Praxis Medical Insights

Initial Assessment and Management

The American Academy of Otolaryngology-Head and Neck Surgery recommends proper humidification with Heat Moisture Exchangers (HMEs), closed-circuit suctioning, and avoiding saline instillation before suctioning to manage tracheostomy-related throat pain and coughing 1
Remove any attachments to the tracheostomy tube that could be causing obstruction, such as speaking valves, caps, or humidifying devices that may have become blocked with secretions 3
Inspect and if necessary, remove and clean the inner cannula to prevent tube occlusion from secretions 3, 4
Use closed-circuit suctioning with an inline suction catheter to manage secretions while minimizing the risk of aerosolization 1, 5
Avoid instillation of saline before suctioning as it increases the risk of coughing and provides little benefit while potentially increasing aerosolization 1

Use Heat Moisture Exchangers (HMEs) with viral filters rather than heated humidification (HH) or nebulized treatments to reduce coughing and secretion buildup 1, 5
For patients with thick secretions, consider HMEs with viral filters that have filtration efficiency >99.9% and bidirectional design 1
Inspect HME filters daily and whenever there is deterioration in ventilation 5

Consider spraying the airways with 4% lidocaine before tube changes or procedures to decrease coughing, being mindful of proper dosing especially in pediatric populations 1
Maintain proper cuff inflation (20-30 cmH2O for air-filled cuffs) to ensure integrity of the ventilation system while preventing tracheal injury 5, 2

For patients with neuromuscular disease and ineffective cough, mechanical insufflation and exsufflation should be used in addition to standard physiotherapy techniques 6
Consider mini-tracheostomy to facilitate secretion clearance in patients with weak cough or excessive secretions 6

Ensure the following equipment is readily available at the bedside: humidification equipment, suction with appropriate suction catheters, spare tracheostomy tubes, clean pot for spare inner cannula, sterile water for cleaning, water-soluble lubricating jelly, tracheostomy dressings and tapes, and personal protective equipment (gloves, aprons, eye protection) 4

For patients on dual antiplatelet therapy following percutaneous coronary intervention, the American College of Cardiology recommends continuing standard antiplatelet therapy to prevent thrombotic events 2