A retrospective medical records review of risk factors for the development of respiratory tract secretions (death rattle) in the dying patient.

AIM: Identification of risk factors predicting the development of death rattle. BACKGROUND: Respiratory tract secretions, often called death rattle, are among the most common symptoms in dying patients around the world. It is unknown whether death rattle causes distress in patients, but it has been globally reported that distress levels can be high in family members. Although there is a poor evidence base, treatment with antimuscarinic medication is standard practice worldwide and prompt intervention is recognized as crucial for effectiveness. The identification of risk factors for the development of death rattle would allow for targeted interventions. DESIGN: A case-control study was designed to retrospectively review two hundred consecutive medical records of mainly cancer patients who died in a hospice inpatient setting between 2009-2011. Fifteen potential risk factors including the original factors weight, smoking, final opioid dose and final midazolam dose were investigated. METHODS: Binary logistic regression to identify risk factors for death rattle development. RESULTS: Univariate analysis showed death rattle was significantly associated with final Midazolam doses and final opioid doses, length of dying phase and anticholinergic drug load in the pre-terminal phase. In the final logistic regression model only Midazolam was statistically significant and only at final doses of 20 mg/24 hrs or over (OR 3.81 CI 1.41-10.34). CONCLUSIONS: Dying patients with a requirement for a high dose of Midazolam have an increased likelihood of developing death rattle.

Systematic review and narrative summary: Treatments for and risk factors associated with respiratory tract secretions (death rattle) in the dying adult.

AIM: To identify effective treatments and risk factors associated with death rattle in adults at the end of life. BACKGROUND: The presence of noisy, pooled respiratory tract secretions is among the most common symptoms in dying patients around the world. It is unknown if "death rattle" distresses patients, but it can distress relatives and clinicians. Treatments appear unsatisfactory, so prophylaxis would be ideal if possible. DESIGN: Quantitative systematic review and narrative summary following Cochrane Collaboration guidelines. DATA SOURCES: CINAHL, MEDLINE, Health Source Nursing and Web of Science were searched for international literature in any language published from 1993 - 2016 using MeSH headings and iterative interchangeable terms for "death rattle". REVIEW METHODS: Randomized controlled trials were appraised using the Cochrane Collaboration's tool for assessing risk of bias. Non-randomized studies were assessed using ROBINS-I tool for assessing risk of bias in non-randomized studies of interventions. Instances of treatment and risk were extracted and relevant key findings extracted in line with Cochrane methods. RESULTS: Five randomized trials and 23 non-randomized studies were analysed. No pharmacological or non-pharmacological treatment was found superior to placebo. There was a weak association between lung or brain metastases and presence of death rattle, but otherwise inconsistent empirical support for a range of potential risk factors. CONCLUSIONS: Clinicians have no clear evidence to follow in either treating death rattle or preventing it occurring. However, several risk factors look promising candidates for prospective analysis, so this review concludes with clear recommendations for further research.