Research ArticleTools for Practice

Reducing death rattle at the end of life

Jen Potter and Christina S. Korownyk
Canadian Family Physician July 2023, 69 (7) 477; DOI: https://doi.org/10.46747/cfp.6907477

Clinical question

Can medications reduce the incidence of terminal respiratory secretions (death rattle) at the end of life?

Bottom line

Best evidence supports prophylactic administration of scopolamine butylbromide (Buscopan, hyoscine butylbromide) in patients close to death but without death rattle, which reduces the number who develop death rattle (13% vs 27% with placebo). Evidence supporting treatment of death rattle once it has begun is less clear, with no evidence that one anti-muscarinic is clearly superior to another. There is no evidence that treatment of death rattle improves patient comfort. It may, however, reduce the distress of people at bedside. Treatment decisions should be guided by conversations with family or caregivers.

Evidence

Prophylaxis

  • In 1 double-blind RCT,1 162 hospice patients in the dying phase (according to a multidisciplinary team) without death rattle were given scopolamine butylbromide, 20 mg subcutaneously 4 times daily, or placebo.

    • - Development of death rattle (score of 2 or 3 on a 3-point scale, higher scores indicating worse condition) at any point prior to death: 13% versus 27% (placebo); number needed to treat of 8.

    • - Adverse events (including restlessness, dry mouth, or urinary retention): no difference.

  • One non-blinded RCT2 with 132 adults close to death but without death rattle examined prophylaxis versus treatment at onset of death rattle with scopolamine butylbromide, 20 mg subcutaneously then 60 mg every 24 hours:

    • - 48% of patients suffered death rattle if treatment was initiated after symptoms were present, versus 6% of patients for whom treatment was initiated prior to symptom onset.

Treatment once death rattle presents

  • Four systematic reviews3-6 of 5 RCTs (10 to 333 participants) found the following.

    • - Three RCTs found no difference between scopolamine hydrobromide and either atropine (1 RCT, 333 patients) or octreotide (1 RCT, 10 patients). Whether outcomes differed between scopolamine hydrobromide and glycopyrronium (1 RCT, 13 patients) was unclear.

    • - Two RCTs found no difference between placebo and either atropine (1 RCT, 160 patients) or scopolamine hydrobromide (1 RCT, 31 patients).

Context

  • Death rattle is defined as noisy breathing caused by mucus in the upper respiratory tract.

    • - It occurs in 12% to 80% of patients in the final 3 days of life.7

    • - It may not distress patients; however, it may be distressing to family and caregivers.1

  • Nonpharmacologic measures include physical repositioning, although evidence to support this is lacking.5

  • Scopolamine butylbromide (Buscopan) is available subcutaneously or orally in Canada.

    • - Scopolamine hydrobromide is different and can cause central nervous system effects.8

Implementation

While glycopyrronium is commonly used for death rattle, there is little evidence of efficacy or tolerability. Prophylaxis with scopolamine butylbromide appears more effective than treatment once death rattle is established, so it is reasonable to consider in a patient’s dying phase. It is important to examine the reasons treatment is being explored, including patient and caregiver distress. Consideration of alternative supportive measures including reassurance and management of other symptoms (eg, pain or dyspnea) may provide greater comfort.

Notes

Tools for Practice articles in CFP are adapted from peer-reviewed articles at http://www.toolsforpractice.ca and summarize practice-changing medical evidence for primary care. Coordinated by Dr G. Michael Allan and Dr Adrienne J. Lindblad, articles are developed by the Patients, Experience, Evidence, Research (PEER) team and supported by the College of Family Physicians of Canada and its Alberta, Ontario, and Saskatchewan Chapters. Feedback is welcome at toolsforpractice@cfpc.ca.

Footnotes

  • Competing interests

    None declared

References

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Reducing death rattle at the end of life
Jen Potter, Christina S. Korownyk
Canadian Family Physician Jul 2023, 69 (7) 477; DOI: 10.46747/cfp.6907477
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