A Guide to Excessive Respiratory Secretion in Hospice

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Introduction

Excessive respiratory secretion is a build up of fluid in the upper respiratory system. Understanding its causes, prevention, and treatment will help most people find relief.

Causes

  • Fluid overload
  • Fluid accumulation in oral cavity during the dying process
  • Tube feedings
  • Aspiration of food/fluid
  • Inability to cough due to weakness
  • Infection
  • Tenacious, thick secretions
  • Disease
  • Oral lesions
  • Oral infections
  • Renal Failure
  • Positioning of patient

Assessment

  • History
  • Onset, acute or chronic
  • Precipitating/relieving factors
  • What diseases/illness does this person have that might cause the excessive secretions
  • Medications
  • Reactions to medications, interventions
  • Associated symptoms (dyspnea, increase work of breathing, use of accessory muscles)
  • Sleep disturbances
  • Psychosocial concerns
  • Spiritual concerns
  • Caregiver concerns
  • Impact on functionality
  • Quality of life

Physical Exam

  • Appearance of patient
  • Cardiopulmonary system
  • Oral cavity
  • Color and consistency of secretions
  • Signs of infection
  • Skin turgor

Non- Pharmacological Interventions

  • Feed upright, thicken liquids
  • Decrease IV fluids
  • Decrease tube feeding
  • Positioning
  • Oral care
  • Distraction from respiratory sounds (soft music, background noise)
  • Consider suctioning only if upper airway secretions are accessible

Pharmacological Interventions

Pharmacological treatment should be based on relieving the cause of excessive respiratory secretions whenever possible. Resolution of underlying factor(s) should be the primary goal whenever possible. Utilize team collaboration in assessment, intervention and education with the patient and family.

  • Hyoscyamine (Levsin®) tablets or drops 0.125-0.25 mg po/sl every 4 h as needed
  • Scopolamine transdermal (Transderm-Scop®) apply 1-2 patches behind ear every 72 h
  • Atropine 0.3 mg sq every 4 h (max 1.2 mg every 4 h)
  • Glycopyrrolate (Robinul®) 1-2 mg po/sl every 4 h as needed

Evaluate and Document symptom at each visit until resolved. Evaluate discontinuing medications as symptoms resolve. Collaborate with psychosocial and spiritual professionals to confirm that symptoms are managed with the most effective combination of non-pharmacological and pharmacological interventions.

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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