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Antisialagogues are medications often used to manage and treat patients with noisy breathing near the end of life. These medications are members of the antimuscarinic class. This educational activity reviews the indications, actions, and contraindications for antisialagogues as agents in the management of noisy breathing near the end of life; use in other applicable disorders will also be discussed. This activity highlights the mechanism of action, adverse event profile, dosing, pharmacodynamics, pharmacokinetics, monitoring, and relevant interactions pertinent for interprofessional team members in the management of patients with noisy breathing near the end of life and related conditions. Objectives: Review the monitoring requirements for patients receiving antisialagogues. Describe the pathophysiology of antisialagogue toxicity. Identify the indications for administration of antisialagogues in the management of noisy breathing near the end of life. Explain the importance of collaboration and communication among the interprofessional team to enhance care coordination for patients affected by noisy breathing near the end of life receiving antisialagogues. Access free multiple choice questions on this topic.

Administration of neostigmine methylsulfate, which does not cross the blood-brain "barrier," can be administered as an antidote in incremental intravenous dosages of 0.25 mg in adults and can be repeated every 5 to 10 minutes until anticholinergic activity noted is reversed up to a maximum of 2.5 mg.[18] If CNS symptoms including restlessness, excitement, convulsions, or psychotic behavior are to occur, physostigmine which does cross the blood-brain "barrier" should be used and slowly administered in dosages of 0.5 to 2 mg administered IV and is repeatable as indicated up to a total of 5 mg in adults.[22] Supportive care generally is undertaken to reverse hypotension, including pressors with supportive care as needed. In acute overdose, a curare-like action may occur in which neuromuscular blockade leading to muscular weakness, including paralysis, where artificial respiration and mechanical ventilation in patients whose code status/advanced directive/POLST allows will need to be instituted and maintained until effective respiratory action returns.[23]

Few randomized clinical trials to effectively compare the antisialogogues exist, and therefore, an interprofessional effort necessary to coordinate the highest level of care for each patient. Individualizing each patient and prioritizing symptom relief to provide supportive care at the end of life must be discussed to improve patient safety and enhance patient-centered care. Coordinating end-of-life care with antisialogogues may at times appear to be a clinically challenging pathophysiological endeavor, and as such, requires the efforts of an interprofessional team, including a clinician who specializes in end-of-life medicine. Nursing interventions alone have demonstrated significant improvement in death rattle therapy; nurses can monitor the patient's response as well as check for adverse events and report to the prescriber.[24] Pharmacists are also essential personnel in planning such interventions; they can assist the prescriber in agent selection, verify dosing, and counsel the patient and/or family regarding the purpose of the drug. Employing an interprofessional team approach to supportive care strategies given the above information remains the best holistic and integrated approach to help achieve the best outcome for the patient and the patient's family near the end of life. [Level 5]