What is the best way to reduce excessive secretions in end-of-life (EOL) care?

From the Guidelines

The best way to reduce secretions in end-of-life care is to use anticholinergic medications, with glycopyrrolate (0.2-0.4mg subcutaneously or intravenously every 4-6 hours) or scopolamine (1.5mg transdermal patch changed every 72 hours, but not recommended for imminently dying patients due to its delayed onset of action) being first-line options, as supported by the most recent and highest quality study 1.

Key Considerations

• Glycopyrrolate is preferred due to its minimal risk of causing delirium, as it does not effectively cross the blood–brain barrier 1.
• Atropine drops (1% solution, 1-2 drops sublingually every 4-6 hours) can also be effective in reducing secretions.
• Non-pharmacological approaches, such as positioning the patient on their side or in a semi-upright position, gentle suctioning if necessary, and reducing fluid intake if appropriate, should be used alongside medications to improve patient comfort.
• Family education is crucial, as secretions often cause more distress to family members than to the patient, who is typically unaware of them due to decreased consciousness.

Medication Administration

• Glycopyrrolate and scopolamine work by blocking acetylcholine receptors, which reduces the production of respiratory secretions.
• It is essential to start these medications early when secretions first become noticeable rather than waiting until the "death rattle" is established.
• The role of mechanical ventilation and oxygen diminishes as life expectancy decreases, and the role of opioids, benzodiazepines, glycopyrrolate, and scopolamine increases 1.

Goals of Care

• These interventions aim to improve comfort rather than extend life, aligning with the goals of end-of-life care, as emphasized in the NCCN clinical practice guidelines in oncology: palliative care 1.

From the FDA Drug Label

In Anesthesia Glycopyrrolate Injection is indicated for use as a preoperative antimuscarinic to reduce salivary, tracheobronchial, and pharyngeal secretions; The best way to help reduce secretions in end of life care is to use glycopyrrolate (IV) as an antimuscarinic agent to reduce salivary, tracheobronchial, and pharyngeal secretions 2.

• Key benefits: reduces secretions, blocks cardiac vagal inhibitory reflexes
• Important consideration: use with caution in patients with renal disease, as renal elimination of glycopyrrolate may be severely impaired 2.

From the Research

Management of Respiratory Secretions

To help reduce secretions in end of life care, several interventions can be considered:

• Anticholinergic medications such as glycopyrrolate, scopolamine, and hyoscine hydrobromide can be used to reduce noisy respirations from retained secretions in terminal patients 3
• Manually-assisted cough and mechanical insufflation-exsufflation can promote expectoration and improve mucous clearance 4
• Percussive ventilation can also be used to improve mucous clearance 4
• Other interventions such as expiratory muscle training, tracheotomy, chest physiotherapy, suctioning, air stacking, electrical stimulation of abdominal muscles, nebulized saline, positive expiratory pressure masks, and high frequency chest wall oscillations may also be beneficial 4

Comparison of Medications

Studies have compared the efficacy of different medications in reducing respiratory secretions:

• A study found that subcutaneous glycopyrrolate, scopolamine hydrobromide, and scopolamine butylbromide were similar in their ability to reduce noisy respirations overall and lower the level of distress exhibited by family members and visitors 3
• Another study found that hyoscine hydrobromide and glycopyrronium had conflicting results in terms of effectiveness in drying up respiratory secretions in terminally ill patients 5
• A feasibility study proposed to compare the efficacy of glycopyrrolate and hyoscine hydrobromide in the treatment of clozapine-induced hypersalivation, with promising evidence that glycopyrrolate may be more successful in treatment with fewer cognitive side effects 6

Research Gaps

Despite the availability of various interventions, there is still a need for more research to identify the best management of respiratory secretions in end of life care:

• A study highlighted the scarcity of research material directly comparing the effects of different medications in the clinical setting 5
• Another study proposed a research agenda to explore the benefit of compassionate education and communication with people close to the dying person 7
• A systematic review found that the evidence still needs to improve in order to identify which treatment is the best for respiratory secretion management in adult palliative care patients 4