How do you assess a patient with lots of phlegm in their throat?

[kate2827]

Hello. 

I had a patient with very gurgly breathing. Lots of phlegm and ineffective cough, dysphasia. I tried to listen to lung sound but due to gurgling, it was hard to know if that is crackle or not. Are there any tips? Patient was old and frail, cannot really take deep breath too. 

Thank you in advance! 

[Been there,done that, ASN, RN]

Your patient needs to be suctioned, before they drown in their own secretions.  Hold them NPO. Notify the provider stat. I would expect orders for a chest xray and a swallow study.

[hppygr8ful, ASN, RN, EMT-I]

What BTDT said!

 

[vampiregirl, BSN, RN]

Agree with above posters recommendations for most settings. 

I work in hospice though so "gurgly" breathing is not uncommon with some disease process progressions (either cardiac/ respiratory or aspiration).

SpO2, HR, RR can be helpful. Does the patient's respiratory status improve with elevation of HOB? New activity intolerance or increase from baseline? Typically my biggest concern is if the patient is dyspneic or respirations are labored.

As for differentiating crackles from rhonchi, I typically listen posteriorly at the bases to midline to assess for crackles although sometimes this isn't helpful with shallow respirations. I also assess if there is any clearance of rhonchi with cough.

Noting presence (or absence) of edema (peripheral, peri-orbital or abdominal) is also helpful. 

So, I guess what I'm really trying to say is that it depends on the setting and patient goals. Regardless though, it's great that you are asking questions like this and appreciate the importance of good assessment!

 

[KathyDay]

Early last month when my husband was on comfort care (esophageal cancer), I expressed my concern about his ineffective cough for the cracking in his throat.  His nurse said they give medications for secretions...which were obviously not working.  Isn't helping the patient to keep a clear airway (suctioning) part of comfort care.  I was horrified...he struggled and groaned to try and clear his throat and could not.  The morning he died, his nurse told me that she did try to suction him earlier in the morning.  He needed it the day before. 

[mtmkjr, BSN]

KathyDay said:

Early last month when my husband was on comfort care (esophageal cancer), I expressed my concern about his ineffective cough for the cracking in his throat.  His nurse said they give medications for secretions...which were obviously not working.  Isn't helping the patient to keep a clear airway (suctioning) part of comfort care.  I was horrified...he struggled and groaned to try and clear his throat and could not.  The morning he died, his nurse told me that she did try to suction him earlier in the morning.  He needed it the day before. 

So sorry about your husband - that must have been so difficult. 

Which brings up the question whether this is end of life secretions or not... Because the care of the patient would be different

[Been there,done that, ASN, RN]

KathyDay said:

Early last month when my husband was on comfort care (esophageal cancer), I expressed my concern about his ineffective cough for the cracking in his throat.  His nurse said they give medications for secretions...which were obviously not working.  Isn't helping the patient to keep a clear airway (suctioning) part of comfort care.  I was horrified...he struggled and groaned to try and clear his throat and could not.  The morning he died, his nurse told me that she did try to suction him earlier in the morning.  He needed it the day before. 

I am so sorry you and your husband had to go through that. I  wish you peace.

[delrionurse]

As mentioned, turn pt to the side and suction them.  A little physio on the back helps also while suctioning. Sometimes when you turn a patient, you can hear the crackles  more clearly after. If the patient is  stationary for a long time, that can cause the secretions to be immobile (and you won't hear anything) and build up if that makes sense.