8th January 2024

Secretions

Secretions can accumulate in a palliative patient’s oropharynx and cause a rattling or gurgling noise (‘death rattle’). This can occur if clearance of secretions is inadequate, such as impaired cough or swallow when approaching the end of life, or due to sedating medications. There may be increased viscosity of secretions due to dehydration or illness, or being nursed in a supine position means secretions accumulate in the hypopharynx.

Secretions may also be excessive if there is a chest infection or fluid overload resulting in pulmonary oedema, both of which can be difficult to diagnose in the final stage of life.

Management

The noises may be distressing for patients or their families but aren’t usually uncomfortable. Explanation may be adequate to reassure the person and their family.

Non-Pharmacological:

• Positioning
• Gentle oral suctioning

Pharmacological:

• Glycopyronnium bromide
• Hyoscine hydrobromide
• Hyoscine butylbromide – Crosses blood-brain barrier
• Side effects can include sedation, confusion, agitation, dry mouth and confusion, which should be closely monitored
• In a patient approaching end of life, antibiotics may be considered if a patient has large amounts of purulent sputum that is causing distress