Respiratory Secretions in the Dying Phase

Dying patients may be unable to cough effectively or swallow which can lead to retained secretions in the upper respiratory tract.

Noisy, bubbly breathing may occur in 70% patients in the terminal phase. There is little evidence to support the effectiveness of drug treatment for this symptom. However it is
established clinical practice to use anticholinergic drugs to try to reduce the accumulation of further secretions.

  • Explanation and reassurance for relatives and carers is paramount.
  • Re-positioning the patient in bed may be very helpful, for example ‘high side lying’ where the patient is positioned more upright with their head tilted to one side to aid drainage of secretions. A fan may also be beneficial.
  • On occasion, for example where there is pooling of saliva in the oropharynx, gentle suction may be appropriate.
  • Hyoscine butylbromide and glycopyrronium do not usually cause drowsiness, confusion and paradoxical excitation since they do not cross the blood-brain barrier.

Anticholinergic, Subcutaneous Route

Hyoscine butylbromide

STAT/PRN Injection: 20 mg

Syringe Driver/pump over 24 Hours: 60 – 120 mg

Glycopyronium

STAT/PRN Injection: 200 micrograms

Syringe Driver/pump over 24 Hours: 600 micrograms – 1200 micrograms

Hyoscine hydrobromide

(also has sedative properties; may exacerbate confusion)

STAT/PRN Injection: 400 micrograms

Syringe Driver/pump over 24 Hours:  1200 micrograms to 1600 micrograms

DISCLAIMER

This Guide is intended for use by healthcare professionals and the expectation is that they will use clinical judgement, medical, and nursing knowledge in applying the general principles and recommendations contained within. They are not meant to replace the many available texts on the subject of palliative care.
Some of the management strategies describe the use of drugs outside their licensed indications. They are, however, established and accepted good practice. Please refer to the current BNF for further guidance.
While WMPCPS takes every care to compile accurate information , we cannot guarantee its correctness and completeness and it is subject to change. We do not accept responsibility for any loss, damage or expense resulting from the use of this information.