Evidencematters0707Evidence MattersVol.1, No.3 SUMMER 2007e Use of Anticholinergics for the Management of Terminal Secretions Melissa Y.Gray, PharmDWhat causes terminal secretions?Terminal secretions are common during the last days of a patients life and are recognized as a strong predictor of impending death.
Secretions accumulate in the lungs or oropharynx when dying patients lose consciousness or are too weak to clear their own secretions.Air passing through or over these secretions during inspiration and expira-tion can cause a noisy, rattling sound, which led to the term death rattle for this phenomenon.1, 2 Excessive secre-tions in dying patients may also be related to infection, pulmonary edema, and/or uid overload.Terminal secretions may be categorized as either type 1 or type 2, based upon their primary source.1 Type 1
secretions are caused by the accumulation of and inability to clear saliva, and type 2 secretions are primarily caused by the accumulation of bronchial secretions in patients unable to expectorate.1 ese subtypes were proposed to indicate whether a patients secretions were likely to respond to anticholinergic therapy.However, the subtypes have never been validated in a clinical study, and it may be dicult for clinicians to determine the patients particular type of secretion.Who is at risk for terminal secretions? e reported prevalence of terminal secretions varies from 23 to 92% depending on the investigators denition and study populations.18 Evidence suggests that patients with lung or brain malignancies or those who undergo a prolonged dying phase are at increased risk for developing terminal secretions.1, 7, 8 Patients with diseases known to inhibit swallowing reexes, such as head and neck or esophageal cancers, or those with neurodegenerative processes have also been associated with a higher risk of terminal secretions.9What is the impact of terminal secretions on patients and their caregivers?Although terminal secretions can contribute to dyspnea, restlessness, and insomnia,1, 9, 10 patients experiencing terminal secretions usually have decreased awareness, therefore, the presence of secretions and associated sounds may be more distressing to family caregivers than to the patient.9 Studies indicate that family distress related to terminal secretions varies and some family members view the development of secretions as a helpful sign of
impending death.11 Family members who think that the sound indicates choking or drowning are more likely to be disturbed by it.12 Because family members (and even some health-care professionals) vary in their interpretations and responses to noisy respirations, it is important to explain the cause of this symptom.10, 12What is the role of anticholinergics for terminal secretions?Anticholinergic (or, more specically, antimuscarinic) agents inhibit secretion production but have no eect on
secretions that are already present.3, 6, 13, 14 erefore, if anticholinergic therapy is indicated, agents should be
initiated at the rst sign of symptoms.e response rate to anticholinergics varies greatly, ranging from 40 to 80%.
18, 13 Salivary (type 1) secretions are more likely to respond to anticholinergic therapy than bronchial (type 2)
secretions.13, 14 One possible explanation for this dierence is that bronchial secretions take longer to accumulate Evidence Matters is Hospice Pharmacias newsletter devoted to promoting evidence-based palliative care.to a clinically noticeable volume.3, 13, 14 Prophylactic treatment with anticholinergic therapy in high-risk patients may
improve outcomes, but more research is needed to support this theory.7 Because the use of anticholinergics may produce signicant side eects, their benets and burdens should be carefully considered, and for some options may be more appropriate.Which anticholinergic should I use and what dose and route are appropriate?e most commonly used anticholinergics to treat excessive secretions include atropine, scopolamine, glycopyrrolate, and hyoscyamine.
Currently, management of terminal secretions is largely based upon anecdotal experience; there is no conclusive empirical evidence that one agent is more eective than the others.3, 6, 13, 14 erefore, appropriate agent selec-tion should be based on the agents adverse eect prole, onset of action, duration of action, route of administration, and cost.While higher doses may be observed in practice, the doses provided below are literature-based recommended starting doses.Atropine (Atreza, Sal-Tropine, Isopto-Atropine, others) is commonly used to manage terminal secretions.
It may be administered by oral (PO), intramuscular (IM), intravenous (IV), or subcutaneous (SC) routes at a starting dose of 0.4 mg every 46 hours as needed.1518 Atropine 1% eye drops can be given orally to the back of the throat or sublingually to provide rapid relief of symptoms.10 e initial recommended dose for the oral administration of eye drops is 12 drops every 46 hours as needed.1618 Findings from a single unpublished study indicated that atropine ophthalmic
solution administered sublingually was eective at reducing terminal respiratory secretions.19 Other studies have
reported limited success using atropine drops for other hypersalivary conditions.2022Scopolamine (Transderm Scop, Scopace, Isopto Hyoscine) may be administered by PO, IM, IV, and SC routes.Oral therapy is initiated at a starting dose of 0.4 mg every 8 hours as needed, whereas parenteral dosage forms are initiated at a starting dose of 0.4 mg every 4 hours as needed.3, 15, 17, 23 Scopolamine is also available as a transdermal patch, which is applied behind the ear and changed every 72 hours.9 ere is limited evidence to support the application of more than one patch
.One case report and one study showed that two patches we
Respiratory Secretions / Congestion
secretions are usually below the larynx and inaccessible to suction. (3, 5 ... o Atropine 1% eyedrops 1 to 2 drops q1 to 2h p.r.n. sublingual (3, 14) or (hospicepharmacia.com)
RespiratorysecretionsandcongestionRESPIRATORY SECRETIONS / CONGESTION Rationale This guideline is adapted for inter-professional primary care providers working in various settings in VIHA and any other clinical practice setting in which a user may see the guidelines as applicable.Respiratory secretions and congestion are common in the terminal phase
23 to 95%.Respiratory secretions (Type I in particular) are a strong predictor of death
48% within 24 hours and 76% within 48 hours of onset.They are not usually distressing to patients in the terminal phase but, in contrast, may dominate the experience and memory of loved ones at the bedside.(1-14)Scope This guideline provides recommendations for the assessment and symptom management of adult patients (age 19 years and older) living with advanced life threatening illness and experiencing the symptom of respiratory secretions and/or congestion.This guideline does not address disease specific approaches in the management of respiratory secretions and/or congestion.Definition of Terms Airway secretion refers to mucus secreted by the submucosal glands and goblet cells.The airway secretion can accumulate due to increased production, decreased mucociliary clearance and ineffective cough reflex.(1)Congestion Type I: Salivary Secretions accumulating when swallowing reflexes are inhibited.(15)Congestion Type II: Bronchial secretions which cannot be coughed up or swallowed.(15)Standard of Care 1.Assessment2.Diagnosis 3.Education 4.Treatment: Non-pharmacological 5.Treatment: Pharmacological Recommendation 1
Respiratory Secretions / Congestion Ongoing comprehensive assessment is the foundation of effective managementof congestion and its related secretions, including interview, physical assessment, medication review, medical and surgical review, psychosocial and physical environment review and appropriate diagnostics (see Table 1).Assessment must determine the cause, effectiveness and impact on quality of life for the patient and their family.(1, 3, 12)Patients with terminal secretions are often not responsive enough to be interviewed.The following questions are important to guide observation and may be asked to family members.Table 1: Respiratory Secretions/Congestion Assessment using Acronym O,P,Q,R,S,T,U and V (8, 12) *
When did it begin? Can the secretions be cleared by coughing or swallowing? How often do they occur?
What brings it on? What makes it better? What makes it worse? Is it does it sound like?
Where are the secretions? Throat? Chest?
everity What is the intensity of this symptom (On a scale of 0 to 10 with 0 being none and 10 being worst possible)? Right now? At best? At worst? On average? How bothered are you by this symptom? Are there any other symptom(s) that accompany this symptom?
Treatment What medications and treatments are you currently using? How effective are these? Do you have any side effects from the medications and treatments? What medications and treatments have you used in the past? nderstanding/
Impact on You
What does the person / family believe is causing this congestion? How is this symptom affecting the family? Is the person distressed?
alues What is your goal for this symptom? What is your comfort goal or acceptable level for this symptom (On a scale of 0 to 10 with 0 being none and 10 being worst possible)? Are there any other views or feelings about this symptom that are important to you or your family? * also include a Physical Assessment (as appropriate for symptom) Identifying the underlying etiology of the secretions and congestion is essential in determining the interventions required.(3, 5, 12, 16) Type of Congestion Factors Contributing
Increased fluid in airway
Oropharyngeal secretions (saliva)
Type I, accumulate near death
Tracheo-bronchial secretions (normal mucous production)
Type II, accumulate over several days as patients deteriorate
and cough weakens
(aspiration, blood, exudates, tumour debris)
Decreased airway diameter
Increased resistance and muscle hypertrophy
Intrinsic or extrinsic compression
Ventilatory , rapid breathing patterns
Education The importance of education regarding treatment of respiratory secretions is to support the family at the bedside.
Drowning and suffocation are not accurate descriptions of what is going on.
Death rattle is a term to avoid, instead use the term congestion.
Prepare the family by reviewing changes they can expect in the patient condition as death approaches.(2, 3, 7, 9, 11-13)
Treatment: Non-pharmacological Prevent aspiration with positioning.(2) Repositioning (move the patient from supine to lateral recumbent with head slightly raised)
to encourage drainage, maintain airway and decrease pooling of secretions.(1, 2, 4, 5, 7-12)Suction: While it may seem to the family that suction should help, most secretions are usually below the larynx and inaccessible to suction.(3, 5, 14)Routine use of suctioning in the hospital setting needs to be discouraged.(1, 2, 5, 8, 14)The exception to this is fulminant pulmonary edema (copious frothing) or thick inspissated mucous, blood or other fluid in the throat or mouth
suctioning may be of value.(2, 3, 9, 12)Provide good mouth care.(3)Avoid over hydration if fluid built up in upper airways(5, 6, 9, 13, 14) especially in lungcancer patients.(10)Recommendation 2
Diagnosis Recommendation 5
Treatment: Pharmacological Anti-cholinergics are effective in reducing both saliva and mucus production.They should be used at the first sign of congestion as anti-cholinergics do not dry up secretions that are already present.(3-5, 9, 13, 16) There is no evidence to support a first choice antic
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