Managing Persistent Cough After Tracheostomy: Concerns and Solutions

Persistent coughing after tracheostomy?

Hello, my mother underwent a tracheostomy in mid-October, and since then she has been experiencing persistent coughing with phlegm.
I understand that tracheostomy patients often have increased secretions, but does this mean they will continue to cough until the tube is removed? She frequently coughs to the point of having headaches, yet during her follow-up visit, the pulmonologist stated that medication was not necessary.
Is it true that she can manage without medication?
Additionally, I purchased a suction machine and a steam inhaler for her, but she dislikes chest percussion and is reluctant to use the steam inhaler (although I have to persuade her to use it).
Recently, her tracheostomy tube became obstructed with phlegm, and I was unable to insert the suction catheter.
What should I do in this situation?
Furthermore, my mother had surgery for a wrist fracture in mid-October, and during general anesthesia, it was discovered that her trachea was narrowed, making intubation impossible (she had a tracheostomy 30 years ago).
They used a mask for anesthesia, but after the surgery, she experienced respiratory distress and was admitted to the intensive care unit.
The physician indicated that a tracheostomy was necessary for her to breathe.
We had informed them beforehand that she had a history of tracheostomy.
Shouldn't the physician have checked for tracheal narrowing prior to intubation if general anesthesia was required? It seems that the attempt to intubate may have caused further injury to the narrowed area, leading to her respiratory difficulties.
I am unsure if this constitutes negligence or if this is standard procedure.

Fei Yiliao Renyuan de Eva, 20~29 year old female. Ask Date: 2005/11/05

Dr. Zhuang Ziyi reply Pulmonology

Hello, both normal individuals and patients produce secretions in the respiratory tract daily.
The ciliary movement of the respiratory epithelial cells transports these secretions towards the trachea and vocal cords, ultimately leading to them being coughed out or swallowed into the stomach via the esophagus.
This is the reason for mucus formation.
Patients may experience an increase in mucus production due to lung infections or diminished cough reflex.
After undergoing tracheostomy, mucus is expelled through the tracheostomy tube and cannot be swallowed into the stomach, leading to the perception of increased mucus volume.
If cough suppressants are used, they may further impair the patient's ability to cough, resulting in mucus accumulation in the bronchi and bronchioles, potentially causing a new wave of infection.
Therefore, such patients typically do not routinely use cough suppressants.

Another possible reason for persistent coughing in tracheostomy patients could be improper positioning of the tracheostomy tube tip, which may irritate the trachea and cause coughing.
This can be diagnosed through chest X-rays or bronchoscopy.
Tracheostomy patients should use a humidifier because they breathe through the tracheostomy tube and cannot regulate the temperature and humidity of the inhaled air through the nasal passages.
This often leads to excessively dry air, causing secretions in the respiratory tract to dry out, which can severely obstruct the tube and lead to respiratory distress.
There are two ways to improve this situation: one is to attach an artificial nose to the tracheostomy tube, and the other is to use a humidifier.
The downside of using an artificial nose is that the patient must remove it when they need to cough, which could lead to tube obstruction and respiratory distress if the patient is confused.
The downside of using a humidifier is that the patient may feel irritation in the respiratory tract, leading to persistent coughing and increased discomfort.
If a patient has previously undergone tracheostomy, it could potentially cause tracheal stenosis; however, if the patient had no respiratory symptoms preoperatively, it indicates that they have adapted to this physiological condition and may not require further examination.
If the patient does exhibit respiratory symptoms, pulmonary function tests can generally be arranged before surgery to clarify the cause of the symptoms.
Typically, patients who are extubated immediately after anesthesia induction do not experience tracheal stenosis or vocal cord edema.
In cases where a patient experiences respiratory distress post-surgery and cannot be intubated, emergency tracheostomy is the only procedure that can effectively protect the patient's airway.
Whether there has been medical negligence should be assessed by the judicial authorities handling medical disputes.
Sincerely, Dr.
Zhuang Ziyi, Internal Medicine.

Reply Date: 2005/11/05

More Info

Managing persistent cough after a tracheostomy can be a challenging situation for both patients and caregivers. Your concerns about your mother's ongoing cough and the production of phlegm are valid, especially considering the physical toll that constant coughing can take on her body.
Firstly, it’s important to understand that after a tracheostomy, patients often experience increased secretions. This is due to the bypassing of the upper airway, which normally helps to humidify and filter the air. Without this natural mechanism, the air entering the lungs can be drier, leading to thicker secretions that are harder to clear. This can result in a cycle of coughing as the body attempts to expel these secretions.
Regarding your question about whether tracheostomy patients will cough until the tube is removed, the answer is not necessarily. While it is common for patients to experience increased coughing and phlegm production, there are strategies to manage these symptoms effectively. Continuous coughing can indeed lead to fatigue and discomfort, including headaches from the strain of coughing.
Your mother's physician's decision not to prescribe cough medication may be based on the understanding that suppressing the cough reflex could lead to an accumulation of secretions, which can increase the risk of infection or airway obstruction. Instead, the focus should be on facilitating the clearance of secretions.
Using a suction machine is a good step, but it is crucial to ensure that it is used correctly and that your mother is comfortable with it. If she is resistant to using the suction device, it may be beneficial to explore other methods of secretion management. For instance, increasing humidity in the air she breathes can help thin the mucus, making it easier to expel. If she is reluctant to use a steam machine, consider alternatives like a humidifier in her room or using saline nasal sprays to keep her airways moist.

The issue of the tracheostomy tube becoming obstructed by phlegm is a common concern. Regular cleaning and maintenance of the tube are essential. If the tube is blocked, it may require immediate suctioning or, in some cases, replacement. If you find that you cannot insert the suction catheter, it may be necessary to consult with a healthcare professional for assistance.

As for the concerns surrounding the initial tracheostomy and the potential for airway narrowing, it is indeed a complex situation. In cases where a patient has a history of tracheostomy, it is standard practice for anesthesiologists to assess the airway thoroughly before any procedure requiring intubation. If there were indications of airway narrowing, further evaluation, such as imaging or a direct airway assessment, would typically be warranted. However, if the patient was asymptomatic prior to surgery, the decision may have been made based on the information available at the time.
If you feel that there was a lack of appropriate assessment or communication regarding your mother's airway status prior to her surgery, it may be beneficial to discuss these concerns with her healthcare team. Open communication can often clarify misunderstandings and provide reassurance about the care being provided.

In conclusion, managing persistent cough after a tracheostomy involves a multifaceted approach that includes ensuring adequate humidity, effective suctioning, and possibly exploring other supportive therapies. Continuous communication with healthcare providers is essential to address any concerns and optimize your mother's care. If symptoms persist or worsen, seeking further evaluation is crucial to ensure her safety and comfort.

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