Refractory death rattle: deep aspiration facilitates the effects of antisecretory agents

Anticholinergic drugs, including atropine, hyoscine butylbromide, and scopolamine, have been shown to be equally effective in the treatment of death rattle. However, anticholinergic drugs may only be effective in reducing the production of further secretions, rather than eliminating the existing ones. A case is described in which a preventive procedure was undertaken to carefully eliminate secretions before starting anticholinergic drugs. Airway aspiration under light anesthesia removed secretions before starting anticholinergic drugs. Low doses of propofol were given intravenously to make a laryngoscopy feasible, allowing the complete aspiration of large amounts of tracheal secretions. No death rattle was perceived until death. Relatives were satisfied with the treatment and the peaceful death. Antisecretory agents may only prevent further accumulation of fluids along the airways and in the pharynx. The use of these drugs, supplemented by this aspiration procedure in carefully selected patients, may help eliminate death rattle in patients with advanced illness who are unable to cough or swallow. Explanation and reassurance to relieve fears and concerns regarding a procedure aimed to improve the quality of end-of-life care are of paramount importance, and active collaboration in decision making facilitates a timely intervention. This preliminary experience may help further research on the best treatment at the end of life.