A tracheostomy is a surgical opening in the neck created to place a tube directly into the windpipe (trachea) to secure an airway or aid breathing. Because the tube bypasses the nose and throat—the body’s natural filters, warmers, and humidifiers—the body naturally produces secretions. Excess mucus is the airway’s response to irritation or the lack of proper conditioning of inhaled air, and managing this mucus is a routine aspect of tracheostomy care.
Optimizing the Airway Environment
The most effective strategy for managing tracheostomy secretions is ensuring the air entering the lungs is adequately conditioned. When the upper airway is bypassed, inhaled air is often cooler and drier, causing the body to produce more mucus as a defense mechanism. This dry air also thickens and crusts secretions, making them difficult to mobilize and remove.
Humidification is provided using devices like heat and moisture exchangers (HMEs) or specialized trach collars that deliver a fine mist. HMEs, sometimes called “artificial noses,” capture moisture and heat from the patient’s exhaled breath and return it to the inhaled air. This helps maintain the thin consistency of secretions and preserves the function of the cilia, which naturally move mucus out of the airways. The optimal relative humidity level for inspired air is between 40 to 60 percent.
Internal hydration status is important for maintaining thin mucus. When the body is dehydrated, it draws fluid from mucus, causing it to become thick, sticky, and more likely to plug the tracheostomy tube. Maintaining sufficient fluid intake, whether through drinking water or intravenous fluids, directly affects the viscosity of respiratory secretions.
Reducing mucus production also involves controlling environmental irritants. Airborne particles like dust, smoke, aerosol sprays, and strong perfumes stimulate the tracheal lining to produce excessive mucus. Avoiding these known irritants minimizes the inflammatory response, helping to keep secretion volume low.
Essential Active Clearance Techniques
Once secretions accumulate, their removal is necessary to prevent airway obstruction. The body’s natural cough is the most effective mechanism for moving mucus toward the tube opening. Caregivers should encourage deep breathing and assisted coughing, which involves applying pressure to the abdomen or chest during the cough to maximize force and mobilize secretions.
When coughing is insufficient, suctioning is the primary method for active clearance. Suctioning should only be performed when necessary, such as when secretions are visible, audible, or if there are signs of respiratory distress. The catheter should be inserted without applying suction until the patient coughs or resistance is met, then withdrawn slightly before applying intermittent suction.
The duration of each suction pass must be limited to no more than 10 to 15 seconds to prevent oxygen depletion. The vacuum pressure should be set to a low or medium range (80 to 120 mmHg for adults) to minimize trauma to the tracheal lining. Using a sterile technique for the catheter and maintaining a clean field for the equipment is necessary to prevent introducing infection into the lower airway.
For thick plugs that resist clearance, a small volume of sterile normal saline may be instilled directly into the tracheostomy tube before suctioning. This practice, known as saline instillation, helps loosen the mucus plug but should only be performed under medical guidance. Allowing the patient to rest for at least 30 seconds between suction passes is necessary to restore oxygen levels.
Systemic and Pharmacological Supports
Beyond environmental control and physical removal, pharmacological agents known as mucolytics are used to manage the quality and quantity of secretions. Mucolytics are prescribed to change the chemical structure of mucus, reducing its viscosity. These medications, such as acetylcysteine or dornase alfa, are administered via a nebulizer, which carries the drug directly into the airways.
Nebulized mucolytics break the disulfide bonds within mucus proteins, making secretions thinner and easier to clear. These treatments require a prescription and medical supervision to ensure appropriate dosing and monitor for side effects. Hypertonic saline, a salt solution stronger than the body’s own, can also be nebulized to draw water into the airway lining, helping to thin secretions.
Addressing underlying medical conditions can also significantly reduce excess secretion production. For instance, uncontrolled allergies, which lead to post-nasal drip, can contribute to mucus accumulation in the trachea. Similarly, managing gastroesophageal reflux disease (GERD) prevents stomach acid from irritating the airways, which would otherwise trigger a defensive increase in mucus.
Dietary adjustments may be helpful, though the link between specific foods and mucus production is individualized. Some individuals report reduced secretions after limiting dairy products. Maintaining a balanced diet rich in vitamins and nutrients supports overall respiratory health and the body’s ability to manage inflammation.
Recognizing Secretion-Related Complications
A change in the characteristics of tracheostomy secretions can signal a serious medical problem. Secretions that change from their normal clear or white color to yellow, green, or brown may indicate a bacterial infection. A foul odor accompanying the mucus is another sign of infection that requires immediate medical assessment.
The presence of blood, such as bright red or rust-colored secretions, should be reported to a healthcare provider. While a small amount of pink-tinged mucus can result from minor irritation due to suctioning, continuous or significant bleeding could indicate trauma or a serious complication within the airway.
Signs of an obstructed airway require emergency action, as they indicate a potential mucus plug. These signs include a whistling noise upon breathing, a sudden increase in shortness of breath, or a gurgling sound that cannot be cleared. The inability to pass a suction catheter through the tube, or an immediate drop in oxygen saturation levels, are indicators of a dangerous blockage.
If a fever develops alongside a change in secretion color or volume, a healthcare provider should be contacted. Other warning signs include persistent difficulty clearing the airway, a change in the patient’s level of consciousness, or increased anxiety or restlessness. These symptoms suggest the respiratory system is under stress and the current management plan is inadequate.