Death Rattle

Non-Pharmacologic:

  • side-lying to facilitate postural drainage

  • Trendelenburg position x 1-2 minutes to move fluids up and suction; higher aspiration risk

  • Gentle oropharyngeal suctioning; avoid frequent suctioning which is disturbing to both patient and family

  • reduce fluid intake

Pharmacological Treatments

  • no evidence-based guidelines
  • anti-cholinergic drugs:  scopolamine, hyoscyamine, glycopyrrolate, atropine
  • S/E:  blurred vision, sedation, confusion, delirium, restlessness, hallucinations, palpitations, constipation, urinary retention
  • tertiary amines (scopolamine, atropine, hyoscyamine) cross BBB; quaternary amines (glycopyrrolate) do not (does not cause CNS toxicity)

Dosages:

  • scopolamine hydrobromide 1.5 mg TD patch (24h to steady state)
  • glycopyrrolate (Robinul) 1mg PO or 0.2 mg SQ/IV
  • hyoscyamine 0.125 PO / SL
  • atropine sulfate 0.1 SQ/IV
  • atropine sulfate 1 gtt of 1% ophthalmic solution SL

 

Notes:

  • Glycopyrrolate 5x more potent cf atropine but poorly absorbed

  • scopolamine patch releases ~1 mg over 72 hours and takes 24 hours to reach steady state

  • place scopolamine patch on hairless skin behind ear, change every 72 hours, more than one patch can be used at a time.

 

References

Wee, Bee, and Richard Hillier. ‘Interventions For Noisy Breathing In Patients Near To Death’.Cochrane Database of Systematic Reviews (1996): n. pag. Web. 12 Dec. 2015.

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