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Referral and warning signs
When to refer
Severe anxiety/agitation unresponsive to initial measures. Intractable cough requiring specialist assessment. Need for complex symptom management strategies.
Red flags
- Sudden onset severe anxiety/agitation (consider delirium, hypoxia, pain).
- Cough associated with haemoptysis or signs of airway obstruction.
- Secretions causing significant respiratory distress (rare).
Signs and symptoms
- Anxiety: Feelings of worry, nervousness, or unease; restlessness, irritability, difficulty concentrating, muscle tension, sleep disturbance.
- Muscle Spasm: Painful, involuntary muscle contractions.
- Excessive Bronchial Secretions ('Death Rattle'): Noisy, moist breathing due to inability to clear secretions, common in the dying phase.
- Intractable Cough: Persistent cough unresponsive to standard treatments, causing distress or interfering with sleep/quality of life.
Risk factors
- Anxiety: Fear of death, pain, breathlessness, psychosocial issues.
- Secretions: Decreased level of consciousness, inability to swallow/cough effectively (dying phase).
- Cough: Underlying lung disease (infection, tumour, COPD, effusion), heart failure, ACE inhibitor use, GERD.
Diagnosis
Clinical assessment
Assess symptoms based on patient/caregiver report and clinical observation. Assess anxiety using appropriate questions/scales. Auscultate chest for secretions/signs of underlying cause of cough. Exclude reversible causes.
Investigations
- Usually based on clinical assessment.
- Chest X-ray may help identify cause of cough (infection, effusion, tumour).
Diagnostic criteria
Clinical assessment of the specific symptom and its impact on the patient.
Management
Non-pharmacological management
- Anxiety: Reassurance, active listening, counselling, relaxation techniques, psychosocial/spiritual support.
- Secretions: Repositioning the patient (e.g., side-lying) can help drainage. Gentle oral suctioning (rarely needed, can be distressing). Explain to family that the noise is often not distressing to the unconscious patient.
- Cough: Treat underlying cause if possible (e.g., antibiotics for infection). Humidification. Avoid irritants.
Pharmacological treatment
- Anxiety / Muscle Spasm:
- - Diazepam 5-10mg PO OD, titrate up to TID PRN. (Child doses in UCG).
- - Lorazepam (alternative benzodiazepine, shorter acting).
- Excessive Bronchial Secretions:
- - Hyoscine Butylbromide 20mg PO/SC OD, titrate up to TID PRN. (UCG reference). Alternatives: Glycopyrronium.
- Intractable Cough:
- - Opioids (Antitussive effect): Morphine low dose (as used for pain/breathlessness, see PAL001) PO Q4H.
- - Codeine Linctus (if available).
- - Consider nebulized saline or local anaesthetic (specialist).
- - Treat specific cause if identified (e.g., bronchodilators for COPD, diuretics for HF).
Monitoring
Monitor effectiveness of treatment in controlling the target symptom. Monitor for side effects of medications (e.g., sedation with benzodiazepines, anticholinergic effects with hyoscine).
Complications
- Anxiety: Poor quality of life, interferes with coping.
- Secretions: Distress to family members.
- Cough: Exhaustion, pain, sleep disturbance, social embarrassment.
Prevention
- Proactive management of anxiety.
- Optimize treatment of underlying respiratory/cardiac conditions to prevent cough.
- Anticipatory prescribing for secretions in the dying phase.
Patient education
- Explanation of the symptom and its likely cause.
- Reassurance and coping strategies for anxiety.
- Explanation about noisy breathing (death rattle) to family.
- How to use prescribed medications.
- Non-drug measures for cough/secretions.
Uganda-specific notes
Diazepam is widely available for anxiety/spasm. Hyoscine butylbromide is available for secretions. Low-dose morphine is effective for intractable cough. Addressing family distress around 'death rattle' is important.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 13, Section 13.2.8