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.
In this article:
- Causes (Related to)
- Signs and Symptoms (As evidenced by)
- Expected Outcomes
- Nursing Assessment
- Nursing Interventions
- Nursing Care Plans
- References
Causes (Related to)
The following are common causes of ineffective airway clearance:
- 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)
The following are common signs and symptoms of ineffective airway clearance. They are categorized into subjective and objective data based on patient reports and assessment by the nurse.
Subjective: (Patient reports)
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
The following are common nursing care planning goals and expected outcomes for ineffective airway clearance:
- 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
The first step of nursing care is the nursing assessment, during which the nurse will gather physical, psychosocial, emotional, and diagnostic data. In the following section, we will cover subjective and objective data related to 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 clear secretions; 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). If blood gasses are available, they may also show signs of respiratory distress.
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
Nursing interventions and care are essential for the patients recovery. In the following section, you will learn more about possible nursing interventions for a patient with 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 and can reduce coughing effectiveness.
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 as ordered.
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 secretions 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.
If the nurse suspects that there is a risk of infection, sputum samples can be cultured for the presence of bacteria.
10. Ensure proper equipment at discharge.
Coordinate with the discharge planner to ensure respiratory equipment needed for the patient, such as a CPAP, nebulizer, oxygen concentrator, or suctioning equipment are delivered. The nurse or RT can also educate the patient or caregiver on how to safely and effectively use the equipment.
Nursing Care Plans
Nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section, you will find nursing care plan examples for ineffective airway clearance.
Care Plan #1
Diagnostic statement:
Dysfunctional ventilatory weaning response related to ineffective airway clearance as evidenced by ineffective cough and respiratory accessory muscle use.
Expected outcomes:
- Patient will demonstrate spontaneous breathing for 24 hours without ventilatory support.
- Patient will demonstrate effective coughing.
- Patient will have clear breath sounds.
- Patient will not manifest retractions and accessory muscle use.
- Patient will have a respiratory rate of 12 to 20 cycles per minute.
Assessment:
1. Assess readiness for weaning.
Parameters for successful weaning include:
- Respiratory rate less than 35 breaths per minute.
- Oxygen concentration of 40% or less on the ventilator.
- Negative inspiratory pressure -20 to -30 cm H2O
- Positive expiratory pressure greater than -15 to -30 cm H2O
- Spontaneous tidal volume greater than 4 to 5 mL/kg
- Vital capacity greater than 10 to 15 mL/kg
- Rested, controlled discomfort
- Willingness to try weaning
- Absence of fever
- Normal hemoglobin levels
2. Auscultate breath sounds.
The patient may exhibit coarse crackles due to the pooling of secretions. Clear breath sounds indicate a patent airway.
3. Monitor respiratory patterns such as rate, depth, and effort.
The patient may manifest tachypnea due to the obstruction caused by the secretions in the airway.
4. Monitor blood gas values and pulse oxygen saturation.
Arterial blood gases revealing hypoxemia or hypoxia and less than 90% oxygen saturation indicate poor oxygenation caused by ineffective clearance.
Interventions:
1. Administer oxygen as ordered.
The use of respiratory muscle use indicates pulmonary distress. Oxygen supplementation reverses hypoxemia.
2. Turn the patient from side to side every 2 hours as ordered.
Body movement mobilizes secretions and optimizes airway secretion clearance.
3. Suction the patient as needed.
Suctioning helps in removing secretions in patients who cannot cough effectively.
4. Provide rest periods with a calm environment.
Successful weaning depends on the patient’s adequate energy resources. Rest periods relieve undue fatigue that may inhibit effective weaning.
5. Administer medications (e.g., bronchodilators or inhaled steroids) as prescribed.
Bronchodilators reduce airway resistance and improve breathing effort.
6. Refer to a respiratory therapist for physiotherapy and nebulizer treatments as indicated.
Respiratory therapists specialize in managing patients requiring ventilatory support. They implement strategies to help the patient wean successfully from the mechanical ventilator and prevent complications post-mechanical ventilation.
Care Plan #2
Diagnostic statement:
Ineffective airway clearance related to the effects of tracheostomy, as evidenced by an inability to clear secretions.
Expected outcomes:
- Patient will demonstrate the ability to clear secretions.
- Patient will not exhibit adventitious sounds such as wheezing and coarse crackles.
Assessment:
1. Assess the respirations.
Note increased rate, irregular rhythm, nasal flaring, and increased use of respiratory accessory muscles. These are indications of respiratory distress. Tachypnea and irregular breathing may indicate airway obstruction.
2. Assess cough effectiveness and productivity.
Coughing can effectively remove secretions. Noting the patient’s ability to cough will determine the level of assistance needed in clearing secretions.
3. Assess secretions.
Note the color, consistency, and quantity of secretions. Secretions may help reveal the underlying pathology of the cough, such as infection, bronchitis, chronic smoking, etc. Thick, tenacious, and discolored secretions may indicate infection and dehydration and increase the risk of hypoxemia.
Interventions:
1. Provide warm, humidified air.
Tracheostomy bypasses the nose, where the air is warmed and humidified. Decreased humidity will thicken secretions, and cool air will reduce ciliary function. Humidification will prevent the drying and crusting of secretions.
2. Encourage the use of an incentive spirometer.
An incentive spirometer facilitates controlled coughing and deep breathing to help clear secretions.
3. Encourage activity and ambulation as tolerated.
Ambulation mobilizes sections.
4. Assist the patient in coughing and breathing maneuvers (e.g., take a deep breath, hold for 2 seconds, and cough twice to three times successively).
Deep breathing promotes oxygenation before controlled coughing.
5. Perform nasotracheal suctioning as needed.
Coughing is the most effective way to remove secretions. However, since the patient cannot cough secretions, suctioning may assist the patient in clearing the airway.
6. Position the patient upright as tolerated.
An upright position facilitates maximum lung expansion and reduced abdominal pressure.
7. Encourage increased fluid intake within the cardiac reserve and renal function.
Adequate hydration reduces the viscosity of secretions. Thinner secretions are easier to mobilize.
References
- Ackley, B.J., Ladwig, G.B.,& Makic, M.B.F. (2017). Nursing diagnosis handbook: An evidence-based guide to planning care (11th ed.). Elsevier.
- Carpenito, L.J. (2013). Nursing diagnosis: Application to clinical practice (14th ed.). Lippincott Williams & Wilkins.
- 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.
- Gulanick, M. & Myers, J.L. (2014). Nursing care plans Diagnoses, interventions, and outcomes (8th ed.). Elsevier.
- Knott, L. (2018, November 27). Mucolytics. Patient.info. Retrieved December 8, 2021, from https://patient.info/chest-lungs/chronic-obstructive-pulmonary-disease-leaflet/mucolytics
- Raimonde, A.J., Westhoven, N.,& Winters, R. (2023). Tracheostomy. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK559124/
- Saeed, F.& Lasrado, S. (2023). Extubation. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK539804/
- 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
