The presence of respiratory secretions is a common event in the final hours and days of life. This phenomenon, which often includes noisy breathing, is part of the dying process. While the sound can be unsettling for family members and caregivers, it is not a source of distress or discomfort for the dying person. Understanding these physiological changes helps caregivers focus on providing comfort and support during this final transition.
The Physiological Cause of Accumulation
The accumulation of secretions occurs primarily because the body loses the muscular coordination required to manage normal fluids. As a person approaches the end of life, their level of consciousness often decreases, which significantly impairs the swallowing reflex (dysphagia).
The muscles that control swallowing and the cough reflex weaken, meaning that normal salivary and respiratory mucus cannot be effectively cleared from the throat and upper airway. These secretions begin to pool in the pharynx and trachea. Since the dying person is often lying down and too weak to move or reposition themselves, gravity is no longer an aid in draining these fluids.
The body is not necessarily producing an excessive amount of fluid, but rather it has lost the ability to manage the normal volume it is still creating. This mechanical failure of the clearing mechanisms is the root cause of the fluid buildup. This pooling then creates the conditions necessary for the characteristic noises that accompany breathing in the terminal phase.
Understanding Terminal Respiratory Noises
The noisy breathing that results from pooled secretions is medically referred to as terminal respiratory secretions or terminal congestion. The noise is a result of air moving turbulently over the fluid collected in the upper airway, producing a wet, gurgling, or rattling sound. This sound is not an indication of suffocation or choking, but simply the mechanical effect of breathing through a layer of liquid.
Terminal respiratory noises are classified into two types based on the fluid’s location. Type 1 sounds originate from saliva and mucus pooled in the oropharynx and are typically more responsive to interventions. Type 2 sounds arise from secretions deeper in the bronchial tubes and are often associated with pre-existing pulmonary conditions.
This sound is a sign, not a symptom, and does not cause distress to the patient. The person experiencing these sounds is typically unconscious or deeply sedated due to their underlying condition. For the dying person, this noise is often comparable to snoring, and care involves reassuring family members who may fear their loved one is in pain.
Comfort-Focused Management and Care
The primary goal of managing terminal secretions is to enhance the patient’s comfort and reduce the distress experienced by observers. Non-pharmacological interventions are the recommended initial approach for managing the secretions. The most effective strategy is to reposition the patient, usually by turning them onto their side or placing them in a semi-prone position.
This side-lying position allows gravity to help drain the pooled secretions out of the mouth and pharynx. Elevating the head of the bed slightly can also be helpful, provided the patient remains comfortable. Gentle oral care, wiping away visible secretions from the mouth, is also helpful, but deep suctioning is usually avoided. Deep suctioning can be uncomfortable, may provoke agitation, and is often ineffective at reaching the location of the sounds.
If repositioning does not adequately manage the noise, medical staff may use medications to decrease the production of new secretions. These medications, known as anticholinergics, work by blocking nerve impulses that stimulate glands to produce fluid. Common examples include scopolamine, hyoscyamine, and atropine. However, these medications only act to dry up new secretions and cannot dissolve the fluid that has already pooled.