These are common in the last days of life, but are generally more troubling for family members than for the patient themselves.

Management

Conservative:

• Avoiding fluid overload - particularly stopping IV or subcutaneous fluids
• Educating the family that the patient is likely not troubled by secretions

Medical:

• hyoscine hydrobromide or hyoscine butylbromide is generally used first-line
  • the BNF does not suggest one is first-line over the other
  • hyoscine butylbromide may be less sedative than hyoscine hydrobromide
• glycopyrronium bromide may also be used

In patients with neurological problems such as Parkinson's disease, glycopyrronium bromide is often preferred over hyoscine hydrobromide. This is because hyoscine hydrobromide can cross the blood-brain barrier and potentially exacerbate the cognitive symptoms. Glycopyrronium bromide, on the other hand, does not cross the blood-brain barrier as readily, making it a safer choice in these patients to manage excessive secretions without worsening their neurological condition.