INEFFECTIVE AIRWAY CLEARANCE
Inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway
Smoking; second-hand smoke; smoke inhalation
Retained secretions; secretions in the bronchi; exudate in the alveoli; excessive mucus; airway spasm; foreign body in airway; presence of artificial airway
Chronic obstructive pulmonary disease (COPD); asthma; allergic airways; hyperplasia of the bronchial walls; neuromuscular dysfunction; infection
Diminished or adventitious breath sounds (rales, crackles, rhonchi, wheezes) Cough, ineffective or absent; sputum Changes in respiratory rate and rhythm Difficulty vocalizing Wide-eyed; restlessness Orthopnea Cyanosis
The patient will
- · Maintain patent airway.
- · Have no adventitious breath sounds.
- · Have a normal chest x-ray.
- · Have an oxygen level in normal range.
- · Breathe deeply and cough to remove secretions.
- · Expectorate sputum.
- · Demonstrate controlled coughing techniques.
- · Have adequate ventilation.
- Demonstrate skill in conserving energy while attempting to clear airway.
- · State understanding of changes needed to diminish oxygen demands.
Interventions and Rationales:
Assess respiratory status at least every 4 hr or according to established standards. Obstruction in the airway leads to atelectasis, pneumonia, or respiratory failure. Monitor arterial blood gases values and hemoglobin levels to assess oxygenation and ventilatory status. Report deviations from baseline levels; oxygen saturation should be higher than 90%.
Monitor sputum, noting amount, odor, and consistency. Sputum amount and consistency may indicate hydration status and effectiveness of therapy. Foul-smelling sputum may indicate respiratory infection.
Turn patient every 2 hr; place the patient in lateral, sitting, prone, and upright positions as much as possible for maximal aeration of lung fields and mobilization of secretions.
Mobilize patient to full capabilities to facilitate chest expansion and ventilation.
Suction, as ordered, to stimulate cough and clear airways. Be alert for progression of airway compromise. Perform postural drainage, percussion, and vibration to facilitate secretion movement.
Provide adequate humidification to loosen secretions. Administer expectorants, bronchodilators, and other drugs, as ordered, and monitor effectiveness. Provide bronchodilator treatments before chest physiotherapy to optimize results of the treatment. Administer oxygen, as ordered, to promote oxygenation of cells throughout the body.
Teach patient an easily performed cough technique to clear airway without fatigue.
Avoid placing patient in a supine position for extended periods to prevent atelectasis.
When helping the patient cough and deep-breathe, use whatever position best ensures cooperation and minimizes energy expenditure, such as high Fowler’s position or sitting on side of bed. Such positions promote chest expansion and ventilation of basilar lung fields.
Encourage adequate water intake (3–4 qt [3–4 L/day]) to ensure optimal hydration and loosening of secretions, unless contraindicated. Encourage sputum expectoration to remove pathogens and prevent spread of infection. Provide tissues and paper bags for hygienic disposal.
If conservative measures fail to maintain partial pressure of arterial oxygen (PaO2) within an acceptable range, prepare for endotracheal intubation, as ordered, to maintain artificial airway and optimize PaO2 Level
Cigna, J. A., & Turner-Cigna, L. M. (2005, September). Rehabilitation for the home care patient with COPD. Home Healthcare Nurse, 23(9), 578–584.