1. Managing Secretions in MND
Dr. Liz Williams Associate Specialist Palliative Care Team Chair MND DSAG BCUHB
29th November 2016

2. Managing Secretions in MND
Management of problems
Non Pharmacological
Phamacological
Nice guidance **
End of life care secretion management
Clinical Case
Normal saliva management
Abnormal saliva management in MND
Definition of Sialorrhoea
Problems with secretions in MND
Assessment

3. Normal Secretion Management and Swallow
Role of Saliva
Digestion
Enables speech & swallow
Cleaning & lubricating
Enables taste
Maintains healthy mucosa and teeth
PHLEGM
thick mucus from respiratory mucus membranes
SALIVA
L per day
Average adult: 600 Swallows /day
A normal swallow is produced by up to 50 pairs of muscles
3 pairs major Salivary Glands and many minor glands
Sympathetic innovation ( flight/flight ): increases protein rich thick mucus
Parasympathetic innovation (rest and digest) : increases serous thin watery saliva

7. Problems caused by Abnormal Secretion Management in MND
Social
Social isolation
Poor communication
Poor social understanding
Poor body image
Increased dependence & level of care
Psychological
Fear
Poor self esteem
Depression
Anxiety

8. Clinical Saliva Score Sheffield validation but still some concerns and not validated For research use

11. Pinapple contains proteolytic enzyme

13. Pharmacological Management of Secretion Problems in MND Thin Watery Saliva II
TRICYCLIC ANTIDEPRESSANTS
Amitryptilline Low dose (start 5-10mg)
Oral / PEG
Night sedation
Avoid with cardiac conditions & Glaucoma
May help emotional lability
ANTIHYPERTENSIVES
Clonidine Low dose
Oral / PEG or CSCI
Avoid in renal failure

14. Pharmacological Management of Secretion Problems in MND Thin Watery Saliva III
BOTULINUM TOXIN (BOTOX)
Medically refractory Sialorrhoea should be considered for Botox therapy**
Grade B recommendation Supported by NICE 2016
Class I & II studies
Review by Miller 2009, Orrell 2010, Young et al 2011
Can cause further weakness and swallowing problems
RADIOTHERAPY
Lower level recommendation Grade C
May be permanent or temporary

15. Pharmacological Management of Secretion Problems in MND Thick, Tenacious Saliva , Mucus & Phlegm I
Review current medication which may dry secretions**
HUMIDIFICATION**
Saline
Saline nebulizers
Humidification of O2 if required
MUCOLYTICS**
Carbocystine
Oral / PEG only mg QDS
Rare risk of peptic ulceration

16. Pharmacological Management of Secretion Problems in MND Thick, Tenacious Saliva , Mucus & Phlegm I
Anxiety and unease from frequent and self limiting choking episodes
BENZODIAZEPINES
Lorazepam
S/L or oral/PEG PRN only
Midazolam
Buccal or nasal or S/C PRN Only
Sedating - consider in refractory problems in EOL care
BETA BLOCKERS
Propranolol
Limited evidence
Monotor BP and HR

18. Secretion Management in MND at End of Life
Anticipatory Antisecretory medication as one of 4As
Hyoscine Hydrobromide & Glycopronium
Just in case PRN medication

19. Just In Case Boxes ( JICB)

20. Further Information www.mndassociation.org www.nice.org.uk
Palliative Care Teams:
East :
Central : ext 7960
West:
Dr. Liz Williams
Tel: