Terminal Secretions

Palliative Care Considerations

• Terminal secretions, or death rattle, is the noise produced by the oscillatory movements of secretions in the upper airways in association with the inspiratory and expiratory phases of respiration.43,44

• As patients lose their ability to swallow and clear oral secretions, accumulation of mucus results in a rattling or gurgling sound produced by air passing through mucus in the lungs and air passages.

• The sound does not represent any discomfort for the patient. However, the sound is sometimes so distressing to the family that it should be treated.

• Terminal secretions are typically seen only in patients who are obtunded or are too weak to expectorate.

• Drugs that decrease secretions are best initiated at the first sign of death rattle, as they do not affect existing respiratory secretions.

• These agents have limited or no impact when the secretions are secondary to pneumonia or pulmonary edema.

Nonpharmacologic Treatment in Palliative Care

• Position the patient on his/her side or in a semiprone position to help facilitate drainage of secretions.

• If necessary, place the patient in the Trendelenburg position (lowering the head of the bed); this allows fluids to move into the oropharnyx, facilitating an easy removal. Do not maintain this position for long, as there is a risk of aspiration.

• Oropharyngeal suctioning is another option, but may be disturbing to both the patient and visitors.

• Fluid intake can also be decreased, as appropriate.

Pharmacotherapy in Palliative Care

• Anticholinergic drugs remain the standard of therapy for prevention and treatment of terminal secretions due to their ability to effectively dry secretions.45-47

• Drugs used for this indication are similar pharmacologically, and one can be selected by anticholinergic potency, onset of action, route of administration, alertness of patient, and cost.

• The most commonly used anticholinergic agents are atropine, hyoscyamine, sco-polamine, and glycopyrrolate.

• Anticholinergic side effects are common and include blurred vision, constipation, urinary retention, confusion, delirium, restlessness, hallucinations, dry mouth, and heart palpitations.

• Unlike the other anticholinergics, glycopyrrolate does not cross the blood-brain barrier and is associated with fewer central nervous system side effects. Gly-

copyrrolate is a potent drying agent when compared to others agents and has the

potential to cause excessive dryness.

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