As children approach the fi nal hours of life, respiratory symptoms are greatly impacted by neurological decline and progressive somnolence. Irregular breathing patterns begin to present as hypoventilation, apnea, Cheyne-Stokes respirations, and agonal breathing. These symptoms may be isolated or occur in combination. The loss of gag reflex, inability to swallow, and the buildup of oral and tracheal secretions lead to gurgled respirations referred to as the death rattle . This can be particularly difficult for family members to observe [ 15 ]. Glycopyrrolate administered SC is used to reduce the production of saliva in unresponsive patients.