Download “Respiratory Tract Secretions” in Palliative Care

“Respiratory Tract Secretions” in Palliative Care in Adults
Introduction
The patient has, or is at risk of developing, excessive respiratory tract secretions/noisy breathing
near the end of life. On average, this occurs in about 50% of people who are dying, from a few
hours up to 3 days before death. The patient is likely to be semi conscious or unconscious and
unlikely to be distressed. However, this symptom can be distressing for relatives, carers and
others involved. Management takes account of this.
Cause
•
•
Fluid pooling in the hypopharynx and airways when the patient is too
weak to expectorate or swallow.
Build up of saliva is the most common cause.
Management
Assessment
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•
Exclude treatable causes (e.g. Left ventricular failure, infection)
Assess patient’s level of consciousness and understanding
Assess relatives’ understanding and anxieties
Non drug management
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Explanation of symptom control plan to patient if conscious or semi-conscious
Explanations to family / carers and reassurance that patient is unlikely to be
distressed if semi-conscious or unconscious. This may ease family’s distress
and remove the need for drugs or other interventions
If possible position patient semi-prone to encourage postural drainage
Oropharyngeal suction if excessive secretions present. Due to distress this
can cause, it is usually reserved for unconscious patients
Drug treatments
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Use of anticholinergic drugs to reduce secretions (see Medication box)
These should be commenced at early indication of secretions as they will not
remove secretions already present
Observe patient for response to the drugs and treat accordingly (see
Medication box)
Observe patient for signs of agitation, excessive tachycardia or distressing dry
mouth due to medications and treat appropriately (see Palliative Care
Guidelines for Agitation and Oral Care on the hospital Intranet / Highland
Hospice website via Information Pack electronic PDF)
Warning – Document uncontrolled when printed
Policy Reference: id1269
Date of Issue: November 2012
Prepared by: Lydia Morrison, Macmillan CNS, NHS Highland
Date of Review: November 2014
Lead Reviewer: Dr Jeremy Keen, Consultant, Palliative Care, Highland Hospice
Version: 2
Authorised by: Policies, Procedures and Guidelines Subgroup of ADTC
Page 1 of 2
Patient has excessive respiratory tract secretions
YES
1. Reposition patient (if possible)
2. Prescribe Hyoscine Butylbromide (Buscopan)
20mg s/c Or Glycopyrronium 200 micrograms s/c as
stat doses
3. If effective but secretions reoccur then give further
s/c dose.
Commence s/c infusion, via syringe pump, of:
Buscopan 60mg over 24 hours.
This can be increased to 80mg after 24 hours if
symptoms persist.
Bolus 20mg s/c 4 hourly can be given as required up
to a total overall maximum dose of Buscopan of
120mg in 24 hours.
OR Glycopyrronium 600micrograms to
1200micrograms s/c over 24 hours via syringe pump.
Bolus of 200 to 400micrograms s/c 4 hourly can be
given as required up to a total overall dose of
Glycopyrronium of 2400micrograms in 24 hours.
NO
1. Prescribe anticipatory medication:
Hyoscine Butylbromide (Buscopan)
20mg s/c 4 hourly as required.
Maximum dose in 24 hrs is 120 mg
Supportive Information:
Anticipatory prescribing in this manner
will ensure that in the last hours / days of
life, there is no delay in responding to the
symptom if it occurs
For Raigmore based staff - If medication
is ineffective and symptoms persist
contact the Raigmore Hospital Palliative
Care Advisory Service on extension
5405 / 6340
For all other staff - For further advice and
for out of hours / weekends, contact
Highland Hospice 24 hour Helpline on
01463 243132
Key References:
Bennett, M. Lucas, V. Brennan, M. Hughes, A. O’Donnell, V. and Wee, B. (2002). “Using anti-mus/carinic
drugs in the management of death rattle: evidence-based guidelines for palliative care”. Palliative Medicine,
Vol 16, pages 369-374
Liverpool Care Pathway (November 2005), Raigmore Hospital, NHS Highland
NHS Highland (2009). “Highland Formulary, third edition”
NHS Worcestshire (2009). “Symptom Control Guidelines for Respiratory Tract Secretions”
Twycross, R. Wilcock, A. and Stark Toller, C. (2009) “Symptom Management in Advanced Cancer, 4th
Edition”. Nottingham: Palliativedrugs.com Ltd. ISBN 978-0-9552547-3-4
Wildiers, H. Dhaenekint, C. Demeulenaere, P. Clement, PMJ. Desmet, M. Van Nuffelen, R. Gielen, J. Van
Droogenbroeck, E. Geurs, F. Lobelle, JP. And Menten, J. (2009). “Atropine, Hyos/cine Butylbromide, or
S/copolamine Are Equally Effective for the Treatment of Death Rattle in Terminal Care”. Journal of Pain and
Symptom Management, Vol 38, pages 124-133
Wildiers, H. and Menten, J. (2002). “Death Rattle: Prevalence, Prevention and Treatment”. Journal of Pain
and Symptom Management, vol 23,4, pages 310-317
Warning – Document uncontrolled when printed
Policy Reference: id1269
Date of Issue: November 2012
Prepared by: Lydia Morrison, Macmillan CNS, NHS Highland
Date of Review: November 2014
Lead Reviewer: Dr Jeremy Keen, Consultant, Palliative Care, Highland Hospice
Version: 2
Authorised by: Policies, Procedures and Guidelines Subgroup of ADTC
Page 2 of 2