Death rattle 1

Death rale
Respiratory / upper airway secreons (‘Death rale’)
This can be very distressing to those around the patient and should be treated prophylactically as it
is easier to prevent secretions forming than to remove secretions that have gathered in the upper
airways or oropharynx. Patients themselves are rarely distressed by noisy secretions and it is helpful
to explain this as well as explaining that the patient is not choking.
Despite re-positioning (including tipping the head of the bed down) and using all available
medication, some patients will continue to breathe noisily. It is sometimes appropriate to consider
intermittent suction but this needs to be assessed on an individual basis taking into account
associated risks including soft tissue trauma.
Glycopyrronium bromide: Give 200µg SC stat and review response after 60 minutes. If effective,
give 0.6-1.2mg/24 hours subcutaneously (either prn in divided doses or via CSCI). Does not cause
sedation.
Hyoscine hydrobromide: Give 200-400µg SC stat and review response after 30 minutes. If effective,
give1.2-2.4mg/24 hours subcutaneously (either prn in divided doses or via CSCI). This is sedative in
high doses. If the patient is conscious and respiratory secretions are not too distressing it may be
more appropriate to use a transdermal patch, (Scopaderm® 1mg over 3 days) or sublingual tablets
(Kwells®).
Hyoscine butylbromide (Buscopan®): Give 20mg SC stat and review the response after 60 minutes.
If effective give 60-180mg/24h via CSCI.

This is a less sedating alternative to hyoscine hydrobromide as it does not cross the blood brain
barrier.

Printed on Sun 11 Dec 2022 21:30:53 GMT

2022-12-11 Palliative Care Guidelines Plus