Respiratory Secretions Care in the last 72 hours of life Paul Tait, pharmacist
50%
Why? Inability to swallow & clear secretions Ineffective cough Reduced consciousness Pooling of secretions in the throat
Why? Secretions saliva bronchial mucosa pulmonary oedema gastric reflux Repetitive rattly breathing
Management Management options include: > General supportive measures; and > Medications Communication is essential.
Research > Consent > Different products marketed globally > Caregiver and staff change on routine basis > Is the symptom distressing? Papers talk about the use of octreotide and anticholinergics
Management - Communication Can be distressing to hear for the > Family; and > Staff Important to: > explain the cause; and > reassure them
Management - General Supportive Measures Repositioning the patient: > shift the pooled secretions, > reduce the noise; and > encourage postural drainage. Be persistent and try different positions! Suctioning: > If there are visible pooled secretions in the oral cavity
Nutrition and Fluids Diminished: > Desire and ability to eat and drink > Ability to communicate thirst or hunger Benefit vs risk Cultural issue
Management - Medications > Australian guidelines - anticholinergics
Pharmacological Characteristics of Anticholinergics Block acetylcholine at receptor level > Cardiovascular > Respiratory > Cerebral > Gastrointestinal > Ophthalmic > Genitourinary > Thermoregulation
Pharmacological Characteristics of Anticholinergics Structural variation within the class Symptom Atropine Hyoscine Hyoscine Glycopyrrolate butylbromide hydrobromide Tachycardia +++ + + ++ Bronchodilatation ++ + + ++ Sedation + 0 +++ 0 Anti-sialagogue effect ++ +++ +++ +++ 0 no effect; + minimal effect; ++ moderate effect; +++ marked effect.
Respiratory Secretions Adverse Drug Reactions Evidence Cost
Evidence > New vs existing secretions > Treatment should be initiated early and as required > Cease if there is no improvement > Equivalent Medication Evidence Hyoscine butylbromide = Glycopyrrolate = Atropine = Hyoscine hydrobromide =
Cost > PBS > Patient and Government contributions. > Concession card holders : $6.30 Medication Evidence PBS Hyoscine butylbromide = Glycopyrrolate = Atropine = Hyoscine hydrobromide =
Adverse Drug Reactions > All have ADRs > Fatigue & other medicines > Blood-brain barrier (BBB) Medication Evidence PBS BBB Hyoscine butylbromide = Glycopyrrolate = Atropine = Hyoscine hydrobromide =
Adverse Drug Reactions > Dosing > Anticipatory prescribing > Up to 6 doses/ 24 hours > Monitor & adjust as needed Medication Hyoscine butylbromide Glycopyrrolate Atropine Hyoscine hydrobromide Starting Dose 20mg SC, every 2 hours prn 200microg SC, every 2 hours prn 600microg SC every 4 hours prn 400microg SC every 4 hours prn
Other Considerations Independence from other conditions > Respiratory tract infections > Pulmonary oedema > Gastro-oesophageal reflux > Breathlessness
Medication Compatibility Medication Syringe compatibility Hyoscine butylbromide midazolam, morphine, oxycodone Hyoscine hydrobromide Glycopyrrolate Atropine morphine, oxycodone, ranitidine chlorpromazine, droperidol, fentanyl, hydromorphone, lignocaine, midazolam, morphine, ondansetron, promethazine, ranitidine midazolam, ranitidine
Resources > CareSearch.com.au > palliaged.com.au palliagedgp and palliagednurse apps > Therapeutic Guidelines (Palliative Care) > Australian Medicines Handbook and Aged Care Companion > Eastern Metropolitan Region Palliative Care Consortium (syringe driver compatibility) > Specialist Palliative Care Services
Respiratory Secretions Care in the last 72 hours of life Paul Tait, pharmacist