Respiratory Secretions at the End of Life


  • 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


(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


  • 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)


  • 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


  • 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


  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.
  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:

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