Would glycopyrrolate help manage gurgling respirations due to retained secretions in a severely demented patient with chronic dysphagia who is too weak to clear their airways?

From the Guidelines

Glycopyrrolate can be used to help manage gurgling respirations (death rattle) in this 90-year-old severely demented patient with chronic dysphagia who is too weak to clear secretions, as recommended in the palliative care guidelines 1. The recommended dosing is typically 0.2-0.4 mg subcutaneously or intravenously every 4 hours as needed, as stated in the guidelines 1. Glycopyrrolate works as an anticholinergic medication that reduces secretion production by blocking muscarinic receptors, thereby decreasing the volume of respiratory secretions. It does not dry up existing secretions but prevents new ones from forming. The medication has minimal central nervous system effects compared to other anticholinergics like scopolamine because it doesn't cross the blood-brain barrier as readily 1. Some key points to consider when using glycopyrrolate include:

• Side effects may include dry mouth, urinary retention, and constipation
• Positioning the patient with the head slightly elevated can also help manage secretions
• This symptom often causes more distress to family members than to the patient himself, who likely isn't experiencing discomfort from the secretions due to his decreased consciousness. Given the patient's condition and the goal of comfort care, glycopyrrolate is a suitable option to manage gurgling respirations, as it can help reduce the volume of respiratory secretions and alleviate discomfort, as recommended by the guidelines 1.

From the Research

Management of Gurgling Secretions

• The patient's condition, characterized by gurgling respirations due to an inability to clear airways, is a common symptom in terminally ill patients, often referred to as "death rattle" 2.
• Anticholinergic medications, such as glycopyrrolate, are used to reduce noisy respirations from retained secretions in terminal patients 3.
• Studies have compared the efficacy of glycopyrrolate to other anticholinergic medications, such as scopolamine and hyoscine hydrobromide, in managing respiratory tract secretions in dying patients 2, 3, 4.

Efficacy of Glycopyrrolate

• One study found that glycopyrrolate may be at least as effective as hyoscine hydrobromide in controlling respiratory tract secretions in dying patients 4.
• Another study reported 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.
• Glycopyrrolate has been shown to produce bronchodilation and decrease airway resistance, which may help in managing gurgling secretions 5.

Considerations for Use

• The pharmacokinetics of glycopyrrolate and its relation to clinical response are not fully understood, and further studies are needed to characterize its properties 6.
• Age may affect the kinetics of anticholinergic agents, including glycopyrrolate, which may be important to consider in elderly patients 6.
• The choice of medication for managing gurgling secretions should be based on individual patient needs and circumstances, as there is no clear evidence to support the choice of one drug over another 2.