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 "death rattle" 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, such as in those with brain injuries or in patients with various disorders leading to increased production or decreased clearance of secretions.
Two sub-types of the death rattle have been proposed:
Type 1 = predominantly salivary secretions.
Type 2 = predominantly bronchial secretions.
- Position the patient on their side or in a semi-prone position to facilitate postural drainage
- 1-2 minutes of Trendelenburg positioning can be used to move fluids up into the oropharynx for easier removal.
- Gentle oropharyngeal suctioning is used although this can be ineffective when fluids are beyond the reach of the catheter - frequent suctioning is disturbing to the patient.
- Reduction of fluid intake.
While there are no evidence-based guidelines, the standard of care is to use muscarinic receptor blockers (anti-cholinergic drugs). These include scopolamine
, and atropine
Adapted from Bickel K and Arnold R. Palliative Care Network of Wisconsin. Fast facts and concepts #109. Death rattle and oral secretions. Internet. Accessed on January 25, 2016.