Death rattle--Fast Fact #109

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    fast fact and concept #109: death rattle and oral secretions
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    title: fast fact and concept #109: death rattle and oral secretions



    author(s): k bickel; r arnold



    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 condition 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, those with brain injury or in patients with various disorders leading to increased production or decreased clearance of secretions. two sub-types of 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.

    treatments:
    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 to move the fluids up into the oropharynx, for easier removal; aspiration risk is increased.
    gentle oropharyngeal suctioning, but this is often ineffective when fluids are beyond the reach of the catheter. frequent suctioning is disturbing to both the patient and the visitors.
    reduce 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) or quaternary amines, which do not (hyoscyamine, glycopyrrolate). drugs which cross the bbb are apt to cause cns toxicity (sedation, delirium).


    (this is supposed to be a nice table but the format doesn't copy with it..sorry!)

    drug (trade name) route starting dose onset
    hyoscyamine hydro. scopolamine patch 1 (~1 mg/3 days) 12 hrs
    hyoscyamine sulph. levsin drops, tabs 0.125 mg 30 min
    glycopyrrolate robinul pills 1mg 30 min
    glycopyrrolate robinul injection (sc,iv ) 0.2 mg 1 min
    atropine atropine injection 0.1 mg 1 min
    atropine multiple eye drops 1gtt (1%) 30 min



    pharmacological pearls:

    glycopyrrolate has five times the anti-secretory potency compared to atropine but is poorly and erratically absorbed, although the clinical significance of this is unclear.
    more than one scopolamine patch can be used, but the time to effect is 12 hours?thus, for acute management, other drugs should be used.
    atropine ophthalmic drops can be used sublingually .


    references:
    back in, jenkins k, blower a, beckhelling j. a study comparing hydrobromide and glycopyrrolate in the treatment of death rattle. palliat med 2001;15:329-336.
    palliative care pocket consultant. ohio hospice & palliative care organization, 2001.
    physicians desk reference, 2003.
    wilders h, menten j. death rattle: prevalence, prevention and treatment. j pain symptom manage 2002;23:310-317.

    copyright/referencing information: users are free to download and distribute fast facts for educational purposes only. citation for referencing: fast facts and concepts #109. death rattle and oral secretions. bickel k and arnold r. march 2004. end-of-life physician education resource center www.eperc.mcw.edu.

    disclaimer: fast facts provide educational information, this information is not medical advice. health care providers should exercise their own independent clinical judgment. some fast fact information cites the use of a product in 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 use.
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