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 refl ex, 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 diffi cult for family
members to observe [ 15 ]. Glycopyrrolate administered
SC is used to reduce the production of
saliva in unresponsive patients.