End of life care - upper airway secretions

Q: 48 years old male in comfort/palliative care in ICU start having a lot of upper respiratory noises from secretions. The family is extremely distressed and asked for some symptomatic relief?

Answer: Noises caused by upper airway secretions are heard in half of dying patients as they cannot swallow or clear them. The presence of respiratory secretions is a strong predictor of death within 48 hours. This could be very discomforting to the family and the patient. Different options to consider includes;

1. Glycopyrrolate: 0.2 mg as a single dose SC. In case of good response, it may be continued with the dose of 0.2 mg q4h prn SC. It can be given as IV also with caution.

(Glycopyrrolate is an excellent choice also in other ICU patients who continue to display high respiratory secretions, particularly vented patients)

2. Atropine: 0.6-0.8 mg SC. If effective, continue using q4h prn.

3. Hyoscine butylbromide: 20 mg as a single dose SC. If effective, continue using 20 mg q4h SC.

Further readings:

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. 

Downing GM, Wainwright W, editors. Medical care of the dying. 4th ed. Victoria (BC): Victoria Hospice Society; 2006. p. 363-393.