Evidence summary

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.

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. [1-3] In the absence of evidence to guide recommendations there is some uncertainty as to the need to treat secretions. However, it is recognised that noisy breathing can be distressing to carers and family and therefore it may be necessary to initiate treatment based on individual needs.

Practice implications

  • 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. [4,5]
  • 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. [4]
  • Suctioning of the oropharynx is sometimes recommended, but its effectiveness has not been well studied, and it may cause patient distress. [6]
  • Counselling of relatives and caregivers is important. Not all find the symptom distressing. [3,7]

  1. Wee B, Hillier R. Interventions for noisy breathing in patients near to death. Cochrane Database Syst Rev. 2008 Jan 23;(1):CD005177.
  2. Jansen K, Haugen DF, Pont L, Ruths S. Safety and Effectiveness of Palliative Drug Treatment in the Last Days of Life-A Systematic Literature Review. J Pain Symptom Manage. 2018 Feb;55(2):508-521.e3. doi: 10.1016/j.jpainsymman.2017.06.010. Epub 2017 Aug 10.
  3. Craig F, Henderson EM, Bluebond-Langner M. Management of respiratory symptoms in paediatric palliative care. Curr Opin Support Palliat Care. 2015 Sep;9(3):217-26. doi: 10.1097/SPC.0000000000000154.
  4. 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. Palliat Med. 2002 Sep;16(5):369-74.
  5. Kolb H, Snowden A, Stevens E. Systematic review and narrative summary: Treatments for and risk factors associated with respiratory tract secretions (death rattle) in the dying adult. J Adv Nurs. 2018 Jul;74(7):1446-1462. doi: 10.1111/jan.13557. Epub 2018 Apr 6.
  6. 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. J Pain Symptom Manage. 2004 Jun;27(6):533-9.
  7. Wee BL, Coleman PG, Hillier R, Holgate SH. The sound of death rattle II: how do relatives interpret the sound? Palliat Med. 2006 Apr;20(3):177-81.

Last updated 27 August 2021