Decreasing "death rattle"

Q: All of the following are good options to decrease "death rattle" at the end of the life care except?

A) Glycopyrrolate 0.1 mg SL q 6 hours/PRN
B) Scopolamine transdermal 1.5 mg patch q 72 hours
C)) Atropine 0.4 to 0.6 mg SC q 4-6 hours/PRN
D) Atropine 1-2 drops 1% ophthalmic solution given SL q 2-4 hours/PRN
E) Epinephrine 0.5 mg SC q 4-6 hours/PRN


Answer: E 

"Death rattle" - sound from upper airway secretions are of distress to a patient as well as to the family. It may also increase the risk of pneumonia in a patient going through the last stages of life.  Before applying the pharmacologic treatment, it would be appropriate to provide emotional support, logical explanation, proper positioning, and cleaning the mouth.

All of the above pharmacological interventions are good options except choice E. Epinephrine has no role in such scenario, rather contra-indicated.

Indeed, choice D is interesting. 3


#palliativecare



References: 

1.  Bennett M, Lucas V, Brennan M, et al. Using anti-muscarinic drugs in the management of death rattle: evidence-based guidelines for palliative care. Palliat Med 2002; 16:369. 

2. Kintzel PE, Chase SL, Thomas W, et al. Anticholinergic medications for managing noisy respirations in adult hospice patients. Am J Health Syst Pharm 2009; 66:458. 

3. Protus BM. Evaluation of atropine 1% ophthalmic solution adminstered sublingually for the management of terminal respiratory secretions. Am J Hosp Palliat Care 2013; 30:388.