Respiratory secretions

Key messages

Definition and prevalence

Respiratory secretions are often observed in patients nearing the end of life. These secretions typically accumulate in the upper respiratory tract due to the patient's diminished ability to swallow or clear their throat, often as a result of decreased consciousness and weakened muscle control. [1,2] The characteristic rattling sound is produced as air passes through the pooled secretions. This sound can be distressing to family members, although patients are unaware of it due to their level of consciousness. [2]

The reported prevalence of respiratory secretions varies widely, ranging from 12% to 92% of dying patients. A weighted mean prevalence of 35% has been noted across multiple studies. [2] The variability in prevalence may be influenced by several factors, including the patient population, care setting, and illness trajectory. It is important to note that, while the presence of respiratory secretions often correlates with the final days or hours of life, it is not always a direct predictor of imminent death. [2,3]

Assessment

Assessing respiratory secretions in patients nearing the end of life involves distinguishing between salivary and bronchial secretions. Salivary secretions result from the inability to swallow, leading to saliva pooling in the hypopharynx, whereas bronchial secretions accumulate deeper within the respiratory tract, often due to fluid shifts or pulmonary changes. [2] This distinction is essential for understanding the source of the problem and guiding appropriate management, as salivary secretions tend to respond differently to treatments than bronchial secretions. [1]

Regular acknowledgement and discussion about respiratory secretions with the family/caregivers, will support the family in managing this difficult and often refractory symptom. As the patient’s condition evolves, continuous monitoring ensures that care remains responsive to changing needs.

Non-pharmacological treatment

Non-pharmacological strategies are considered essential in managing respiratory secretions at the end of life. Repositioning is a commonly recommended approach that aims to facilitate the drainage of secretions, particularly bronchial secretions, which can accumulate in the airways. Changing the patient's position may reduce the volume and noise of secretions, which can be distressing for family members. As opposed to acute respiratory distress, health professionals would not sit the patient upright in bed, but rather nurse them from side to side with the head of the bed raised if required. After a patient’s position has been changed you may witness an increase in respiratory noise as fluid shifts.

Suctioning is occasionally employed, but it is generally only recommended if secretions are visibly pooling and exiting the mouth. When necessary, gentle oral suctioning may provide temporary relief. However, suctioning is known to cause discomfort and distress for both patients and families, and may stimulate further secretion production, making it less effective as a long-term solution. [4] Studies suggest that suctioning can decrease the sound of respiratory secretions in some cases, but this improvement is often temporary, and many healthcare professionals express reservations about its overall benefit. [2]

Hydration management is another important aspect of non-pharmacological care. Excessive hydration can increase the production of respiratory secretions, particularly in patients who are unable to effectively clear fluids from their airways. Ceasing all forms of hydration may help reduce secretion build-up, although more research is needed to fully understand the relationship between hydration and secretion management. [4] This approach is commonly recommended as a preventative measure in combination with other non-pharmacological interventions.

Pharmacological treatment

Pharmacological interventions are frequently used in conjunction with non-pharmacological interventions to manage respiratory secretions. Anticholinergic agents are the most used medications. These drugs work by blocking muscarinic receptors to reduce secretion production rather than clearing existing secretions. [2] Common agents include glycopyrrolate and hyoscine butylbromide, both of which are preferred because they do not cross the blood-brain barrier, minimising the risk of neurological side effects such as terminal restlessness. In contrast, hyoscine hydrobromide, which does cross the blood-brain barrier, is associated with increased risk of confusion, agitation, and restlessness. [1]

These medications should be administered subcutaneously, as this route is more effective and comfortable for patients in the terminal phase. [2] Early administration of anticholinergics is advised, as these drugs are generally less effective once significant secretions have accumulated. If the medication is ineffective after 24 hours, it is typically discontinued to avoid unnecessary side effects such as dry mouth or urinary retention. [5]

Glycopyrrolate is often used due to its high muscarinic receptor selectivity, and studies suggest it is particularly safe and effective, even at higher doses, without exacerbating muscular weakness. [1] Hyoscine butylbromide is also a widely used option and has shown efficacy in reducing the occurrence of respiratory secretions when administered prophylactically. [6] Continuous infusion via a subcutaneous pump may be considered if the initial doses are effective, providing consistent symptom control in patients who are close to death. [2]

Equity and access

The management of respiratory secretions at the end of life can vary across different populations, particularly among underserved groups such as those in rural and remote areas, culturally and linguistically diverse (CALD) communities, Aboriginal and Torres Strait Islander peoples, and individuals in institutional settings like prisons. In rural and remote areas, access to medications such as glycopyrrolate and hyoscine butylbromide may be limited due to logistical challenges, including fewer healthcare facilities and long distances to specialist services. This can result in delays in symptom management, potentially leading to increased distress for patients and families, who may already face emotional burdens in navigating palliative care. [2] Additionally, healthcare professionals in these areas may have fewer opportunities to access specialised training in managing complex symptoms like respiratory secretions, which could affect the quality of care provided. [4] Telehealth and mobile palliative care units are emerging solutions that might mitigate some of these access issues, though further efforts are required to ensure equitable care.

For Aboriginal and Torres Strait Islander peoples, barriers to managing respiratory secretions are often multifactorial, influenced by geographic isolation, historical mistrust of healthcare services, and culturally unique views on end-of-life care. Challenges such as long travel distances to palliative care facilities and limited culturally appropriate care options may delay symptom management, particularly when it comes to respiratory secretions. Incorporating traditional practices into care, alongside Western medical interventions, may improve engagement with palliative services and facilitate more timely management of symptoms. [4,7] Efforts to build trust and improve healthcare literacy within these communities might also reduce some of the barriers faced when seeking palliative care.

CALD populations may encounter additional challenges in managing respiratory secretions due to language barriers and cultural beliefs. The absence of interpreters and culturally appropriate healthcare providers can complicate conversations about treatment options, including the use of anticholinergics. Some families may hesitate to accept treatments like suctioning due to cultural concerns around patient dignity and comfort, further delaying symptom management. [7] This highlights the importance of culturally competent care, with efforts to provide clear explanations of the benefits and limitations of available interventions in ways that respect family values and traditions.

In institutional settings, such as prisons, managing respiratory secretions may be complicated by systemic barriers. Limited access to medications, along with staffing shortages and restrictive institutional protocols, may delay effective symptom management. Incarcerated individuals often present with higher rates of comorbidities, which can complicate respiratory secretion management further, making it more challenging to provide comprehensive end-of-life care. [8] Addressing these barriers may require targeted interventions, including staff training and improved access to palliative care resources within correctional settings.

Care context

In paediatric palliative care settings, while pharmacological interventions like glycopyrrolate and hyoscine butylbromide may be used, care is often taken to limit the distress caused by interventions such as suctioning, which can be particularly upsetting for families. [1] Paediatric palliative care teams tend to focus on family-centred care, ensuring that parents and caregivers are well-informed and supported in making decisions that balance symptom relief with comfort and quality of life. [1,3,4]

Implications for families and carers

Managing respiratory secretions at the end of life can be distressing for families and carers, as the sound of secretions may be interpreted as a sign of patient suffering. This often increases anxiety and emotional distress, particularly when families are unaware that respiratory secretions may not cause discomfort for the patient. Providing clear, compassionate explanations early about the nature of these secretions and reassuring families that the patient may not be distressed by them can help alleviate their emotional burden. [2,3] Non-pharmacological interventions, such as repositioning the patient, may offer families a way to participate actively in care, which can provide a sense of control during this challenging time. [2]

Families and carers who provide care in non-hospital settings, such as at home, may face additional challenges due to a lack of immediate access to professional support and medications. These challenges can exacerbate feelings of helplessness when managing distressing symptoms like respiratory secretions. Ensuring that carers are provided with adequate education, resources, and access to palliative care teams for guidance in both pharmacological and non-pharmacological approaches can help alleviate these burdens and promote more confident caregiving. [1]