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death rattle

Etiology: - inability to clear secretions from the oropharynx at the end-of-life Pathology: - secretions oscillate up & down the respiratory tract during inspiration & expiration - no indication that this causes distress for patients Clinical manifestations: - noisy or rattling respirations at the end-of-life Complications: - often results in anxiety for the family & caregiver(s) Management: 1) prepare family, reassurance, anticipatory guidance [6] 2) repositioning may allow secretions to drain 3) mouth hygeine with sponge swab may be helpful 4) anticholinergics to reduce secretions a) of benefit only when secretions affect respiration [6] a) atropine eyedrops under the tongue every 2 hours to reduce secretions (treatment of choice) [1,2,3] b) scopalamine patch (onset of action ~24 hours) c) scopalmine 20 mg SQ QID [5] prophylaxis [5] d) hyoscyamine 0.125 mg SL every 8 hours e) glycopyrrolate 0.2 mg SQ every 8 hours 5) oral suction probably not useful - avoid suctioning with catheter [4] - avoid oropharyngeal suction as this results in unnecessary discomfort - anticholinergics do not dry up secretions already present

Related

end of life

General

noisy rattle

References

  1. Geriatric Review Syllabus, 7th edition Parada JT et al (eds) American Geriatrics Society, 2010 - Geriatric Review Syllabus, 9th edition (GRS9) Medinal-Walpole A, Pacala JT, Porter JF (eds) American Geriatrics Society, 2016 - Geriatric Review Syllabus, 10th edition (GRS10) Harper GM, Lyons WL, Potter JF (eds) American Geriatrics Society, 2019
  2. Protus BM, Grauer PA, Kimbrel JM. Evaluation of atropine 1% ophthalmic solution administered sublingually for the management of terminal respiratory secretions. Am J Hosp Palliat Care. 2013 Jun;30(4):388-92. PMID: 22833553
  3. Shinjo T, Okada M. Atropine eyedrops for death rattle in a terminal cancer patient. J Palliat Med. 2013 Feb;16(2):212-3. PMID: 22747099
  4. Medical Knowledge Self Assessment Program (MKSAP) 18, American College of Physicians, Philadelphia 2018
  5. van Esch HJ, van Zuylen L, Geijteman ECT et al Effect of Prophylactic Subcutaneous Scopolamine Butylbromide on Death Rattle in Patients at the End of Life. The SILENCE Randomized Clinical Trial. JAMA. 2021;326(13):1268-1276 PMID: 34609452 https://jamanetwork.com/journals/jama/fullarticle/2784661
  6. Albert RH. End-of-Life Care: Managing Common Symptoms. Am Fam Physician. 2017 Mar 15;95(6):356-361. PMID: 28318209 Free article. Review.