Principles of managing respiratory tract secretions in the last days of life

The inability to cough effectively or to swallow and clear secretions from the oropharynx or trachea in the last days of life causes pooling of secretions in the throat, which results in repetitive noisy rattly breathing. This is a normal part of the dying process and is unlikely to be distressing for patients, but can be upsetting for families and carers to hear. The mainstay of management is explaining the cause of the noisy rattly breathing to families and carers and reassuring them that it is normal, to reduce their distress—see Guidance for explaining the dying process and aspects of care in the last days of life to family members and carers for an example explanation.

Repositioning the patient may help shift pooled secretions, reduce noise, and encourage postural drainage; try different positions to find which works best. If pooled secretions are visible in the oral cavity, consider removing them with a swab or sponge. Suction may be considered; however, do not use suction in the hard or soft palate region because this can cause tissue injury. Do not suction beyond the oral cavity because this is likely to stimulate the gag reflex and can cause distress.

An anticholinergic drug may be used to reduce the production of respiratory secretions and manage rattly breathing in the last days of life. However, there is limited evidence to support this practice and, as it is unlikely that patients experience distress from this symptom, anticholinergic use is often to address family, carer or staff distressvan Esch, 2021.

For patients who do not respond to treatment, and they or their family or carer appear to be distressed, seek specialist palliative care advice.