Rattle breathing

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With death rattle , rattle breathing , präfinalem or terminal rattling , even death rattles ( English Death Rattle ) called a noisy is breathing of dying in the last hours or days before the death called.

The sound is caused by the fact that the persons concerned are no longer capable of salivary reflex to swallow or mucus hochzuräuspern or cough up. This in turn causes a loose obstruction (narrowing) in the airways (from the glottic area to the main bronchi ). In addition, the slack throat walls can hit each other with the breath flow and be responsible for this noise.

Affected patients are often very weakened and impaired in consciousness, up to and including unconsciousness. It is assumed that rattle breathing is not perceived as stressful by the dying person. There is no breathlessness or risk of suffocation as long as inhalation is free. Relatives sometimes believe that prolonged rattle breathing is evidence of discomfort and inaction on the part of the practitioner. Appropriate, tactful clarification is usually helpful. Since rattle breathing as an indication of imminent death can be very stressful for fellow patients present, this is one of the reasons why dying people in hospitals are usually placed in single rooms.

Pathophysiology

The secretion of saliva or mucus occurs through the salivary glands and the bronchial mucous membrane . The loss of the swallowing and coughing reflexes causes secretions to accumulate in the throat ( oropharynx ) and bronchi .

Manifestations

According to Bennett, there are two types of rattle breathing.

Type I.

Type I rattle breathing results from increased saliva secretion in the final hours of an unconscious or clouded patient. The loss of the swallowing reflex occurs suddenly. This form of rattle breathing is characterized by a better response to anticholinergics .

Type II

Type II rattle breathing is characterized by a predominantly bronchial mucus secretion that is formed over several days. The mostly awake patient is no longer able to cough effectively due to the increasing weakness. The probability of pneumonia ( pneumonia ) is very large. The greater the time lag between being unable to cough and dying, the sooner type II develops.

frequency

Rattle breathing is the most commonly observed symptom during the final hours of a person's life. About 56 to 92% of dying people get rattle breathing during this phase.

Treatment indications

While the dying phase under desiccosis (dehydration due to lack of fluids and, as a result, less secretion and rattle breathing) is described as not tormenting, the sometimes loud boiling, gurgling or rattling breathing noise creates the appearance of an agonizing agony. However, if the facial features appear relaxed, if breathing is free and not strenuous, treatment is not necessary. If, on the other hand, there are signs of stress, palliative care or palliative medical treatment is indicated.

The noises can have an unpleasant, unsettling and threatening effect on relatives or caregivers who are present; some fear that the patient will suffocate. This can potentially exacerbate an already existing stressful situation. The main task of the caring staff is therefore to provide information about the cause and course of rattle breathing as well as the stress and effectiveness of certain symptomatic treatment options.

treatment

Restricting your fluid intake may reduce the length of your rattle breathing.

Attempts were made very early to curb rattle breathing by suction . However, this measure only makes sense if inhalation is hindered by strong secretion. Otherwise the suction may cause more harm than good, as the secretion deep in the trachea or bronchi cannot be reached with the suction catheter . Constant suction therefore only leads to increased secretion production and can also trigger bleeding. It is also an uncomfortable procedure for the patient. It is therefore important to explain to the relatives that rattle breathing is a typical symptom of the end phase and that the patient generally does not have any shortness of breath.

Drug therapy is primarily based on the administration of anticholinergics: the subcutaneous administration of scopolamine , which in addition to the antisalivatory effect (inhibition of saliva production) also has a sedative effect, is suggested by some authors as a treatment and is often carried out as such. However, the results of two studies are contradicting its effectiveness. At least for type I rattle breathing, the effectiveness seems to be rather dubious. Glycopyrronium bromide apparently has a significantly greater reduction in the death rattle than scopolamine. Other drugs that can be used are butylscopolamine and atropine .

If there is rattle breathing of type II, repositioning the patient, for example from the supine to the side position, can reduce the noise development by redistributing the secretion.

literature

  • B. Hipp, M. Letizia: Understanding and responding to the death rattle in dying patients. In: Medsurg Nurs , 18, 2009, pp. 17-21. PMID 19331295 (Review)
  • B. Wee, R. Hillier: Interventions for noisy breathing in patients near to death. In: Cochrane Database Syst Rev , 2008, CD005177. PMID 18254072 (Review)
  • K. Bickel, RM Arnold: Death rattle and oral secretions - second edition # 109. In: J Palliat Med , 11, 2008, pp. 1040-1041. PMID 18788968
  • B. Wee et al. a .: Death rattle: its impact on staff and volunteers in palliative care. In: Palliat Med , 22, 2008, pp. 173-176. PMID 18372381
  • BL Wee u. a .: The sound of death rattle I: are relative distressed by hearing this sound? In: Palliative Medicine , 20, 2006, pp. 171-175. PMID 16764221
  • BL Wee u. a .: The sound of death rattle II: how do relative interpret the sound? In: Palliative Medicine , 20, 2006, pp. 177-181. PMID 16764222
  • EJ Kompanje: “The death rattle” in the intensive care unit after withdrawal of mechanical ventilation in neurological patients. In: Neurocrit Care , 3, 2005, pp. 107-110. PMID 16174877
  • JL Spiess, SD Scott: Anticholinergic agents for the treatment of “death rattle” in patients with myasthenia gravis. In: Journal Pain Symptom Manage , 26, 2003, pp. 684-686. PMID 12850651
  • MI Bennett: Death rattle: an audit of hyoscine (scopolamine) use and review of management. In: J Pain Symptom Manage , 23, 2002, pp. 310-317. PMID 8898506
  • R. Leinmüller: Pain therapy in old age: a certificate of poverty. In: Deutsches Ärzteblatt , 98, 2001, pp. A-801 / B-661 / C-617
  • S. Eychmüller: Fluid substitution in the terminal phase - a controversial discussion. In: The pain , 15, 2001, pp. 357-361. doi: 10.1007 / s004820170010
  • S. Kränzle: Shortness of breath. (PDF; 782 kB)
  • Eberhard Klaschik : Pain therapy and symptom control in palliative medicine . In: Stein Husebø , Eberhard Klaschik (ed.): Palliative medicine . 5th edition. Springer, Heidelberg 2009, ISBN 3-642-01548-4 , pp. 207-313, here: p. 300.

Web links

Individual evidence

  1. ↑ a b Cornelia Knipping (Ed.): Textbook Palliative Care . 2nd Edition. Hans Huber, Bern 2007, ISBN 978-3-456-84460-2 , p. 472 .
  2. ↑ a b c d e f B. and S. Husebø u. a .: B The last days and hours. Palliative care for the seriously ill and the dying . (PDF) pp. 19-20
  3. ↑ E. Aulert, F. Nauck, L. Radbruch (eds.): Textbook of Palliative Medicine . Schattauer, 2007, ISBN 3-7945-2361-X ( p. 386ff ).
  4. ^ A b c Elisabeth Albrecht: Symptoms in the dying phase. In: Claudia Bausewein , Susanne Roller, Raymond Voltz (eds.): Guideline Palliative Care. Palliative medicine and hospice care. Elsevier, Munich 2015, p. 349. ISBN 978-3-437-23313-5
  5. ^ M. Bennett: Death rattle: an audit of hyoscine (scopolamine) use and review of management. In: J Pain Symptom Manage 12, 1996, pp. 229-233. PMID 8898506
  6. ↑ R. Fainsinger et al. a .: A perspective on the management of delirium in terminally ill patients on a palliative care unit. In: Journ Palliative Care 9, 1994, pp. 4-8.
  7. ↑ A. Hughes et al. a .: Management of death rattle. In: Palliative Medicine , 11, 1997, pp. 80-81.
  8. ↑ SB Husebø, S. Husebø: Palliative medicine - also in old age? In: The Pain 2001.
  9. ↑ Ulrike Pribil: The last hours - accompanying and caring for dying people. In: Sabine Pleschberger, Katharina Heimerl, Monika Wild (eds.): Palliative care. Basics for practice and teaching. Facultas Universitätsverlag, Vienna 2002, p. 192.
  10. ↑ Rainer Teufel: To die right? - Maintenance in the final phase . In: Zeitschrift für Palliativmedizin , March 2017, p. 79
  11. ↑ M. Thöns and M. Zenz: Restrictive fluid intake in the terminal phase can reduce suffering . In: Palliative Medicine . 7, 2006. doi : 10.1055 / s-2006-954155 .
  12. ↑ Gliemann S, 3rd symposium of the Bavarian Hospice Foundation on October 13, 2003. Workshop "General Symptom Control"
  13. ^ AC Hughes et al. a .: Management of "death rattle". In: J Pain Symptom Manage 12, 1996, pp. 271-272. PMID 8942121
  14. ↑ a b Eberhard Klaschik : Pain therapy and symptom control in palliative medicine. 2009, p. 300.
  15. ↑ Palliative medicine for all elderly people. ( Memento of March 8, 2014 in the Internet Archive ) Retrieved August 4, 2016
  16. ↑ E. Rupacher: Results of two studies on the treatment of death rattles. (PDF; 624 kB)