Death Rattle - A Brief Review

Palliative Medicine Grand Round
Death Rattle - A Brief Review
Dr Alice Ka Wai Mok,
Palliative Care Unit, Shatin Hospital, Hong Kong.
Correspondence: mkw474@ha.org.hk
ABSTRACT
Death rattle is a phenomenon frequently observed during the final hours of dying patients. Its
occurrence is thought to cause distress on relatives and staff. The control of death rattle includes both
general measures and pharmacological means. This article is a brief review of literature looking into the
impacts of death rattle. The efficacies of the different anti-muscarinic drugs in the management of death
rattle are also studied.
HKSPM Newsletter 2010 Apr Issue No.1 p33-34.
Death rattle is a phenomenon frequently
observed during the final hours of dying patients.
Its occurrence is often thought to cause negative
impacts on relatives and staff. Different
anti-muscarinic medications have been used as
the pharmacological means of controlling death
rattle. Studies have looked into the meaning of
death rattle and the relative efficacy of the
different medications in symptoms control.
Introduction
Death rattle is the noise cause by the turbulent
air flow through the accumulated secretions in
the oropharynx and bronchial tree. This is often
observed at the final stage of life when patients
are no longer capable of swallowing, resulting in
the pooling of secretions. Studies found the
incidence of death rattle ranged from over 20% to
half of all dying patients1-4 . The occurrence of
death rattle is recognized as a strong predictor of
imminent death. Wildiers2 noted that 76% of
patient died within 48 hours of onset, while Käss
et al3 found the median time of death since the
onset of death rattle was 16 hours only.
The salivary glands and the bronchial mucosa
are the main sources of airway secretions. Two
muscarinic receptors, the M2 and M3, are
involved in the regulation of secretions. While
vagal stimulation increases the volume of airway
secretions, it has been shown that
anti-muscarinic drugs effectively reduce the
secretions by antagonizing acetylcholine at the
muscarinic receptors.
Impact of Death Rattle
Death rattle is a common phenomenon
among the dying patients. Studies have found the
Newsletter of Hong Kong Society of Palliative Medicine
Death Rattle: A Brief Review
HKSPM Newsletter 2010 Apr Issue 1 P33
incidence of 23% to 49% 2-4 . Wee BL et al 5-6
looked into the meaning of death rattle to
relatives and found relatives interpret the sound
of death rattle in a variety of ways. About half of
the relatives found it distressing. Others,
however, were neutral or found it a helpful sign of
impending death. These authors also looked into
the impact of death rattle on staff and volunteers 7
and found that most expressed negative feelings
about hearing the sound which may influence
their decision to intervene.
Management of Death Rattle
Both non-pharmacological and pharmacological
measures could be applied to dying
patients with death rattle. These patients should
be positioned on their side or in a semi-prone
position with occasional gentle suctioning of
oropharyngeal fluids. Communication with
relatives will be helpful in addressing fears and
distress caused by the rattling noise.
Anti-muscarinic medication is the mainstay of
pharmacological therapy for the management of
death rattle. Common drugs being used include
hyoscine hydrobromide, glycopyrronium,
hyoscine butylbromide and atropine.
Several studies had compared the
effectiveness among these medications. Hughes
et al8 did a prospective audit and found that a
single dose of any of the drugs hyoscine
hydrobromide, hyoscine butylbromide and
glycopyrrolate led to improvement in 35-54% of
patients. Results demonstrated no overall
difference in symptoms alleviation among the
three drugs. Back et al9 compared hyoscine
hydrobromide and glycopyrrolate in the treatment
of death rattle noting the noise scores at the start,

30 minutes, an hour and 4-hourly thereafter. They
concluded that glycopyrrolate 0.2mg is less effective
at reducing death rattle than hyoscine hydrobromide
0.4mg when assessed at 30min, and the
use of glycopyrrolate may lead to an increased
need for other sedatives or anti-emetic medications.
Using the Liverpool Care Pathway, Hugel
et al 10 also compared these two medications.
They found a significant difference in the overall
response between the two groups. All patients in
the glycopyrronium group had some response to
the medication whereas 22% of patients in the
hyoscine group had no response. More patients
in the hyoscine group died with respiratory tract
secretions present.
In the Cochrane review 2008 11 , only one
study 12 fulfilled the inclusion review criteria. This
was a randomized controlled trial examining the
efficacy of scopolamine 0.5mg iv / sc given at
time zero, four and eight hours. The intervention
group showed a tendency to reduced death rattle
than the control group in the first 10 hours but the
difference was not significant.
Recently a Belgium group conducted a
multicenter open-label, prospective, randomized
trial comparing the effectiveness of atropine,
hyoscine butylbromide and scopolamine for the
treatment of death rattle 13 . They assigned
patients randomly to one of the three groups
given a sc bolus dose of the respective
medication followed by a regular dose or
continuous infusion of the drug. In the atropine
group, a bolus of 0.5mg was followed by
3mg/24hr infusion or 0.5 mg q4H. In the
scopolamine group, the bolus dose given was
0.25 mg then followed by 1.5mg /24 hr infusion or
0.25mg q4H. For the hyoscine butylbromide
group, a 20mg bolus was followed by 60mg/24hr
infusion or 10mg q4H. The rattling was scored at
30min, 60min, 4, 12, 24 hours and then, every 24
hours till death. They concluded from this study
that treatment effectiveness improved steadily up
to 24 hours and there was no significant
difference in effectiveness among the three drugs
either at 1 hour or up to 48 hours. The treatment
is more effective when started at a lower baseline
rattle score although this difference in efficacy as
a function of intensity was no longer seen after 48
hours of treatment. They found no difference in
the median and mean survival time among the 3
groups, and similar effectiveness was seen
among different classes of primary tumors or
among different age categories.
Newsletter of Hong Kong Society of Palliative Medicine
Death Rattle: A Brief Review
HKSPM Newsletter 2010 Apr Issue 1 P34
Conclusion
Death rattle is a frequent clinical sign at the
end of life, and its occurrence is a strong
predictor of imminent death. Rattling noises have
been shown to cause distress to relatives and
staff thus warranting interventions. Management
of death rattle included both non-pharmacological
and drug treatment. Where different
anti-muscarinic drugs are available for the control
of respiratory secretions, there is to date no
evidence of significant differences in
effectiveness among these medications used.
References
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Wee B. Using anti-muscarinic drugs in the management
of death rattle : evidence-based guidelines for palliative
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