How Does Salt Water Work To Thin Secretions?

I don’t doubt that hypertonic saline can help some patients clear stubborn, thick secretions. I’ve seen the studies showing that it works wonders for people with bronchiectasis—those who constantly deal with thick mucus. And yes, studies show it can help with COPD, but let’s be honest, the results aren’t anywhere near as dramatic as they are for bronchiectasis patients.

And here's where the problem starts, folks. It's these studies that have the medical community on this hypertonic saline kick. Now, don't get me wrong—hypertonic saline (or what I like to call saltwater) definitely has its place, but let's not get carried away. We don’t exactly see bronchiectasis patients walking through our doors every day, but doctors? Well, they're regularly ordering hypertonic saline for just about anyone who’s coughing. 

In fact, I’ve had days recently when all of my patients are on a regimen of Albuterol/Duoneb mixed with hypertonic saline. Throw in a dose of Pulmicort (which, by the way, seems to be another "kick" going around the medical community—I'll tackle that one later) and you’ve got a full-blown treatment cocktail that keeps the RT in the room for too long. 

So, in theory here’s how it works, folks. This saltwater solution has a high concentration of salt—so much that it creates an osmotic effect. It pulls water into the mucus, thinning it out and making it less sticky. So, when that thick mucus starts to loosen up, the body can more easily expel it. And when the airways clear up, what happens? You get that productive cough, the body clears out the gunk, and the patient can breathe easier.

But here’s the question—if the patient’s already coughing up the mucus on their own, and already breathingi easy, why throw more saltwater into the mix? Shouldn’t we be a bit more strategic about when and why we use this treatment? Just a thought.

Author links open overlay panel

Are Docs Over prescribing Hypertonic Saline (Salt Water)

Let’s revisit something I mentioned the other day: "X-rays can help a doctor determine if hypertonic solution is necessary." Now, if you’ve been paying attention, you know that doctors are now looking at X-rays to decide when to order hypertonic saline—what I like to call "silly saltwater treatments." And while that’s part of the picture, it’s not the whole story.

Another argument for prescribing hypertonic saline comes when the patient is producing secretions. The thinking goes, "This patient’s coughing up secretions, so we need to order hypertonic saline."

But hold on a second. If the patient is already clearing secretions on their own, isn’t that a good sign? The body’s doing its job, right? So why in the world would you want to make more secretions for them to deal with? Doesn’t that sound a bit counterproductive?

It’s a question worth asking. What do you think—does this logic make sense, or are we just complicating things for the sake of it?

My Dad Introduced us to CHiPs

Some of my fondest childhood memories revolve around TV nights with my family. One such night, a seemingly small decision by my dad forever altered our Saturday night traditions and introduced us to the thrilling world of CHiPs.

It was a typical evening in our home. We kids were sprawled on the floor, lying over the freshly vacuumed, dark carpet. My mom sat behind us in her recliner, perhaps holding one of my younger siblings. Bobby, my older brother, and David, a year younger, were to my right as we gathered around the old 1970s TV. It was one of those big, clunky sets—you could even smell the warm electronics if you sat close enough. We called it the "boob tube," as a playful nod to its bygone nickname.

That night, we were watching Wonder Woman. Mom didn’t care what we watched; she was lost in her own world, enjoying the serenity of being with her boys while holding the baby on her lap. The glow of the TV seemed to reflect her peaceful aura.

Then Dad walked in. “Hey, there’s a really good show on the other channel,” he said, with that authoritative yet curious tone that only dads can pull off. As the commercial break rolled in, he grabbed the dial and switched the channel. “Do you want to check it out?” he asked.

Suddenly, the screen lit up with a high-speed chase, gleaming motorcycles, and the unmistakable swagger of Ponch and Jon from CHiPs. We were transfixed. Within moments, my brothers and I were leaning closer to the screen, our attention fully captured by this adrenaline-pumping, action-packed show.

Dad, sensing our immediate interest, probably couldn’t resist teasing us a little. “Or do you want to go back to that girl show?” he quipped. Without hesitation, and in complete unison, we all shouted something along the lines of, “No way! This is awesome!” From that night forward, we were hooked. I don’t think we ever missed another episode.

Wonder Woman still had its moments when CHiPs wasn’t on, but as fate would have it, Wonder Woman was canceled not long after. Meanwhile, CHiPs lived on, becoming a staple of our family’s Saturday nights. Ponch and Jon, with their camaraderie and daring adventures, felt like extended family members.

Looking back, it wasn’t just the show itself that made CHiPs special; it was the way my dad brought us together, introducing us to something new that we could all enjoy as a family. My favorite part of the show, though, was always the car crashes. Sometimes we waited through the whole show just to watch the big crash at the end of the episode. Or, even better, there was a crash right at the beginning—or the allusion of one coming up. The sight of watching cars tumble and crash and crunch was enjoyable—even though it’s not necessarily something we’d like to endure in reality. But, on TV, it was awesome.

It’s funny how a simple channel change could spark such lasting memories, but that’s the magic of family moments like these. They stay with you forever.

Can't Go Higher Than 6L on a Nasal Cannula? Poppycock!

We've had access to nasal cannulas since the 1960s, and early studies determined the best flow rates. Back then, it was believed that the maximum effective flow rate was 6 liters per minute (LPM). Higher flows, it was thought, wouldn’t make a difference. Well, since then, we’ve proved that idea is poppycock.

It happens too often. I get called to a patient's room because the SpO₂ is less than 88%. The nurse has already turned the nasal cannula up to 6 LPM and says, "I would have turned it up higher, but we were taught you can't go higher than 6 LPM on a nasal cannula."

So, I come in, turn the flow up to 8 LPM, and the SATs come up to 88%. The nurse looks surprised and says, "Oh, I was taught you can't do that."

Well, here's the thing: if it works, it works—so why not use it? But I still hear, "But we were told not to!"

And that’s the real issue. Somewhere along the way, outdated rules about flow limits became ingrained in practice without a full understanding of why. Traditional nasal cannulas are often recommended for flows up to 6 LPM to avoid discomfort or drying out the nasal passages. Additionally, as mentioned earlier, flows higher than 6 LPM were once believed to be ineffective. However, in acute situations, improving oxygenation must take priority. If increasing the flow achieves the desired result and the patient tolerates it, why not use it?

It's time to rethink rigid rules and prioritize what truly benefits the patient in the moment.

Today, nasal cannulas can deliver flows up to 15 liters per minute and even higher, often with great success. If you’re in a pinch with a patient on 6 LPM and their oxygen saturation (SAT) is still under 88%, there’s no reason you can’t turn the nasal cannula up to 8 or even 10 LPM. I’ve seen this work just fine.

Rather than immediately running to grab a mask or high-flow nasal cannula equipment, simply increasing the cannula flow rate beyond 6 LPM can buy you valuable time. This quick adjustment allows you to focus on stabilizing the patient or addressing other needs in the room. Once the patient is stable, or you’ve completed your immediate tasks, you can then set up the necessary high-flow equipment to provide the oxygen they need.

If you aren’t nearby and a nurse reports that the patient’s oxygen saturation (SAT) is low, you can reassure them it’s okay to turn up the nasal cannula flow as high as needed to maintain adequate SATs. This approach helps the patient in the moment while buying you time to get to them. Whether you’re finishing your current task or walking to the patient’s location, this quick action can make a significant difference in stabilizing the situation until you arrive.

In many cases, this approach can prevent unnecessary delays and help ensure better patient outcomes. So, let’s put the outdated 6 LPM myth to rest and use the tools we have with confidence.

Where is the evidence?

So I ask people for evidence supporting their argument. And sometimes they come back to me with a study showing that what they are saying is true. And I say to them, "I'm sorry, but one study is not science. Science is repeat studies showing the same thing." So I insist that, to support their argument, that they show me a second study showing the same thing. 

Sometimes the argument ends their, as it should. Although, too often the argument continues, as the person I am debating insists that the one study supports their claim. Sadly, this is how it has become in medicine -- where a pharmaceutical or some other company or the government does one study. And whatever that one study shows is what is considered as "The Fact." 

But, one study does not make a fact. Science uses evidence to prove what is or is not. By its nature, science is argument. It's debate. It’s controversy. It is attempting to disprove or prove a theory, not blindly adhering to one.

So, allow me to postulate some theories that have flooded the respiratory therapy community. 

1. Prior to COVID breathing treatments DO spread COVID. (No study. Hospital policy was that we had to switch any breathing treatment orders to inhalers which do not spread germs. Doctors not happy because breathing treatments solve all lung ailments. 
2. After COVID, breathing treatments DO NOT spread COVID. (based on one study. Hospital policy was changed to we can give them breathing treatmentes as needed or wanted). 
3. BiPAP, high flow nasal cannula, intubation, bronchoscopy, extubation are all procedures that spread aerosols. (No study. Anyone in the room must don NRB and other PPE. 
4. Hypertonic saline helps COPD patients cough up secretions. (One study showed the experimental group had a 2% more likelihood of coughing up secretions compared with the control. This is compared with another study showing hypertonic saline significantly helped bronchiectasis patients expecgtorate secretions.  Regardless, we now order them on anyone regardless of indication)
5. Many studies show breathing treatments work just as well as inhalers when proper technique is done. (Doesn't matter, everyone gets breathing treatments because.... because... because...). 
6. Pulmicort added to systemic steroids helps open up lungs (No study has ever showed that patients receiving systemic steroids will benefit from the added BID pulmicort breathing treatments. To the contrary, patients not in the hospital setting usually wisely stop taking inhaled steroids when on systemic steroids. But in the hospital setting reduntant therapy is indicated). 
7. 20 mg of albuterol will lower potassium (some studies show it may lower it a little bit, but not nearly as much as other medicines. Plus, if this were true, I would have never survived the 80's, where I'd sometimes use one inhaler in a day). 

It seems as though, when there is no study, the people making the rules do whatever they want. Actually, they do whatever sounds good. Or, in the case of breathing treatments for COVID, doctors were complaining that they coudn't  order them. So, when one study came out showing breathing treatments did not spread germs, they went with that study. No point doing a second study to confirm the first). 

Personally, there is no evidence that breathing treatments do spread germs and no evidence that they don't. If a patient has COPD or asthma, breathing treatments should be given as needed regardless of whether the patient has COVID or flu. If you're worried about spreading germs, wear an N-95 mask. Done. 

When it comes to pulmicort and hypertonic saline, I'm still looking for studies to verify they help with anything other than a select few patients. Yet, because it sounds good, we'll probably keep doing them, even though that's not sound science. 

Don’t Nebulize Hydrogen Peroxide!

It’s sad that this even needs to be said, but there’s a troubling craze on the Internet about nebulizing hydrogen peroxide.

Let me make this crystal clear: Do not put hydrogen peroxide in your nebulizer.

Any responsible respiratory therapist, nurse, or doctor will agree—there is absolutely nothing beneficial about nebulizing hydrogen peroxide, and it can seriously harm your lungs and airways.

What is Hydrogen Peroxide?

Hydrogen peroxide is a versatile and affordable disinfectant, a staple in homes and hospitals alike. Its bubbling action kills bacteria, viruses, and fungi, making it perfect for cleaning wounds, sanitizing surfaces, whitening laundry, and tackling stubborn mold. Its no-rinse, residue-free nature makes it a go-to for safe and effective cleaning.

For years, it was even used in respiratory care to clean inner cannulas in patients with tracheostomies. This was before disposable cannulas became widely available. Back then, we removed the inner cannula, cleaned it with mini pipe cleaners and gauze, and rinsed it in a mixture of water and hydrogen peroxide. Finally, we rinsed it thoroughly in pure water to remove any residue.

What We Know Now

We did this for years—until research made it clear that hydrogen peroxide can destroy lung tissue.

While it’s a potent disinfectant, inhaling it can cause significant damage. Reactive oxygen species in hydrogen peroxide lead to oxidative stress, which inflames and irritates the delicate alveoli in the lungs. Prolonged or concentrated exposure can cause serious respiratory complications, making its use strictly external.

As a result, we stopped using it for cleaning inner cannulas. In fact, I recently completed a mandatory tracheostomy care class, and one of the key lessons was about the harms hydrogen peroxide can do to the lungs. One of the test questions at the end asked: “Hydrogen peroxide is a safe and effective way to clean an inner cannula.”

Years ago, I might have answered “True.” But today, with updated knowledge, the correct answer is an emphatic False.

What the Internet Says

Unfortunately, misinformation abounds online. As someone who moderates health-focused Facebook pages, I’ve seen countless posts claiming that hydrogen peroxide can be nebulized. People even link to dubious “studies” touting it as an effective treatment for ailments like COVID-19—or even as a preventative measure.

Let me be clear: there is no credible evidence to support these claims. On the contrary, nebulizing hydrogen peroxide poses significant risks to your lung health.

The Bottom Line

Hydrogen peroxide has its uses, but inhalation is not one of them. Trust medical professionals, not random internet advice. And please, for the sake of your lungs, keep hydrogen peroxide out of your nebulizer.

New Evidence Suggests X-Rays Are the Key to Choosing Respiratory Medications

In a groundbreaking development, newly surfaced "evidence" suggests that X-rays may be the ultimate tool for determining the best respiratory medications. X-rays, a staple in medical diagnostics for decades, are now being touted as the go-to method for diagnosing everything from asthma to COVID-19.

For years, X-rays have been relied upon to peer inside the lungs and assess conditions like COPD, pneumonia, heart failure, pneumovirus, and bronchiectasis. It seems only natural to use these images to choose the right course of treatment, right? After all, what could be more precise than a blurry, two-dimensional image when deciding which inhaler to prescribe?

As respiratory conditions continue to evolve, patients can look forward to even more innovative (and potentially questionable) uses of X-rays in their treatment plans. It's all part of the cutting-edge, evidence-backed healthcare we’ve come to expect.

How to Use X-Rays to Determine Respiratory Treatment

Mucus Plugging
If the X-ray shows signs of mucus plugging, it's simple: prescribe Mucomyst and hypertonic saline solution, twice a day (BID). But why stop there? Go ahead and escalate it to every four hours (Q4) or even every hour (QID) for the truly committed. After all, who needs moderation when you're fighting mucus, right? This should be done even if the patient is not short of breath, shows no evidence of thick, stubborn secretions, or if it completely ignores the respiratory therapist. Because who needs their expertise when you have X-rays?