Care at the end of life: Management of “death rattle”

Contributed by: Sarah Burton-Macleod MD CCFP(PC) - View bio

Case

84-year-old Gladys has been hospitalized from home, where she lived independently, with delirium in the setting of a community-acquired pneumonia (COVID-19 negative). Further work-up revealed evidence of suspected underlying widely metastatic malignancy. Her daughter, Laurel, who is also her agent as per her personal directive, has noticed a bit of decline in recent months, but nevertheless is surprised by this news. She tells you that her mother has always been very independent and would not want any attempts to prolong her life if she would not be expected to return home and tend her garden. As her condition continues to decline rapidly, she asks you to focus on comfort. You change her Goals of Care Designation to C2, expecting that death is imminent. You streamline her medications, discontinuing all except those contributing to her comfort, and ensure she has medications available to relieve pain, dyspnea, nausea and agitation, as needed. Laurel agrees to discontinue her IV fluids. Gladys looks very comfortable and Laurel thanks you for your care.

You are somewhat surprised when you are paged by her nurse that Laurel is upset and would like to speak with you. When you walk into the room, you notice Gladys, now unresponsive, has upper airway congestion. Laurel anxiously asks you why her mother sounds ‘like she is going to choke’ when breathing and what can she do about it if she does. 

Issue

Providing comfort at the end of life, with particular focus on the symptom management of death rattle.

Death rattle can be a significant source of distress for families at the bedside as patients near the end of life. Explanations as to the etiology of the upper respiratory secretions and non-pharmacological approaches are important. In addition, medications can also help to reduce this distressing symptom, though emerging evidence suggests the timing of their initiation may impact effectiveness. 

Background

Death rattle has been defined as the sound of “noisy breathing caused by presence of mucus in the respiratory tract.”^1,2 It is also common, with prevalence rates quoted between 12-92% in a systematic review from 2014.³ Though unlikely to be a source of distress for the patients, who are often unresponsive at this point, it may be a source of distress for family at the bedside, especially if they feel it is indicative of discomfort for the patient. 

Evidence

In a 2014 systematic review, the evidence for the use of antimuscarinic medications, long recommended to relieve this symptom because of distress it may cause to family, was examined. Antimuscarinic medications were recommended on the basis that they competitively antagonize acetylcholine at muscarinic receptors, leading to decreased production of secretions in the bronchial as well as salivary and GI tracts.^3,4 This review found no evidence that the use of any antimuscarinic drug was superior to no pharmacologic treatment; however, many studies did not include a placebo group and more studies were needed.³ 

Since that time emerging evidence indicates that if an antimuscarinic medication is provided earlier on in the development of the symptom (either at first development of it or even prophylactically), that such medications can be effective.^1,4 In fact, an RCT looking at the use of scopolamine butylbrominde (Buscopan) given prophylactically did significantly reduce the occurrence of death rattle compared with placebo.¹ The potential explanation for this lies in role that antimuscarinics play, though they decrease mucus production, they do not necessarily affect the mucus already present. Other antimuscarinic medications described in the literature include scopolamine (hyoscine) hydrobromide, atropine and glycopyrrolate with preliminary evidence that effectiveness of these are relatively equivalent.^3,5 Of note, scopolamine hydrobromide and atropine are tertiary amines that cross the blood-brain barrier, leading to added central effects such as sedation, whereas glycopyrrolate and Buscopan do not.⁴ Regarding scopolamine and glycopyrrolate specifically, there is lack of clear evidence that either is more effective, with a few limited comparison studies showing mixed results.^6,7,8

The communication with family at the bedside around this symptom is very important regardless of pharmacologic approach. It has been shown that the health care professional’s interpretation of the symptom can significantly affect the family’s perceptions. Also, that not all family members are distressed by it.^9,10,11 Addressing the underlying etiology of the death rattle symptom and reassuring the family around concerns of choking, where appropriate, will help ease distress. In addition, non-pharmacological interventions may include repositioning of the patient and even gentle suctioning of secretions if needed. Re-evaluation of parenteral fluids is often recommended, though one study did not find a significant correlation with amount of fluids and severity of the symptom.¹²

Back to the case

You explain the underlying cause to her daughter and reassure her it is not a sign that she will choke. Also, that it is not likely to be a source of distress to Gladys. Laurel seems visibly relieved after this conversation. Repositioning allows for temporary relief. As Gladys is now unresponsive, increased sedation with hyoscine hydrobromide (scopolamine) is not a relevant concern, and so you prescribe it 0.4mg sc q6h ATC and q2h prn for upper respiratory congestion. Had she been still experiencing periods of alertness, and the goal was to preserve these as much as possible, glycopyrrolate would have been a good option. 

Gladys passed away through the night that night, very peacefully, with her daughter at the bedside. 

Summary and recommendations

This case highlights the symptomatic management of death rattle. Though it is unlikely it is a source of distress to patients who are usually unresponsive at this point, it may be a source of distress to family members at the bedside. For this reason, communication around the etiology of it, reassurance that it is unlikely to be uncomfortable for the patient, and that it is not indicative of imminent choking risk is the main recommendation. In addition, repositioning of the patient, reassessment of fluid volumes, and possibly gentle suctioning can be considered. Antimuscarinic agents can be helpful but their effectiveness seems to be correlated with timing and it is best to begin them early, if not prophylactically, for this symptom. Which antimuscarinic agent often depends on local availability and patterns of practice, but those that cross the blood-brain barrier will be more likely to increase sedation which may be pertinent in the clinical context. 

Please note that these medications are often included in the end-of-life care pathways available at many institutions (and in the ‘C2’ order set in Connect Care). 

References

1. Van Esch HJ, van Zuylen L, Geijteman ECT, Oomen-de Hoop E, Huisman BAA, Noordzjj-Nooteboom HS, 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. 
2. Bennett M, Lucas V, Brennan M, Hughes A, O’Donnell V, Wee B. Association for Palliative Medicine’s Science Committee. Using Anti-Muscarinic drugs in the management of death rattle: evidence-based guidelines for palliative care. Palliative Medicine. 2002. 16(5): 369-374. 
3. Lokker ME, van Zuylen L, van der Rijt CCD, van der Hide A. Prevalence, Impact, and Treatment of Death Rattle: A Systematic Review. Journal of Pain and Symptom Management. 2014. Jan 47(1): 105-122.
4. Mercadante S, Marinangeli F, Masedu F, Valenti M, Russo D, Ursini L, et. al. Hyoscine Butylbromide for the Management of Death Rattle: Sooner Rather than Later. Journal of Pain and Symptom Management. 2018. Dec 56(6) 902-7.
5. Wildiers H, Dhaenekint C, Demeulenaere P, Clement PMJ, Desmet M, Van Nuffelen R, et. al. Atropine, Hyoscine Butylbromide, or Scopolamine are equally effective for the Treatment of Death Rattle in Terminal Care. Journal of Pain and Symptom Management. 2009. 38(1): 124- 133.
6. Hughes A, Wilcock A, Corcoran R, Lucas V, King A. Audit of three antimuscarinic drugs for managing retained secretions. Palliative Medicine. 2000; 14: 221-222.
7. Back IN, Jenkins K, Blower A, Beckhelling J. A study comparing hyoscine hydrobromide and glycopyrrolate in the treatment of death rattle. Palliative Medicine. 2001;15: 329-336.
8. Hugel H, Ellershaw J, Gambles M. Respiratory tract secretions in the dying patient: a comparison between glycopyrronium and hyoscine hydrobromide. Journal of Palliative Medicine. 2006; 9: 279-284. 
9. Wee BL, Coleman PG, Hillier R, Holgate SH. The sound of death rattle I: are relatives distressed by hearing this sound? Palliative Medicine. 2006. 20: 171-5.
10. Wee BL, Coleman PG, Hillier R, Holgate SH. The sound of death rattle II: how do relatives interpret the sound? Palliative Medicine. 2006. 10: 177-181.
11. Matsunuma R, Suzuki K, Matsuda Y, Mori M, Watanabe H, Yamaguchi T. Palliative care physicians’ perspectives of management for terminally ill cancer patients with death rattle: a nationwide survey. Japanese Journal of Clinical Oncology. 2020. 50(7): 830-3. 
12. Lokker ME, van der Heide A, Oldenmenger WH, van der Rijt CCD, van Zuylen L. Hydration and symptoms in the last days of life. BMJ Supportive and Palliative Care. 2021. 11: 335-343.,