Respiratory Secretions at the End of Life

KEYPOINTS

• Noises caused by upper airways secretions are heard in approximately 50% of dying patients
• Caused by air passing through airways with secretions present (as the patient is unable to swallow or clear them)
• The presence of respiratory secretions is a strong predictor of death (76% die within 48 hours from onset of this symptom)
• Repositioning the patient is often helpful and all that is necessary
• Anticholinergic medications (e.g. atropine) can be helpful in many cases to reduce the secretions and noise

• Children, like adults, may be unaware of this symptom but it can be very distressing for family members
• Ongoing support and education of family around this symptom is very important to minimize the distress of the family witnessing this in their dying child

ASSESSMENT

(see Foreword)

• A clinical assessment is all that is required
• Other investigations would not be appropriate at this stage as the patient’s condition is very poor and death can be expected in the near future

MANAGEMENT

• Much of the management focuses on teaching and support of the family who may find this symptom difficult to watch or hear
• Repositioning the patient is often helpful in decreasing the noise
  • Place the patient on their side with upper body elevated
• Good mouth-care can also be helpful
• Administering anticholinergic medications can sometimes be helpful for upper airway secretions:
  • Hyoscine hydrobromide 0.4 mg as a single dose SC. Several doses q30 minutes may be required. If effective, continue using 0.3-0.6 mg q4h SC
  • Atropine 0.6-0.8 mg SC. If effective, continue, using q4h and prn
  • Glycopyrronium/glycopyrrolate 0.2 mg as a single dose SC. If effective, continue using 0.2 mg q4h and prn SC
  • Hyoscine butylbromide 20 mg as a single dose SC. If effective, continue, using 20 mg q4h SC
• Suctioning is usually not necessary (or helpful) and may be distressing to the patient
  • Consider suctioning if thick mucous, blood or other fluid is in the mouth/throat and can be easily removed with a soft catheter (i.e. no deep suctioning or rigid suctioning)

• Glycopyrronium/glycopyrrolate
  • 4-10 mcg/kg q6h IV/SC (max of 200 mcg/dose)
• Hyoscine hydrobromide
  • 1-12 years: 10 mcg/kg SC/IV as single dose
  • 20-60 mcg/kg over 24 h in SC or IV infusion
• Hyoscine butylbromide
  • Less than 6 years: 0.3 mg/kg/dose tid PO/SC/IV
  • 6-12 years: 5-10 mg up to tid PO/SC/IV

PITFALLS/CONCERNS

• Anticholinergic drugs as mentioned above should be used cautiously in patients who are still responsive as they can cause agitation. They generally are used in patients close to death
• Glycopyrronium/glycopyrrolate and hyoscine butylbromide (as compared to atropine and hyoscine hydrobromide) do not cross the blood brain barrier and may therefore cause less CNS effects
• Treatment with these agents is not always successful in reducing the secretions so it is important to support family

• Parenteral glycopyrronium/glycopyrrolate can be given PO (at same dose) and is usually well tolerated by children

PALLIATIVE TIPS

• Explaining to the family that the noisy respiratory secretions are unlikely to be distressing for the patient who is unconscious is an important part of helping to support the family
• The drug treatments are quite effective for upper airway secretions, but will not work for secretions deep in the lungs, pulmonary oedema, pneumonia, etc.
• Hydration with IV fluids may increase the severity of this symptom – use fluids cautiously in the dying

SOURCES/REFERENCES

1. Bennett M, Lucas V, Brennan M, Hughes A, O’Donnell V, Wee B. Association for Palliative Medicine’s Science Committee. Using antimuscarinic drugs in the management of death rattle: evidence-based guidelines for palliative care. Palliat Med 2002;16(5):369-74. http://www.ncbi.nlm.nih.gov/pubmed/12380654
2. Downing GM, Wainwright W, editors. Medical care of the dying. 4th ed. Victoria (BC): Victoria Hospice Society; 2006. p. 363-393.
3. NHS Clinical Knowledge Summaries. Palliative cancer care - secretions. [Online]. Available from: URL:http://cks.library.nhs.uk

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