Mucus Management: How to lose the ooze and improve swallowing

As Speech-Language Pathologists, we are often at the forefront of managing secretions in our patients with dysphagia, a critical aspect of airway protection and overall health. Because our role has become intimately involved with the oral cavity, by definition, we come across the inevitable issue of mucus management. Unruly secretions are a big part of what we manage because when they’re a problem, they seem to be the biggest problem. So, what’s the secret to secretions? Want the run down? Here’s the thick and dirty:

Mucus often gets a bad rap. We tend to ignore it until it becomes a problem – when it's thick, sticky, takes on alarming colors, or makes an unwelcome appearance, say, during a cold or after choosing unwisely spicy food on a date. But mucus isn't just in our noses and throats; it's a crucial player throughout the body. It lines our entire respiratory tract, from the mouth down to the lungs' tiny air sacs, and also plays a vital role in our digestive system and other functions.

Mucus has several key jobs. It acts like flypaper, trapping foreign particles. It forms a selective barrier, guarding the delicate cells beneath. It serves as a lubricant, helping the tiny hairs (cilia) in our airways move properly. And, it acts like a river delivery system for immune defenses, like white blood cells, to combat germs. Maybe the next time you reach for a tissue, you'll have a bit more appreciation for this hardworking substance. Or maybe not...

When Mucus Misbehaves

Typically, mucus is mostly water (around 90-99%), giving it a relatively thin consistency. However, as we all know from experience, its viscosity, volume, and even color can change significantly during illness. When you're sick and feel congested, unable to clear your airways, it's tempting to blame the mucus itself. But really, it's just trying to do its job – perhaps a bit too enthusiastically. 

During an infection, mucus thickens as it becomes loaded with immune cells, defensive chemicals, and the germs it's fighting. In the case of allergies, the body overreacts to allergens, leading to an excessive production (hypersecretion) of mucus, making the situation feel worse than the initial trigger. This is particularly relevant for individuals with dysphagia, whose compromised swallow and cough may already be insufficient to clear their airways. It’s like a drowning victim grabbing a ten-pound weight instead of a life preserver. These secretions, when immobile, eventually thicken over time like concrete, plugging up the airways and removing the space normally dedicated to airflow. 

Further, the airway's cleaning crew carrying countless broomsticks (the cilia) can become impaired. Factors like infections, smoking, or chronic respiratory conditions (such as COPD or cystic fibrosis) can damage these cilia, stopping their coordinated sweeping motion. This paralysis means mucus, along with trapped debris, doesn't get moved up and out effectively. So, you end up with more mucus that is also thicker and harder to expel.

Even external factors play a role. Cold, dry air can trigger increased mucus production as the body tries to add moisture to the air being inhaled. This is similar to why individuals with a tracheostomy often produce more mucus; the trach tube bypasses the nose and mouth, which normally warm, filter, and humidify air before it reaches the lungs. And don't forget hydration–  Since mucus is primarily water, dehydration makes it thicker and more difficult to manage.

Why Mucus Management Matters

Excessive or thick mucus isn't just inconvenient; it can pose serious health risks. It can obstruct airways, potentially leading to breathing difficulties or even suffocation. Additionally, when thick mucus hinders the body's natural filtering and clearing mechanisms, it creates an environment where germs can thrive, increasing the risk of lung infections. This can initiate a vicious cycle: more inflammation leads to more secretions, which further impair breathing and attempts to clear the airway.

What are we doing wrong? 

While some medications like scopolamine or certain antihistamines reduce secretions, they can sometimes backfire by making the remaining mucus thicker and stickier, thus harder to clear. A more effective approach often involves using medications that help the body manage mucus naturally. These can include bronchodilators to open airways, steroids to reduce inflammation, and mucolytics or expectorants to thin the secretions. This strategy focuses on helping the body's own clearance mechanisms work better – like finding an alternate, less congested route instead of just honking in traffic.

Direct intervention, like suctioning, is another tool. Suctioning, whether in the trachea or the back of the throat (oropharynx), is essentially introducing a vacuum into a very sensitive airway. Is it needed sometimes? Absolutely. Is it needed constantly? Usually not. Will it make the problem worse if done too frequently? Most definitely.

So, how do we differentiate? When secretions are genuinely thick, difficult to manage, and copious, suctioning is vital to maintain a clear, open airway – you know, for those relatively important functions like… breathing. However, for some patients, suctioning might become routine, used more for convenience or perceived comfort rather than a strict necessity.

Alternatives

What are the alternatives? Instead of immediately resorting to suctioning, or perhaps letting a patient frequently use a Yankauer suction tool themselves, consider education first. Can we teach the patient to produce a strong, effective cough or a forceful throat clear? Can we use expiratory muscle strength training to strengthen the cough? Can effortful swallowing help manage the secretions? These techniques empower the patient to use their own physiology. For patients with a tracheostomy tube, it's worth evaluating if they are suitable for a speaking valve. A speaking valve allows for upper airway airflow and the subglottic pressure needed for a natural and effective cough to expel secretions from the airway. 

What else can we do? After discussing with the physician, consider some of the following interventions if medically cleared and in collaboration with the respiratory team: 

• Hydrators/Mucolytics (E.g., Mucinex) to loosen up the secretions

• Bronchdilation: to open up the airways (Thick stuff gets stuck in small tubes!)

• Hydration to loosen up secretions by hydrating the patient through drinking more or IV fluids as needed.

• Chest Physiotherapy to break up that “cement” 

• Breathing techniques: A non-pharmacological technique taught by respiratory therapists to more easily expel those pesky secretions.

Final Thoughts on Phlegm

Mucus is undoubtedly beneficial, serving critical protective functions. But it’s easy to forget its benefits when we have too much of it. While thick or excessive mucus might be a mere annoyance for healthy individuals, for patients with compromised health, it can have severe consequences. Therefore, advocating for appropriate mucus management strategies, including thoughtful use of interventions like suctioning (as needed only!) alongside supportive measures and patient education, is a huge part of our role as SLPs. And we’re not in this alone. Collaborating with our interdisciplinary team is essential to managing a complex and multifaceted issue such as secretion management. Doctors, nurses, and respiratory therapists can lend their knowledge, experience, and expertise to help us reach our goal: To help the patient breathe and eat the things they love again.

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References: 

CDC. (2006). Principles of Epidemiology in Public Health Practice, Third Edition: An Introduction to Applied Epidemiology and Biostatistics. Centers for Disease Control and Prevention.

Lai, S. K., Wang, Y. Y., Wirtz, D., & Hanes, J. (2009). Micro- and macrorheology of mucus. Advanced drug delivery reviews, 61(2), 86–100.

Lieleg, O., & Ribbeck, K. (2012). Biological hydrogels as selective diffusion barriers. Trends in cell biology, 21(9), 543-551.

Mall, M. A. (2008). Role of Cilia, Mucus, and Airway Surface Liquid in Mucociliary Clearance: Past, Present, and Future. Journal of internal medicine, 263(2), 171-177.

Shen, Y., et al. (2018). Mucus, Mucins, and cystic fibrosis. Pediatric pulmonology, 53(Suppl 1), S17-S28.

Smith, T. G., et al. (2014). Therapeutic benefit of lavage and mucolytics in cystic fibrosis and other muco-obstructive diseases. Journal of Cystic Fibrosis, 13(2), 133-140.

Zheng, C., & Clements, J. D. (2018). Regulation of Mucosal Immunity and Innate Host Defense by LT and CT Adjuvants. Frontiers in immunology, 9, 1487.