Problems related to respiratory secretions can be caused by infection or aspiration, or by pooling of normal oropharyngeal secretions in a patient who is weak or unable to swallow or cough effectively (for instance in motor neurone disease) or who has a reduced state of consciousness. The latter situation is common as death approaches ('death rattle'). Pulmonary oedema also causes increased respiratory secretions.

What is known 

• There is currently no evidence to show that medications for treating respiratory secretions at the end-of-life are more effective than placebo, although the evidence base is extremely small. [1]

What it means in practice 

• Agents which are being studied include hyoscine hydrobromide, hyoscine butylbromide and glycopyrronium bromide. These agents inhibit salivary secretions more than bronchial secretions.
• At this stage no particular medication is able to be recommended. If used, the choice should also include consideration of the side effect profile of the various drugs available – delirium / agitation, sedation, dry mouth, urinary retention and palpitations. Glycopyrrolate and hyoscine butylbromide do not enter the Central nervous system (CNS) and so contribute less to delirium than hyoscine hydrobromide. Side effects are presumed to be less distressing in an unconscious patient. [2]
• Repositioning the patient from side to side in a semi-upright position is recommended as a nursing strategy for patients with terminal secretions, though there is little good quality evidence available, and none compares this with medications. [2]
• Suctioning of the oropharynx is sometimes recommended, but its effectiveness has not been well studied, and it may cause patient distress. [3]
• Counselling of relatives and caregivers is important. Not all find the symptom distressing. [4-5]

• Using anti-muscarinic drugs in the management of death rattle: evidence-based guidelines for palliative care. (Bennett, Lucas et al. 2002)

Link to prescribing information
NB Prescribing information may not yet have been updated to include the most recent evidence.

• Online Palliative Medicine Handbook 
  Click on “Notes on Prescribing”
  This prescribing information is from the UK and some medications may not be available in Australia
• Therapeutic Guidelines for Palliative Care
  An Australian source of prescribing information not available directly online through CareSearch, but can be accessed online in most hospitals, or purchased

Related CareSearch pages 
End of life care
Cough
Delirium

References 

1. Wee B, Hillier R. Interventions for noisy breathing in patients near to death. Cochrane Database of Systematic Reviews. 2008 Jan 23;(1):CD005177.  
2. Bennett M, Lucas V, Brennan M, Hughes A, O’Donnell V, Wee B; Association for Palliative Medicine’s Science Committee. Using anti-muscarinic drugs in the management of death rattle: evidence-based guidelines for palliative care. Palliative Medicine. 2002 Sep;16(5):369-374.  
3. Morita T, Hyodo I, Yoshimi T, Ikenaga M, Tamura Y, Yoshizawa A, et al. Incidence and underlying etiologies of bronchial secretion in terminally ill cancer patients: a multicenter, prospective, observational study. Journal of Pain and Symptom Management. 2004 Jun;27(6):533-539. 
4. Wee BL, Coleman PG, Hillier R, Holgate SH. The sound of death rattle I: are relatives distressed by hearing this sound? Palliative Medicine. 2006 Apr;20(3):171-5.  
5. Wee BL, Coleman PG, Hillier R, Holgate SH.  The sound of death rattle II: how do relatives interpret the sound? Palliative Medicine. 2006 Apr;20(3):177-81. 

This page was created on 29 April 2008 and is due for review in April 2010