3.6 Airway Clearance, Home Care & Discharge Planning

3.6 Airway Clearance, Home Care & Discharge Planning

Suctioning Complications & Immediate Management

Respiratory therapists must recognize and immediately treat acute suctioning complications:

1. Severe Vagal Bradycardia: Direct mechanical stimulation of parasympathetic vagal fibers in the posterior pharynx, larynx, or carina induces immediate reflex bradycardia, frequently accompanied by cardiac arrest in neonates.
   • Action: Immediately terminate suctioning, withdraw the catheter, administer 100% FiO2, and initiate manual bag-valve-mask or ventilator manual breaths.
2. Acute Hypoxemia and Cyanosis: Caused by suction-induced pulmonary derecruitment and interruption of ventilation.
   • Action: Re-attach mechanical ventilator, deliver lung recruitment breaths, and increase FiO2 as clinically indicated.
3. Airway Mucosal Hemorrhage: Caused by excessive vacuum pressure or deep suctioning.
   • Action: Verify vacuum regulator is set within 60–80 mmHg (neonates) or 80–100 mmHg (pediatrics); switch immediately to measured shallow suctioning.
4. Elevated Intracranial Pressure (ICP): Agitation and coughing during suctioning drastically elevate cerebral blood flow and ICP. In premature neonates (<32 weeks), sudden ICP fluctuations rupture fragile germinal matrix capillaries, producing life-threatening Intraventricular Hemorrhage (IVH).

---

Bronchopulmonary Hygiene Modalities in Pediatrics & Neonates

When retained secretions impair gas exchange, evidence-based airway clearance techniques must be customized to the patient's gestational age, neuromuscular status, and underlying pathophysiology.

1. Chest Physiotherapy (CPT) and Neonatal Positioning

• Avoid routine Trendelenburg or steep head-down drainage in very preterm or neurologically vulnerable infants. It can worsen reflux, aspiration, oxygenation, hemodynamics, and cerebral venous drainage.
• Choose a flat, side-lying, prone under monitored conditions, or slightly head-elevated position based on the infant’s disease and unit protocol. Use gentle age-appropriate percussion only when indicated, protecting bony prominences and abdominal organs.

2. High-Frequency Chest Wall Oscillation (HFCWO / Vest Therapy)

HFCWO utilizes an inflatable thoracic vest connected via bilateral hoses to an air-pulse generator that delivers high-frequency oscillatory compressions (5 to 25 Hz).

• Mechanism: Creates rapid transient expiratory airflow spikes, shearing secretions from peripheral airway walls, reducing mucus viscosity, and propelling sputum cephalad toward central airways.
• Clinical Indications: Primary maintenance therapy for Cystic Fibrosis (CF), non-CF bronchiectasis, and ciliary dyskinesia in cooperative children (generally $\ge 2$ to 3 years old).
• Precautions: Contraindicated in unstable chest wall trauma, active hemoptysis, severe coagulopathy, and untreated tension pneumothorax.

3. Positive Expiratory Pressure (PEP) & Oscillatory PEP

• PEP Therapy (10 to 20 cmH2O): Patient exhales actively against a variable expiratory resistor. Generates positive backpressure that splints collapsible small airways open and promotes collateral ventilation through the Pores of Kohn and Canals of Lambert, allowing gas to get behind retained secretions and pop them loose.
• Oscillating PEP (Flutter, Acapella, Aerobika): Combines positive expiratory pressure with high-frequency mechanical oscillations (10 to 30 Hz). The vibrations thin sputum and mobilize it toward large airways. Ideal for ambulatory children with CF or atelectasis who can follow multi-step instructions.

4. Mechanical Insufflation-Exsufflation (MI-E / CoughAssist)

Patients with neuromuscular disease (e.g., Spinal Muscular Atrophy [SMA], Duchenne Muscular Dystrophy [DMD], Guillain-Barré syndrome, high quadriplegia) suffer from profound expiratory muscle weakness.

• Diagnostic Indicator: Peak Cough Flow (PCF) $<160\text{ L/min}$ indicates severe cough insufficiency and inability to clear secretions during respiratory tract infections (normal pediatric PCF is $>270\text{ L/min}$).
• Mechanism of Action: MI-E applies a positive pressure breath (+20 to +40 cmH2O) to maximally inflate the lungs (insufflation), followed immediately by an abrupt, rapid switch to negative pressure (-20 to -40 cmH2O) (exsufflation). This rapid pressure shift creates a high expiratory flow that closely simulates a natural, vigorous cough, shearing mucus from large airways without requiring patient effort.

Table 3.3.2: Bronchopulmonary Hygiene Modalities Comparison

---

NPS Exam Traps Callout Box: Secretion Clearance & Hygiene

[!WARNING] NPS Exam Trap 1: Preterm Suctioning Pre-Oxygenation Do not automatically expose a preterm infant to 100% oxygen for suctioning. If the infant predictably desaturates, use the smallest temporary FiO2 increase that maintains the prescribed range and return to baseline promptly.

NPS Exam Trap 2: Saline Lavage in Thick Secretions Vignettes frequently describe an intubated pediatric patient with thick, pluggy secretions and decreasing tidal volumes. A tempting distractor is "instill 2 mL normal saline into the ETT." This is WRONG and harmful. The correct intervention is to evaluate and optimize active heated humidification (ensure 37°C and 100% relative humidity) and verify systemic fluid balance.

NPS Exam Trap 3: Trendelenburg Postural Drainage in Preemies Avoid routine head-down drainage in a very preterm infant. Select a safer position from the infant’s secretion location, oxygenation, reflux and aspiration risk, neurologic status, and monitored response.

Home Airway-Clearance & Discharge Verification

Match airway-clearance technique to diagnosis, secretion burden, age, cooperation, and contraindications. Before discharge, have caregivers demonstrate suction depth, pressure selection, catheter sizing, equipment cleaning, humidification, recognition of obstruction, emergency bag-mask or tracheostomy response, and when to call emergency services. Confirm electrical backup, portable power, oxygen or ventilator supply duration, spare equipment, prescriptions, vendor contacts, and follow-up. Teach-back verifies performance more reliably than asking whether the caregiver understands.

---

Nutritional Status, Feeding Complications & the Child with Obesity

Nutrition is a respiratory problem in pediatrics: it determines the muscle reserve available for breathing and drives several of the most common causes of recurrent aspiration and airway obstruction. The NPS content outline requires managing care based on nutritional status, naming feeding complications and morbid obesity explicitly.

1. Complications of Feedings

• Feeding intolerance: Abdominal distension, emesis, rising gastric residual volume, and new abdominal tenderness in a supported infant raise concern for intolerance. A distended abdomen splints the diaphragm, reduces functional residual capacity and compliance, and increases both work of breathing and required ventilator pressure. Report new distension in a CPAP or ventilated preterm infant promptly - it can be an early sign of necrotizing enterocolitis rather than simple swallowed gas.
• Aspiration: Children with neurologic impairment, an unsafe swallow, gastroesophageal reflux, or a tracheostomy carry recurrent aspiration risk. Suggestive findings include coughing or desaturation with feeds, a wet or gurgly voice, repeated dependent-segment infiltrates, and chronic wheeze that does not respond to bronchodilator. Management is multidisciplinary - swallow evaluation, feed thickening or route change, positioning, and reflux treatment - not more suctioning alone.
• Malposition of the feeding tube: A gastric tube can enter the airway, coil in the pharynx, or migrate across the gastroesophageal junction. Auscultating insufflated air is not a reliable confirmation method. Verify position by the institution's specified method; radiography is definitive and is the standard before feeds or medication in a high-risk child. In an infant on noninvasive support, a malpositioned or occluded tube also defeats gastric decompression, so worsening distension despite a tube in place should trigger verification rather than reassurance.
• Growth failure: Chronic lung disease raises resting energy expenditure while dyspnea limits intake, so failure to thrive is simultaneously a consequence of and a contributor to respiratory failure in bronchopulmonary dysplasia and cystic fibrosis.

2. The Child with Severe Obesity

• Sleep-disordered breathing: Obesity is a leading pediatric risk factor for obstructive sleep apnea, and adenotonsillar hypertrophy frequently coexists. Suspect it with snoring, witnessed apnea, restless sleep, morning headache, and daytime somnolence. Polysomnography establishes severity; untreated severe disease can progress to chronic hypoventilation and pulmonary hypertension.
• Altered respiratory mechanics: Chest-wall and abdominal mass lower functional residual capacity and compliance and promote dependent atelectasis, so the safe apnea time during intubation is shorter and desaturation arrives faster than the child's size suggests.
• Airway management: Preoxygenate deliberately, position in a ramped "ear-to-sternal-notch" alignment rather than supine and flat, anticipate difficult mask ventilation and a restricted laryngoscopic view, and have rescue devices immediately available.
• Weight-based settings and dosing: Set tidal volume from ideal (predicted) body weight, never total body weight, or the delivered volume will be dangerously large. Drug dosing differs by agent - some agents use total body weight, others ideal or adjusted weight - so follow the pharmacy protocol rather than one universal rule.
• Post-extubation risk: Obesity combined with obstructive sleep apnea raises the risk of post-extubation upper-airway obstruction and opioid-related hypoventilation, warranting a higher-acuity monitoring plan.