# 109 Death Rattle and Oral Secretions, 2nd ed

FAST FACTS AND CONCEPTS #109


Author(s): Katherine Bickel and Robert Arnold MD

Background   As the level of consciousness decreases in the dying process, patients lose their ability to swallow and clear oral secretions. As air moves over the secretions, which have pooled in the oropharynx and bronchi, the resulting turbulence produces noisy ventilation with each breath, described as ‘gurgling ‘or ‘rattling noises.’ While there is no evidence that patients find this ‘death rattle’ disturbing, the noises may be disturbing to the patient’s visitors and caregivers who may fear that the patient is choking to death. However, similar sounds may occur in patients who are not imminently dying, such as in those with brain injuries or in patients with various disorders leading to increased production or decreased clearance of secretions. Two sub-types of the death rattle have been proposed, although the significance regarding treatment has not been established: Type 1 = predominantly salivary secretions and Type 2 = predominantly bronchial secretions. Death rattle is a good predictor of near death; one study indicated the median time from onset of death rattle to death was 16 hours.

Non-Pharmacological Treatments

  • Position the patient on their side or in a semi-prone position to facilitate postural drainage
  • A minute or two of Trendelenburg positioning can be used to move fluids up into the oropharynx for easier removal; aspiration risk is increased, however.
  • Gentle oropharyngeal suctioning is used although this can be ineffective when fluids are beyond the reach of the catheter. Frequent suctioning is disturbing to both the patient and the visitors.
  • Reduction of fluid intake.

Pharmacological Treatments   While there are no evidence-based guidelines, the standard of care is to use muscarinic receptor blockers (anti-cholinergic drugs). These include scopolamine, hyoscyamine, glycopyrrolate, and atropine. All of these agents can cause varying degrees of blurred vision, sedation, confusion, delirium, restlessness, hallucinations, palpitations, constipation, and urinary retention. The primary difference in these drugs is whether they are tertiary amines which cross the blood-brain barrier (scopolamine, atropine, hyoscyamine) or quaternary amines, which do not (glycopyrrolate). Drugs which cross the blood-brain barrier are apt to cause CNS toxicity (sedation, delirium).
 

 

Drug Trade Name Route Starting Dose Onset

scopolamine (hyoscine)

hydrobromide

Transderm

Scop

Patch

One 1.5mg

atch

~12 h (24 h to steady state)
hyoscyamine Levsin PO,SL 0.125mg 30min
glycopyrrolate Robinul PO 0.2mg 30min
glycopyrrolate Robinul SubQ, IV 0.1mg 1min
atropine sulfate Atropine SubQ, IV 0.1mg 1min
atropine sulfate multiple Sublingual 1gtt (1% opth. soln) 30min

 

Pharmacological pearls

  • Glycopyrrolate has five times the anti-secretory potency compared to atropine but is poorly and erratically absorbed. The clinical significance of this is unclear.
  • The scopolamine patch releases ~1 mg over 72 hours. It takes 24 hours to reach steady state and for acute symptoms other drugs should be used. The patch should be placed on hairless skin just behind the ear, is changed every 72 hours, and more than one patch can be used at a time.
  • Hyoscyamine is available in short-acting, sustained-released, orally dispersible tablet, and oral solution forumations.

References

  1. Back IN, Jenkins K, Blower A, Beckhelling J. A study comparing hyoscine hydrobromide and glycopyrrolate in the treatment of death rattle. Palliat Med .2001; 15:329-336.
  2. Ohio Hospice & Palliative Care Organization. Palliative Care Pocket Consultant. Dubuqe, IA: Kendall Hunt Publishing; 2001.
  3. Twycross R, Wilcock A, eds. Hospice and Palliative Care Formulary USA. Nottingham, UK: Palliativedrugs.com Ltd; 2006.
  4. Wilders H, Menten J. Death rattle: prevalence, prevention and treatment. J Pain Symptom Manage. 2002; 23:310-317.
  5. Wee B, Hillier R. Interventions for noisy breathing in patients near to death. Cochrane Database of Systematic Reviews 2008, Issue 1. Art. No.: CD005177. DOI: 10.1002/14651858.CD005177.pub2.

Fast Facts and Concepts are edited by Drew A Rosielle MD, Palliative Care Center, Medical College of Wisconsin. For more information write to: drosiell@mcw.edu. More information, as well as the complete set of Fast Facts, are available at EPERC: www.eperc.mcw.edu.

Version History: This Fast Fact was originally edited by David E Weissman MD and published in March 2004. 2nd Edition was edited by Drew A Rosielle and published April 2008. Re-copy-edited in April 2009.

Copyright/Referencing Information: Users are free to download and distribute Fast Facts for educational purposes only. Bickel K, Arnold R. Death Rattle and Oral Secretions, 2nd Edition. Fast Facts and Concepts. April 2008; 109. Available at: http://www.eperc.mcw.edu/fastfact/ff_109.htm.

Disclaimer: Fast Facts and Concepts provide educational information. This information is not medical advice. Health care providers should exercise their own independent clinical judgment. Some Fast Facts cite the use of a product in a dosage, for an indication, or in a manner other than that recommended in the product labeling. Accordingly, the official prescribing information should be consulted before any such product is used.

ACGME Competencies: Medical Knowledge, Patient Care

Keyword(s): Non-Pain Symptoms and Syndromes