specific behaviors or factors that worsen secretions and airway clearance 
• Patient/caregiver will demonstrate techniques to effectively clear secretions 
• Patient/caregiver will verbalize signs and symptoms of ineffective airway clearance

Nursing Assessment for Ineffective Airway Clearance

1. Identify patients at risk for ineffective airway clearance.
Those with diseases and disorders that specifically cause respiratory dysfunction; cystic fibrosis, asthma, emphysema, or neuromuscular disorders that affect the ability to breathe; ALS, myasthenia gravis, those with swallowing impairments or a poor gag/cough reflex, and patients who are on mechanical ventilation or have a tracheostomy are at risk for poor airway clearance.

2. Assess lung sounds.
Diminished lung sounds or adventitious lung sounds such as wheezing, stridor, rhonchi, or crackles can result from an accumulation of secretions or a blocked airway.

3. Assess respirations.
Note the rate, depth, pattern, and use of accessory muscles when breathing. Increasing rate, nasal flaring, and accessory muscle use is an attempt to compensate for ineffective breathing.

4. Evaluate the ability to swallow or cough.
Assessing the patient’s gag reflex and ability to cough and swallow will determine their ability to protect their airway and guide further interventions.

5. Note changes in mental status or restlessness.
An increase in restlessness, anxiety, or confusion can signal the brain is not getting enough oxygen.

6. Assess sputum color and consistency.
Assess sputum for color; green, white, or yellow secretions can signal an infection. Very thick mucus may make coughing and clearing the airway difficult.

7. Assess ABGs and oxygen saturation.
Monitor ABGs for changes to prevent respiratory failure. Oxygen saturation should be kept at 90% or greater (preferably 94% or higher, but this will depend on the patient’s medical history).

8. Assess for dehydration.
Dehydration causes mucus to thicken and makes clearing the airway harder. Assess skin turgor, mucous membranes, and lab work for signs of dehydration.

Nursing Interventions for Ineffective Airway Clearance

1. Position to decrease secretions.
Maintain an elevated head of bed as tolerated to help prevent secretions from accumulating. Sliding down in the bed or a slumped posture prevents proper lung expansion.

2. Suction as needed.
Patients may require naso/tracheal/oral suctioning to clear the airway, especially in the presence of an artificial airway or if the patient is unable to cough or swallow.

3. Mobilize secretions.
Teach coughing and deep breathing exercises. If coughing is painful the patient can splint the abdomen with a pillow. Use an incentive spirometer to keep the lungs expanded. Encourage movement and walking to mobilize secretions.

4. Give respiratory medications.
Administer bronchodilators to open airways, mucolytics or expectorants to thin mucus and make it easier to cough up, and antibiotics to treat respiratory infections.

5. Involve respiratory therapy.
Respiratory therapists can incorporate more advanced interventions and can recommend treatment changes. They often administer nebulizer treatments and can apply humidification to oxygen to prevent dryness. They can also perform chest physiotherapy which loosens and improves drainage.

6. Encourage fluid intake.
Drinking plenty of fluids thins secretions and prevents dehydration. Instruct patients to drink 2L of water a day if not contraindicated.

7. Discuss lifestyle modifications.
Patients who smoke should be advised to quit, especially if they have lung conditions such as COPD or asthma as this only exacerbates their conditions. Patients who are subjected to smoke inhalation at a worksite should use a mask.

8. Educate on signs of ineffective airway clearance and prevention.
Patients and caregivers should be educated on signs and symptoms to seek treatment promptly. This can include signs of infection such as a fever or change in mucus color and amount as well as any changes to respiratory rate or pattern. Instruct on proper techniques to suction and that a humidifier in the home can keep secretions thin.

9. Obtain sputum sample.
Sputum samples can be cultured for the presence of bacteria which can then be effectively treated.

10. Ensure proper equipment at discharge.
Coordinate with the discharge planner to ensure equipment such as a CPAP, nebulizer, oxygen concentrator, and suctioning equipment are delivered. The nurse or RT can also educate the patient or caregiver on how to safely and effectively use the equipment.

References and Sources

1. Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2008). Nurse’s Pocket Guide Diagnoses, Prioritized Interventions, and Rationales (11th ed.). F. A. Davis Company.
2. Knott, L. (2018, November 27). Mucolytics. Patient.info. Retrieved December 8, 2021, from https://patient.info/chest-lungs/chronic-obstructive-pulmonary-disease-leaflet/mucolytics
3. Spader, C. (2020, November 15). What Is Chest Physiotherapy? | Why Chest PT Is Done & What to Expect. Healthgrades. Retrieved December 8, 2021, from https://www.healthgrades.com/right-care/lungs-breathing-and-respiration/chest-physiotherapy

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