Secretion Management Considerations

- 1) Increased secretions and mucous plugging of the bronchial tree are extremely common causes for increased oxygen requirement and difficulty with ventilation in patients with severe respiratory failure from lung infections.
- 2) Anecdotal evidence regarding COVID-19 patients suggests that secretions are problematic in some patients. Additionally, in-line suction (closed system) devices that minimize aerosol formation and de-recruitment are not usually available in austere settings.
- 3) Heated humidification prevents desiccation (drying out) of secretions and promotes ciliary clearance.
  - Heated-humidification devices are designed to be used along with ventilators (e.g., Hamilton H900).
  - Heat-Moisture Exchangers (HME) are supplies that fit in-line with the ventilator tubing and trap heat and moisture within the circuit.
  - HME Filters (HME-F) are supplies that fit in-line with the ventilator tubing and provide HME and microbiologic filtration.
- 4) Pharmacologic treatment for secretions generally falls into one of three categories: mucolytics (break up mucous), bronchodilators, or anti-sialagogues (anti-salivation).
  - Mucolytics:
    - Pre-treat with for 10-15 minutes.
    - 20% N-acetylcystine (Mucomyst) as 1-2mL direct instillation into ETT every 6 hours as needed for secretion control.
    - 3% Saline (Hypertonic Saline) as 5mL direct instillation into the ETT every 6 hours as needed for secretion control.
  - Bronchodilators: Albuterol will help dry up secretions. While ultimately decreasing secretion volume, bronchodilators may also increase the risk of a mucous plug formation. Use with caution.
  - Anti-Sialagogues: Has the greatest effect on oral secretions with modest effect on pulmonary secretions (and therefore not routinely recommended for COVID-19 patients). However, antisialagogues such as scopolamine and glycopyrrolate are often effective at attenuating the increased secretions caused by high dose ketamine.
- 5) Percussive chest physiotherapy is often provided by respiratory therapists in Role 3 facilities to facilitate secretion clearance. Manual (with hands) or mechanical (with percussive physical therapy devices) can be used to create the same effect.