| Strategy | How to Implement | Typical Dose / Setting | Key Pearls & Cautions |
|---|---|---|---|
| Heated-humidified HFNC | Large-bore nasal cannula connected to heated humidifier (37 °C) | 30–60 L min-1; FiO2 to keep SpO2 > 92 % | Restores 100 % RH, thins mucus & adds mild PEEP; watch for gastric distention |
| Systemic hydration | IV balanced crystalloids or encourage PO fluids if safe | Maintain euvolemia; avoid over-hydration in HF/ARDS | Dehydration is the easiest reversible “mucolytic” |
| Nebulised saline | In-line or mouthpiece nebuliser | 3–5 mL 0.9 % q4–6 h; step up to 3 % if secretions remain viscous | Hypertonic draws water into ASL; pre-treat with albuterol in reactive airways |
| N-acetylcysteine (N-AC) | Jet neb via mask or mouthpiece | 3 mL 10 % (or 1–2 mL 20 %) q4–6 h | Bronchospasm risk → give albuterol first; avoid in frank hemoptysis |
| Hypertonic saline 7 % | Nebulise as alternative/adjunct to N-AC | 3 mL q6–8 h | Monitor serum Na+ with frequent doses |
| Dornase alfa | Mouthpiece neb (off-label outside CF) | 2.5 mg q24 h | Consider for lobar collapse or DNA-rich sputum; expensive |
| Mechanical insufflation-exsufflation (MI-E / “Cough-Assist”) | Face-mask or mouthpiece interface | +40 / −40 cm H2O, 3–5 cycles × 3–6 sets q4–6 h | Continuous SpO2/ECG; stop if SpO2 < 90 % or haemodynamic drop |
| OPEP devices (Acapella®, Aerobika®) | Active exhalations through device followed by huff-cough | 10–20 breaths × 4–6 sessions day-1 | Small, patient-controlled; contraindicated if unable to form good seal |
| Manual/air-stack cough | Caregiver timed abdominal thrust or air-stack via resuscitation bag | 3–5 assisted coughs per session; repeat q4 h | Simple for neuromuscular disease; watch for rib fracture in frail pts |
| Chest physiotherapy (CPT) | Postural drainage, percussion & vibration | Each lung segment 3–5 min q2 h | Combine with turns/early sitting for best effect |
| Deep oropharyngeal suction | Yankauer or large-bore suction catheter | PRN & at least q2 h; set suction 80–120 mm Hg | Avoid mucosal trauma; pre-oxygenate if severe hypoxaemia |
| Early mobilisation | Bed-to-chair, ambulation as tolerated | N/A | Enhances cephalad mucus movement & prevents atelectasis |
| NIV/BiPAP “boost” sessions | Full-face mask between clearance sessions | IPAP 10–14 / EPAP 5–6 cm H2O | Helpful for hypercapnia or lobar collapse; monitor gastric insufflation |
| Flexible bronchoscopy | Diagnostic & therapeutic lavage/suction | As indicated if clearance fails within 6–12 h | Low threshold in lobar opacity or hypoxaemia; requires procedural sedation |
| Analgesia / lighter sedation | Limit opioids; use multimodal pain control | N/A | Excess sedation blunts cough; pain inhibits deep breaths |
| Head-of-bed ≥ 30° | Maintain semi-Fowler position; side-to-side rotation | N/A | Reduces aspiration & promotes drainage |
| Culture-directed antibiotics | Obtain sputum culture if purulent; start/adjust antibiotics accordingly | Per culture & local guidelines | Treats bronchitis/pneumonia driving secretion load |
Tip — Combine 2–3 complementary strategies (e.g., HFNC + N-AC + MI-E) and reassess work of breathing and chest imaging every 6–12 h. Escalate to bronchoscopy or NIV if lobar collapse or CO2 retention persists.
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