respiratory secretions (terminal)

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Excessive respiratory secretions can cause loud rattles in the airways and throat. When in extremis, these crepitations are known as the death rattle. If the patient (or, when the patient is comatose, the relatives and friends) become very distressed by these.

Dying patients may be unable to cough effectively or swallow which can lead to retained secretions in the upper respiratory tract. Noisy, bubbly breathing may occur in 70% patients in the terminal phase. There is little evidence to support the effectiveness of drug treatment for this symptom. However it is established clinical practice to use anticholinergic drugs to try to reduce the accumulation of further secretions.

  • explanation and reassurance for relatives and carers is paramount
  • repositioning the patient in bed may be very helpful, for example 'high side lying' where the patient is positioned more upright with their head tilted to one side to aid drainage of secretions. A fan may also be beneficial
  • on occasion, for example where there is pooling of saliva in the oropharynx, gentle suction may be appropriate
  • hyoscine butylbromide and glycopyrronium do not usually cause drowsiness, confusion and paradoxical excitation since they do not cross the blood-brain barrier

Treatment options include repositioning, suction and the administration of anticholinergic drugs. Various anticholinergic agents may be used in the management of respiratory secretions (2):

  • Hyoscine butylbromide (20mg s.c. stat; 60-120mg/24 hours s.c. infusion), or,
  • Glycopyrronium bromide (0.2mg s.c. stat; 0.6-1.2 mg/24 hrs s.c. infusion),or,
  • Hyoscine hydrobromide (0.4 mg s.c. stat; 1.2-2.4mg/24hrs s.c. infusion)

NICE also suggest atropine as an alternative in addition to those stated above (3).

The respective summary of product characteristics must be consulted before prescribing any of the drugs mentioned.

Notes (3):

  • when giving medicine for noisy respiratory secretions:
    • monitor for improvements, preferably every 4 hours, but at least every 12 hours
    • monitor regularly for side effects, particularly delirium, agitation or excessive sedation when using atropine or hyoscine hydrobromide
    • treat side effects, such as dry mouth, delirium or sedation
  • consider changing or stopping medicines if noisy respiratory secretions continue and are still causing distress after 12 hours (medicines may take up to 12 hours to become effective)
  • consider changing or stopping medicines if unacceptable side effects, such as dry mouth, urinary retention, delirium, agitation and unwanted levels of sedation, persist

Reference:

  1. West Midlands Palliative Care Physicians (2007). Palliative care - guidelines for the use of drugs in symptom control.
  2. West Midlands Palliative Care Physicians (2012). Palliative care - guidelines for the use of drugs in symptoms control.
  3. NICE (December 2015). Care of dying adults in the last days of life

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