NANDA Definition: Inability to clear secretions or obstructions from the respiratory

tract to maintain airway patency

Maintaining a patent airway is vital to life. Coughing is the main mechanism for clearing
the airway. However, the cough may be ineffective in both normal and disease states
secondary to factors such as pain from surgical incisions/ trauma, respiratory muscle
fatigue, or neuromuscular weakness. Other mechanisms that exist in the lower
bronchioles and alveoli to maintain the airway include the mucociliary system,
macrophages, and the lymphatics. Factors such as anesthesia and dehydration can affect
function of the mucociliary system. Likewise, conditions that cause increased production
of secretions (e.g., pneumonia, bronchitis, and chemical irritants) can overtax these
mechanisms. Ineffective airway clearance can be an acute (e.g., postoperative recovery)
or chronic (e.g., from cerebrovascular accident [CVA] or spinal cord injury) problem.
Elderly patients, who have an increased incidence of emphysema and a higher prevalence
of chronic cough or sputum production, are at high risk.

Defining Characteristics:

• Abnormal breath sounds (crackles, rhonchi, wheezes)

• Changes in respiratory rate or depth
• Cough
• Hypoxemia/cyanosis
• Dyspnea
• Chest wheezing
• Fever
• Tachycardia

Related Factors:

• Decreased energy and fatigue

• Ineffective cough
• Tracheobronchial infection
• Tracheobronchial obstruction (including foreign body aspiration)
• Copious tracheobronchial secretions
• Perceptual/cognitive impairment
• Impaired respiratory muscle function
• Trauma

Expected Outcomes

• Patient's secretions are mobilized and airway is maintained free of secretions, as

evidenced by clear lung sounds, eupnea, and ability to effectively cough up
secretions after treatments and deep breaths.

Plan of Care for:

Nursing Diagnosis: Ineffective airway clearance

Related Factors:

• Decreased energy and fatigue

• Ineffective cough
• Tracheobronchial infection
• Tracheobronchial obstruction (including foreign body aspiration)
• Copious tracheobronchial secretions
• Perceptual/cognitive impairment
• Impaired respiratory muscle function
• Trauma

NOC Outcomes (Nursing Outcomes Classification)

Suggested NOC Labels

NIC Interventions (Nursing Interventions Classification)

Suggested NIC Labels

• Airway Management
• Airway Suctioning

Ongoing Assessment

• Assess airway for patency.--Maintaining the airway is always the first priority,
especially in cases of trauma, acute neurological decompensation, or cardiac
arrest.
• Auscultate lungs for presence of normal or adventitious breath sounds, as in the
following:
o Decreased or absent breath sounds These may indicate presence of mucus
plug or other major airway obstruction.
o Wheezing These may indicate increasing airway resistance.
o Coarse sounds These may indicate presence of fluid along larger airways.
• Assess respirations; note quality, rate, pattern, depth, flaring of nostrils, dyspnea
on exertion, evidence of splinting, use of accessory muscles, and position for
breathing.--Abnormality indicates respiratory compromise.
• Assess changes in mental status.--Increasing lethargy, confusion, restlessness,
and/or irritability can be early signs of cerebral hypoxia.
• Assess changes in vital signs and temperature.--Tachycardia and hypertension
may be related to increased work of breathing. Fever may develop in response to
retained secretions/atelectasis.
 • Assess cough for effectiveness and productivity.--Consider possible causes for
ineffective cough (e.g., respiratory muscle fatigue, severe bronchospasm, or thick
tenacious secretions).
• Note presence of sputum; assess quality, color, amount, odor, and consistency.
This may be a result of infection, bronchitis, chronic smoking, or other condition.
A sign of infection is discolored sputum (no longer clear or white); an odor may
be present.

Send a sputum specimen for culture and sensitivity as appropriate. Respiratory

infections increase the work of breathing; antibiotic treatment is indicated.
• Monitor arterial blood gases (ABGs).--Increasing PaCO2 and decreasing PaO2 are
signs of respiratory failure.
• Assess for pain.--Postoperative pain can result in shallow breathing and an
ineffective cough.
• If patient is on mechanical ventilation, monitor for peak airway pressures and
airway resistance.--Increases in these parameters signal accumulation of
secretions/ fluid and possibility for ineffective ventilation.
• Assess patient’s knowledge of disease process.--Patient education will vary
depending on the acute or chronic disease state as well as the patient’s cognitive
level.

Therapeutic Interventions

• Assist patient in performing coughing and breathing maneuvers.--These improve

productivity of the cough.
• Instruct patient in the following:
o Optimal positioning (sitting position)
o Use of pillow or hand splints when coughing
o Use of abdominal muscles for more forceful cough
o Use of quad and huff techniques
o Use of incentive spirometry
o Importance of ambulation and frequent position changes--Directed
coughing techniques help mobilize secretions from smaller airways to
larger airways because the coughing is done at varying times. The sitting
position and splinting the abdomen promote more effective coughing by
increasing abdominal pressure and upward diaphragmatic movement.
• Use positioning (if tolerated, head of bed at 45 degrees; sitting in chair,
ambulation).--These promote better lung expansion and improved air exchange.
• If patient is bedridden, routinely check the patient’s position so he or she does not
slide down in bed.--This may cause the abdomen to compress the diaphragm,
which would cause respiratory embarrassment.
• If cough is ineffective, use nasotracheal suctioning as needed:

- Explain procedure to patient.

o Use soft rubber catheters. This prevents trauma to mucous membranes.

 o Use curved-tip catheters and head positioning (if not contraindicated).
These facilitate secretion removal from a specific side (right versus left
lung).
o Instruct the patient to take several deep breaths before and after each
nasotracheal suctioning procedure and use supplemental oxygen as
appropriate. This prevents suction-related hypoxia.

- Stop suctioning and provide supplemental oxygen (assisted breaths by

Ambu bag as needed) if the patient experiences bradycardia, an increase in
ventricular ectopy, and/or desaturation.

o Use universal precautions: gloves, goggles, and mask as appropriate. If

sputum is purulent, precautions should be instituted before receiving the
culture and sensitivity report.

--Suctioning is indicated when patients are unable to remove secretions from the
airways by coughing because of weakness, thick mucus plugs, or excessive mucus
production.

• Institute appropriate isolation precautions for positive cultures (e.g., methicillin-

resistant Staphylococcus aureus [MRSA] or tuberculosis).
• Use humidity (humidified oxygen or humidifier at bedside).--This loosens
secretions.
• Encourage oral intake of fluids within the limits of cardiac reserve.--Increased
fluid intake reduces the viscosity of mucus produced by the goblet cells in the
airways. It is easier for the patient to mobilize thinner secretions with coughing.
• Administer medications (e.g., antibiotics, mucolytic agents, bronchodilators,
expectorants) as ordered, noting effectiveness and side effects.
• For patients with chronic problems with bronchoconstriction, instruct in use of
metered-dose inhaler (MDI) or nebulizer as prescribed.
• Consult respiratory therapist for chest physiotherapy and nebulizer treatments as
indicated (hospital and home care/rehabilitation environments). Chest
physiotherapy includes the techniques of postural drainage and chest percussion
to mobilize secretions in smaller airways that cannot be removed by coughing or
suctioning.

Coordinate optimal time for postural drainage and percussion (i.e., at least 1 hour
after eating). This prevents aspiration.
• For patients with reduced energy, pace activities. Maintain planned rest periods.
Promote energy-conservation techniques.--Fatigue is a contributing factor to
ineffective coughing.
• For acute problem, assist with bronchoscopy.--This obtains lavage samples for
culture and sensitivity, and removes mucus plugs.
• If secretions cannot be cleared, anticipate the need for an artificial airway
(intubation). After intubation:
 - Institute suctioning of airway as determined by presence of adventitious
sounds.

o Use sterile saline instillations during suctioning. This helps facilitate

removal of tenacious sputum.

Education/Continuity of Care

• Demonstrate and teach coughing, deep breathing, and splinting techniques.--

Patient will understand the rationale and appropriate techniques to keep the
airway clear of secretions.
• Instruct patient on indications for, frequency, and side effects of medications.
• Instruct patient how to use prescribed inhalers, as appropriate.
• In home setting, instruct caregivers regarding cough enhancement techniques and
need for humidification.
• Instruct caregivers in suctioning techniques. Provide opportunity for return
demonstration. Adapt technique for home setting.
• For patients with debilitating disease being cared for at home (CVA,
neuromuscular impairment, and others), instruct caregiver in chest physiotherapy
as appropriate.--This may also be useful for the patient with bronchiectasis who is
ambulatory but requires chest physiotherapy because of the volume of secretions
and the inability to adequately clear them.
• Teach patient about environmental factors that can precipitate respiratory
problems.
• Explain effects of smoking, including second-hand smoke.--Smoking contributes
to bronchospasm and increased mucus production in the airways.
• Refer patient and/or significant others to smoking-cessation group, as appropriate,
and discuss potential use of smoking-cessation aids (e.g., Nicorette Gum,
Nicoderm, or Habitrol) to wean off the effects of nicotine.
• Instruct patient on warning signs of pending or recurring pulmonary problems.
• Refer to pulmonary clinical nurse specialist, home health nurse, or respiratory
therapist as indicated.

Nursing Diagnosis:

Related Factors:

Risk Factors: