The Death Rattle and the Old Man's Friend

Abstract

To the Editor: Sir William Osler first referred to pneumonia as “the old man's friend”—identifying it as a common cause of relatively peaceful death in the late 1800s.1 Pneumonia remains among the most common primary or proximate causes of death in 2012.2 Most pneumonias share the common feature of defeating the normally robust mechanical, cellular, and immune mechanisms to prevent infection of the lower respiratory tract. Denudation of the trachea or bronchi due to viral (e.g., influenza) infections or toxic inhalants (e.g., smoking-related injury) predisposes to bacterial superinfection and subsequent pneumonia.3 Dysphagia is also a well-studied risk for aspiration of upper aerodigestive secretions causing pneumonia,3 but little has been written about another antecedent, encountered by clinicians regularly and recognized since the time of Laennac. This is upper airway incompetence marked by the sound of air gurgling through secretions above the glottis, heard with or without the stethoscope, when individuals speak or breathe—gargouillement.4 Laennac may also have been first to connote gurgling breath sounds with death—“the death rattle.”5 There is no published research that ties the “death rattle” or gargouillement to pneumonia, even though early clinicians acknowledged this association.4, 5 One study demonstrated gurgling in 20 individuals admitted during a 5-month period to a 24-bed hospital ward; 11 developed pneumonia, and the odds of pneumonia in gurglers were 130 times those of nongurglers.6 The epidemiology of inappropriate pooling of supraglottic secretions and gurgling, rates of subglottic aspiration in such individuals, and subsequent rates of pneumonia of those who aspirate are all unknown. There are some data that describe the relationship between advancing age and disease and aspiration. For example, of 127 home-based elderly adults (mean age 84), 44% had “laryngeal penetrations” seen on nasopharyngeal endoscopy. Medications (neuroleptics), stroke, and other neurological disorders were risks, and odds of aspiration were 12 times as great in those with abnormal water swallowing tests.7 In another study, subglottic aspiration was noted in 62% of hospitalized elderly adults and 6% of ambulatory normal elderly adults. Pooled secretions in the larynx were associated with aspiration, but age was not.8 “Wet phonation” is highly associated with subglottic penetration of secretions,9 and another study showed that “none of the patients coughed or cleared their throats after penetrating/aspirating.”10 Risk factors for pathological pooling of secretions and gurgling include neurological disorders,7 dementia,6 acute nonneurological illness in elderly adults,6, 10 and sedating medications.6 There are no data to support that risk of gurgling increases with age, except insofar as diseases and medications that predispose to gurgling accumulate with age. There is abundant evidence that antipsychotics increase the risk of pneumonia, presumably by causing occult micro-aspiration.7 There is a subset of such individuals with extreme medication-induced blunting of upper respiratory reflexes unto gurgling.6 If it is accepted that gurgling breath sounds promote pneumonia and that pneumonia is a common cause of death in elderly adults, a number of research questions arise that may be of interest to those—geriatricians, internists, intensivists, palliative care clinicians—who provide care at the end of life. What are the epidemiology, risks, and reversible causes of gurgling? For reversible causes, what are countermeasures (e.g., levels of care and monitoring, medications, positions, frequent oropharyngeal suctioning) that can be taken to mitigate risk until gurgling is corrected by treating underlying causes? For irreversible causes of gurgling, is pneumonia inevitable? If so, is there any long-term benefit to treating the pneumonia with antibiotics or endotracheal intubation if it will only recur, or do such treatments simply prolong dying—inevitably of pneumonia or its complications? All who gurgle are not certain to develop pneumonia and die.6 Gargouillement may be a rattle, but not necessarily a death rattle. Perhaps a more-accurate description in 2013 is that gurgling is a “risk-of-death rattle,” and greater understanding of gurgling sounds may permit clinicians to more-deliberately identify and treat reversible causes. To the extent that gurgling may signal extreme risk,6 this clinical sign, easily recognized by simple physical examination, might also be a useful additional trigger for rapid response, assessment, and treatment for as-yet-to-be-determined reversible causes or to allow those whose gurgling portends recurrent pneumonia to die peacefully—as Osler described—without multiple endotracheal intubations and trials of death-prolonging critical care. Conflict of Interest: Dr. Manthous has no financial conflicts of interest relevant to this manuscript. Author Contributions: Dr. Manthous is responsible for the entire content of this paper. Sponsor's Role: None.