INTRODUCTION
Seen often in dying people who are too weak to expectorate and are no longer able to clear their oral and upper airway secretions. The pooled secretions in the oropharynx and bronchi vibrate as air moves over them. It is audible and is described as noisy, rattling, gurgling and unpleasant. Often call ‘death rattle’.
DEFINITION
Death rattle frequently occurs in dying people, and has been observed in 23% - 92% of cases. The death rattle is an indicator of impending death.
Classifications:
- Type I due to salivary secretions
- Type II due to accumulated bronchial secretions in the presence of pulmonary disease and infections, tumour, fluid retention, or aspiration.
Studies suggest that people who develop noisy respirations have the following risk factors:
- Lung cancer
- Chest infections i.e. pneumonia
- Brain tumours
- Head and neck cancers
- Pulmonary diseases i.e. Asthma, Bronchitis, Bronchiectasis
- Neuromuscular disorders ie. Myasthenia gravis, Gullain-Barre syndrome
ASSESSMENT
1. Consider the person’s diagnosis – the person has the risk factors and has noisy rattly breathing. There are no standardised assessment tools to classify or measure the intensity of secretions but some research has used subjective noise scores.
2. Consider the distress of the person – are they restless or frowning?
3. Consider the distress of the person’s family/whānau – they may be anxious and fear the person is choking to death or drowning. Approximately half of those relatives and friends who witness it, as well as hospital staff, find the noise of respiratory tract secretions distressing.
MANAGEMENT
- Anticipate problems if the person has risk factors that increase airway secretions
- Re-position the person, often on their side in a semi-recumbent position, to facilitate postural drainage. Or raise the head of the bed and prop the person up with pillows
- Carefully assess hydration and reduce or cease parenteral fluids if required
- Explain the changes being observed in the dying person to the family and whanau. Communicate skilfully with compassion and sensitivity. Reassure the family the reason their loved one is not able to cough or clear their throat is due to their unconscious state. The patient is not usually distressed.
- Distraction therapy e.g. music, television, family talking and reminiscing
- Aromatherapy therapy e.g. use of the following essential oils in an Aroma Burner or Vaporiser – Eucalyptus, cypress, ylang ylang, lavender, lemon, lime, cypress, marjoram, cedar wood.
- Regular mouth and lip cares. Whip away any dribbling with tissues. Use appropriate mouth swabs ie. Den Tips© Disposable Oral Swabs to gently wipe any loose secretions out of the mouth if the person allows it
- Oxygen at the end of life is often not necessary and can be discontinued. If the person remains on oxygen and thick secretions are a problem consider humidifying oxygen
CONTACT US
A registered nurse is available 24 hours a day, 7 days a week to offer support and advice over the phone to either patients, families or other health professionals.
