Noisy upper respiratory tract secretions: pharmacological management

Upper respiratory tract secretion accumulation with noisy breathing (‘death rattle’) is caused by salivary secretions pooling within the hypopharynx. It occurs in people who cannot swallow, usually in the last days of life.1–3 It is reported in 12%–92% of dying patients3–6; the weighted mean prevalence is 35%.5 The noise and secretions can be distressing for some family members and staff.5–8 They are reportedly not associated with subjective respiratory distress,4 5 although those with the problem often have impaired consciousness so patient impact is unclear.5 Antimuscarinic drugs (eg, glycopyrronium and hyoscine butylbromide) reduce new secretion formation.2–4 Systematic reviews have found no benefit of antimuscarinics over placebo. They advise against their routine use once noisy upper respiratory tract secretions are present.3 5 9 Although they reduce production, they do not remove existing secretions. The idea of preventative prophylactic …