A Guide to Excessive Respiratory Secretion in Hospice

Excessive respiratory secretions are common in hospice care, causing discomfort for patients and caregivers alike. In this article, we will explore the causes, assessment, and treatment of excessive secretions to provide relief for all involved.

Causes of Excessive Secretions in Hospice

Fluid Overload – Various factors, including fluid overload in the body, can cause end-of-life mucus secretions. This may result from intravenous fluids, tube feedings, or oral intake.

Disease and Infection – Underlying diseases like renal failure can also contribute to excessive secretions. Infections in the oral cavity or respiratory system may also cause secretions to increase.

Positioning – The positioning of the patient can affect secretions. Lying flat or with the head of the bed elevated may result in the pooling of oral secretions and difficulty clearing them.

Assessing Excessive Secretions in Hospice

History and Onset – Consider the patient’s medical history and the onset of secretions. Determine if any precipitating or relieving factors are present and whether the secretions are acute or chronic.

Medications and Associated Symptoms – Examine the patient’s medications and any potential reactions. Look for associated symptoms, such as difficulty breathing, sleep disturbances, and psychosocial or spiritual concerns.

Physical Exam – Perform a thorough physical exam, focusing on the patient’s appearance, cardiopulmonary system, oral cavity, and skin turgor. Assess the color and consistency of the mucus secretions and check for signs of infection.

Non-Pharmacological Interventions for End-of-Life Secretions

Positioning and Oral Care – Ensure the patient is positioned appropriately to help manage secretions. Provide regular oral care to maintain a clean and comfortable environment.

Distraction Techniques – Help distract the patient from respiratory sounds by using soft music or background noise.

Medication for Secretions

Hyoscyamine (Levsin®) – Administer hyoscyamine tablets or drops (0.125-0.25 mg) orally or sublingually every four hours as needed.

Scopolamine Transdermal (Transderm-Scop®) – Apply one to two scopolamine patches behind the ear every 72 hours.

Atropine – Give atropine injections (0.3 mg) subcutaneously every four hours as needed, with a maximum of 1.2 mg every four hours.

Glycopyrrolate (Robinul®) – Administer glycopyrrolate (1-2 mg) orally or sublingually every four hours.

Ongoing Evaluation and Collaboration for Excessive Secretions

Evaluate and document the patient’s symptoms at each visit until they are resolved. Consider discontinuing medications as symptoms improve. Collaborate with psychosocial and spiritual professionals to ensure that the most effective combination of non-pharmacological and pharmacological interventions is utilized to manage excessive secretions in hospice care.

Ongoing Management of End of Life Secretions

Focus on maintaining patient comfort and providing reassurance to caregivers. In addition to the previously mentioned pharmacological and non-pharmacological interventions, consider the following:

Suctioning – Use suctioning only when necessary and when upper airway secretions are accessible. Over-suctioning can cause discomfort and may not be effective in managing secretions.

Humidification – Consider using a humidifier to help moisten the air and make breathing easier for the patient.

Palliative Care Consultation – Involve a palliative care specialist if available. They can provide additional guidance on managing secretions during the end-of-life phase.

Addressing Caregiver Concerns and Providing Support 

Managing excessive secretions in hospice care can be challenging for caregivers. It’s essential to address their concerns and provide support to ensure the best care possible for the patient.

Education and Communication – Educate caregivers about the causes and management of excessive secretions. Encourage open communication about their concerns and any changes they observe in the patient’s condition.

Coping Strategies – Help hospice caregivers develop coping strategies to deal with the emotional challenges of providing hospice care. Encourage self-care and provide resources for counseling or support groups.

Collaborative Care – Foster a collaborative approach to care by involving the entire hospice team, including nurses, aides, managers, and other healthcare professionals. This collaboration ensures that everyone is working together to provide the best possible care for the patient.

Conclusion

Excessive respiratory secretions can be challenging to manage in hospice care, but understanding their causes, prevention, and treatment options is crucial for relief and comfort. Collaborative care, effective communication, and ongoing evaluation are essential to addressing this issue. By implementing the strategies discussed in this article, healthcare professionals can better support patients and caregivers in managing excessive secretions and ensuring the best possible quality of life during hospice care.

FAQ

How long do end-of-life secretions last?

End-of-life secretions, commonly known as “death rattle,” can last anywhere from a few hours to a few days before death. The duration varies based on the patient’s medical condition, hydration status, and the effectiveness of any interventions used to manage these secretions.

Why do secretions increase at the end of life?

Secretions increase at the end of life primarily due to the body’s decreased ability to clear fluids and the weakening of muscles involved in swallowing. Body systems become less efficient at the end of life, leading to a buildup of secretions in the throat and lungs. Secretions are a natural part of the dying process. While distressing for loved ones, it typically does not cause discomfort for the dying person.

What does hospice use to dry up secretions?

Hospice care often uses anticholinergic medications, such as hyoscine butylbromide (Buscopan), glycopyrrolate, and Hyoscyamine (Levsin®) to dry up secretions in patients experiencing excessive mucus or saliva. These drugs reduce the production of secretions and alleviate symptoms, thus improving patient comfort in their final days.

References

Clinical Practice Guidelines: The Hospice of the Florida Suncoast (2008).

Grauer P, Shuster J & McCrate-Protus B. (2008). Palliative Care Consultant: A reference guide for palliative care 3RDed. Kendall/Hunt publishing Co.

Storey, P., Knight, C.F. & Schonwetter, R.S. (2003). Pocket Guide to Hospice/Palliative Medicine. AAHPM:Chicago

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