Managing excessive respiratory secretions in the last days of life

Published: 15^th September 2023

Key practice points

• In patients with excessive respiratory secretions, non-pharmacological interventions include minor positional changes, e.g. upright position with the patient’s head to the side, and regular mouth care, e.g. swabbing secretions that accumulate in the mouth
• Prioritise education and reassurance for the family/whānau; explain the causes of abnormal breathing noises and reassure them that the patient is not in distress or experiencing discomfort
• Pharmacological treatment is usually only considered if the patient is unconscious (or semi-conscious) and the excessive secretions are impacting their care or causing distress for the family/whānau. Adverse effects of treatment are common, e.g. worsening dry mouth, therefore it should be stopped if not effective.
• The first-line pharmacological treatment is subcutaneous hyoscine butylbromide:
  • Glycopyrronium bromide is another treatment option
• If the patient’s symptoms do not respond to appropriate treatment, contact the local hospice or palliative care team for advice

Excessive respiratory secretions in the last days of life

In the last days of life, excessive respiratory secretions accumulate in the airways when the person no longer has the awareness or energy to clear the fluid.¹ Inspired (and expired) air passes over the secretions that settle in oropharynx, laryngopharynx and bronchi causing vibrations and a crackling noise, sometimes referred to colloquially as the “death rattle”.¹ These sounds can be significantly distressing for the person’s family/whānau as they can be misinterpreted as signs of “drowning” or suffocating.²

Excessive respiratory secretions can be classified as either Type I, caused by salivary secretions or Type II, caused by the build-up of fluid in the lungs.³ Type II fluid retention is often the result of pulmonary disease, e.g. COPD, asthma, bronchitis, bronchiectasis, cystic fibrosis and lung cancer.³ Other contributory factors to excessive respiratory secretions include heart failure, cardiac dysfunction, discontinuation of corticosteroid treatment (for raised intracranial pressure), neuromuscular disorders, e.g. myasthenia gravis, head and neck cancers and brain tumours.³

Management of patients with excessive respiratory secretions

Family/whānau can help with the patient’s positional changes and mouth care, e.g. providing small amounts of fluid or ice chips, applying lip emollients.⁴ Elevating the patient’s upper body in bed and positioning their head to the side may reduce breathing noises.⁴ In most cases, suction is unlikely to be beneficial, and it can increase secretions and damage the oropharynx/laryngopharynx.^{4, 5} Swabbing secretions that accumulate in the mouth with a small sponge may provide some relief.³ It may be helpful to suggest background music to mask the breathing sounds if this eases distress for the family/whānau.⁴

Reassure family/whānau that the noises made in response to respiratory secretions are not signs that their loved one is in distress, but a normal part of the dying process.^{2, 6} Concepts to explain to the family/whānau include:

• Their loved one no longer has enough energy to swallow or cough up the fluid in their throat (or is not aware they need to due to declining level of consciousness)
• The noise itself is the sound of air travelling over the pooled fluid (this can be likened to sucking the last of a drink out of a glass with a straw – even small amounts of fluid can make a loud noise)
• Their loved one is not drowning or suffocating
• It often indicates a transition into deep unconsciousness and that death is getting closer
• Medicines will not remove the secretions that are already there; repositioning the person will likely provide more benefit

Support the use of traditional techniques and methods for symptom relief that the patient or their family/whānau want to try if they are unlikely to cause harm, e.g. Rongoā Māori, Ayurvedic or Chinese herbal medicines.