Refractory death rattle: deep aspiration facilitates the effects of antisecretory agents

Anticholinergic drugs for death rattle in dying patients with cancer: multicentre prospective cohort study

BACKGROUND

This study aimed to investigate the effectiveness of anticholinergics (AC) for death rattle in dying patients with cancer.

METHODS

This is a prospective cohort study enrolled Terminally ill adult (20 years or older) patients with cancer who developed substantial death rattle (Back score ≥2) from 23 palliative care units in Japan. AC treatment for death rattle was prescribed according to primary physician's decision. The primary outcome was the proportion of patients whose death rattle improved, which was defined as a Back score of ≤1. We compared the proportion of improved cases in patients treated with (AC group) and without (non-AC group) AC, controlling potential confounders by employing propensity score weighting.

RESULTS

Of the 1896 patients enrolled, we included 196 who developed a substantial death rattle. Of these, 81 received AC. 56.8% in the AC group and 35.4% in the non-AC group had an improved death rattle at 8 hours after baseline. In the weighted analysis, AC group showed significant improvements in death rattle, with an adjusted OR of 4.47 (95% CI 2.04 to 9.78; p=0.0024). All sensitivity analyses achieved essentially the same results. In the subgroup analysis, ACs were strongly associated with death rattle improvement in men, patients with lung cancer, and type 1 death rattle (adjusted OR 5.81, 8.38 and 9.32, respectively).

CONCLUSIONS

In this propensity score-weighted analysis, ACs were associated with death rattle improvement in terminally ill patients with cancer who developed substantial death rattle.

TRIAL REGISTRATION NUMBER

UMIN-CTR (UMIN00002545).

Management of Physical Symptoms in Patients with Advanced Cancer During the Last Weeks and Days of Life

Patients with advanced cancer are faced with many devastating symptoms in the last weeks and days of life, such as pain, delirium, dyspnea, bronchial hypersecretions (death rattle), and intractable seizures. Symptom management in the last weeks of life can be particularly challenging because of the high prevalence of delirium complicating symptom assessment, high symptom expression secondary to psychosocial and spiritual factors, limited life-expectancy requiring special considerations for prognosis-based decision-making, and distressed caregivers. There is a paucity of research involving patients in the last weeks of life, contributing to substantial variations in clinical practice. In this narrative review, we shall review the existing literature and provide a practical approach to in-patient management of several of the most distressing physical symptoms in the last weeks to days of life.

COVID-19 End-of-life Care: Symptoms and Supportive Therapy Use in an Australian Hospital

Background

Descriptions of symptoms and medication use at end of life in COVID‐19 are limited to small cross‐sectional studies, with no Australian longitudinal data.

Aims

To describe end‐of‐life symptoms and care needs of people dying of COVID‐19.

Methods

This retrospective cohort study included consecutive admitted patients who died at a Victorian tertiary referral hospital from 1 January to 30 September directly due to COVID‐19. Clinical characteristics, symptoms and use of supportive therapies, including medications and non‐pharmacological interventions in the last 3 days of life were extracted.

Results

The cohort comprised 58 patients (median age 87 years, interquartile range (IQR) 81–90) predominantly admitted from home (n = 30), who died after a median of 11 days (IQR 6–28) in the acute medical (n = 31) or aged care (n = 27) wards of the hospital. The median Charlson Comorbidity Score was 7 (IQR 5–8). Breathlessness (n = 42), agitation (n = 36) and pain (n = 33) were the most frequent clinician‐reported symptoms in the final 3 days of life, with most requiring opioids (n = 52), midazolam (n = 40), with dose escalation commonly being required. While oxygen therapy was commonly used (n = 47), few (n = 13) required an anti‐secretory agent.

Conclusions

This study presents one of the first and largest Australian report of the end of life and symptom experience of people dying of COVID‐19. This information should help clinicians to anticipate palliative care needs of these patients, for example, recognising that higher starting doses of opioids and sedatives may help reduce prevalence and severity of breathlessness and agitation near death.

Hyoscine Butylbromide for the Management of Death Rattle: Sooner Rather Than Later

CONTEXT

Death rattle (DR) is a dramatic sign in the dying patient. Existing studies with anticholinergic agents are controversial, as this class of drugs has been commonly administered without considering the rationale of the mechanism of action. A meaningful use of these drugs may provide a better outcome.

OBJECTIVES

The aim of this study was to assess the efficacy of hyoscine butylbromide (HB), given prophylactically in comparison with HB administered once DR occurs.

METHODS

Dying patients having a score of ≥3 in the Richmond Agitation-Sedation Scale-palliative version were included in the study. HB (60 mg/day) was given when DR occurred (Group 1) or as pre-emptive treatment (Group 2). The onset of DR (death rattle free time) and intensity of DR were recorded at intervals until death.

RESULTS

Eighty-one and 51 patients were randomized to Group 1 and 2, respectively. Patients in Group 2 survived longer than those in Group 1 (P < 0.05). DR occurred in 49 (60.5%) and three patients (5.9%) in Group 1 and 2, respectively (P = 0.001). A significant difference in the number of patients reporting DR was found at intervals examined (30 minutes, one hour, and then every six hours until death [P = 0.001]). In Group 1 and 2, DR free time was 20.4 (20.5) and 27.3 hours (25.2), respectively (P = 0.001). In Group 1, the treatment was considered effective in 10 patients (20.4%) only, after a mean of 14.4 hours (SD 8.57).

CONCLUSION

The prophylactic use of HB is an efficient method to prevent DR, whereas the late administration produces a limited response, confirming data from traditional studies performed with anticholinergics. This could be considered a new paradigm to manage a difficult and dramatic sign, such as DR.

Treatment Recommendations for Respiratory Symptoms in Cancer Patients: Clinical Guidelines from the Japanese Society for Palliative Medicine

BACKGROUND

Respiratory symptoms, dyspnea, cough, and death rattle, are common and distressing in advanced cancer patients. Palliation of respiratory symptoms is important to improve quality of life in cancer patients and their families/caregivers. Currently published clinical guidelines for the management of these respiratory symptoms in cancer patients did not cover the topics comprehensively or were not based on formal process for the development of clinical guidelines.

METHODS

The Japanese Society for Palliative Medicine (JSPM) decided to develop comprehensive clinical guidelines for the management of respiratory symptoms in cancer patients following the formal guideline developing process.

RESULTS

This article provides a summary of the recommendations with the rationales, as well as a short summary of the developing process, of the JSPM respiratory symptom management guidelines. We established 26 recommendations and all recommendations are based on the best available evidences and expert consensus.

DISCUSSION

More future clinical researches and continuous guideline updates are required to improve the quality of respiratory symptom management in cancer patients.

Death rattle: critical review and research agenda

The aim of this critical review was to assess the literature regarding the treatment of death rattle at the end of life to provide an update information regarding this difficult issue. To provide suggestions for future research agenda, the approach was analytic and based on clinical considerations, rather than on raw evidence only. Both published and unpublished reports from an extensive search of electronic databases. Any randomized-controlled trial or clinical reports with a significant number of patients was considered. Eleven reports fulfilled the inclusion criteria in this systematic review. Four controlled studies, four comparative audits, and three clinical reports with a significant number of patients were selected. Despite anticholinergic or antimuscarinic medications are the drugs of choice in practice, there is a lack of supporting evidence for the use of anticholinergics to treat death rattle. Regardless of the methodological limitations of existing studies, an a priori observation was missed. Most studies were performed with the intent to treat rather than to prevent death rattle. However, from a pharmacological perspective, anticholinergic agents are unable to reduce the secretions once they are formed, but may just limit a further production. In conclusion, studies on the use of antisecretive agents provided only minor evidence of efficacy, ultimately raising questions about the routine inclusion of anticholinergic treatment in end of life pathways for the treatment of death rattle. However, this observation could be confuted by the use of these same drugs used earlier in a prophylactic perspective, in the context of a comprehensive management of the dying patients.

Management of death rattle at end of life

Noisy breathing or death rattle is a common clinical sign in the final days of life. When it occurs, the level of consciousness is usually low and it is generally assumed that patients are not distressed by it. Despite the assumption that patients are not distressed, death rattle is usually actively treated in palliative care settings through a combination of pharmacological and non-pharmacological measures. Anti-cholinergic or anti-muscarinic medications are the drugs of choice in practice, even in the absence of patient distress, despite there being no conclusive evidence to suggest that any drug is superior to placebo. In addition, a recent Cochrane review suggested that there is a lack of supporting evidence for the use of anti-cholinergics to treat death rattle (Wee and Hillier, 2010). The choice of drug is based on the various properties of the drug and the desired effects. However, treatment is focused on alleviating the perceived distress of family members rather than aimed specifically at benefiting the patient. Moreover, anti-cholinergic drugs can result in unpleasant side-effects such as urinary retention and dry mouth for patients who are probably unable to report symptoms. Recent research calls for prescribers to consider carefully why they are treating death rattle. Moreover, families need to be reassured and have it explained to them that it is unlikely that the patient is distressed and why this is the case.

Randomized double-blind trial of sublingual atropine vs. placebo for the management of death rattle

CONTEXT

Noisy breathing because of respiratory tract secretions (RTS), often referred to as "death rattle," occurs in up to half of all dying patients. Despite a lack of evidence showing benefit compared with placebo, antimuscarinic medications have been used in an attempt to decrease noise associated with RTS and to decrease family distress.

OBJECTIVES

The goal of this study was to compare the efficacy of the antimuscarinic medication atropine with that of placebo in reducing noise associated with death rattle.

METHODS

Terminally ill adult hospice inpatients who developed noisy breathing as a result of RTS were randomized to double-blind treatment with atropine or placebo. Study drug was given as a single sublingual dose. Noise from breathing was monitored at baseline and at two and four hours.

RESULTS

One hundred thirty-seven participants were randomized to atropine or placebo. Reduction in noise score from baseline to two hours after dose occurred in 37.8% and 41.3% of subjects treated with atropine and placebo, respectively (P=0.73). Noise score reduction at four hours occurred in 39.7% and 51.7% of subjects treated with atropine and placebo, respectively (P=0.21). Differences between groups were not significant at either time point. Atropine was well tolerated. Heart rate increased slightly in both groups (+1.1/minute for atropine and +3.1/minute for placebo) but not significantly.

CONCLUSION

Sublingual atropine given as a single dose was not more effective than placebo in reducing the noise associated with death rattle.

Evaluation of Atropine 1% Ophthalmic Solution Administered Sublingually for the Management of Terminal Respiratory Secretions

Terminal respiratory secretions (TRS) or “death rattle” is a common symptom in the dying patient. Current practice for the prevention and treatment of TRS involves the use of oral, sublingual, transdermal, or parenteral anticholinergic medications. A retrospective chart review of patients admitted to a hospice inpatient unit for terminal care and treated with sublingual atropine 1% ophthalmic drops for TRS was conducted. A total of 19 of 22 patients treated with atropine had documented reduction or resolution of TRS. This study suggests that atropine 1% ophthalmic drops administered sublingually are a reasonable option for the management of TRS. Problematic cardiac or central nervous system symptoms were not found in the present study. Results should aid hospice programs who are seeking guidance on the management of TRS with atropine 1% ophthalmic drops.

Atropine eyedrops for death rattle in a terminal cancer patient

"Death rattle" is a term used to describe the noisy sound produced by dying patients caused by the oscillatory movements of secretions in the upper airways. Antimuscarinic drugs, including atropine, scopolamine (hyoscine hydrobromide), hyoscine butylbromide, and glycopyrronium, have been used to diminish the noisy sound by reducing airway secretions. We report on the effectiveness of sublingual atropine eyedrops in alleviating death rattle in a terminal cancer patient. We present a 58-year-old man with pancreatic cancer who was admitted to our hospital because of severe dyspnea, cough, and death rattle with excessive bronchial secretion as a result of multiple lung metastases. We administered 1% atropine eyedrops sublingually to obviate the need for subcutaneous infusions and to prevent somnolence. On the basis of our experience, we conclude that atropine eyedrops, administered sublingually for distressing upper respiratory secretions, may be an effective alternative to the injection of antimuscarinic drugs, or as an option when other antimuscarinic formulations are not available.