"The Death Rattle" in the Intensive Care Unit After Withdrawal of Mechanical Ventilation in Neurological Patients

Abstract

The noise produced by oscillatory movements of secretions in the oropharynx, hypopharynx, and trachea during inspiration and expiration in unconscious terminal patients is often described as "the death rattle." The secretions are produced by the salivary glands and bronchial mucosa. These patients are usually too weak to expectorate or swallow the migrating secretions. Sputum usually only accumulates in these areas if there is a significant impairment of the cough reflex, as in deep coma or near death. Reported incidence of death rattle in terminal patients varied between 6 and 92%. Death rattle was most commonly reported in patients dying from pulmonary malignancies, primary brain tumors, or brain metastases, and predicts death within 48 hours in 75% of the patients. After withdrawal of artificial ventilation from the intensive care unit, excessive respiratory secretion resulting in a rattling breathing during the last hours of life is not uncommon, especially not in pulmonary and neurological patients. The distressing experience and negative influence in the bereavement process indicates an ethical demand to treat this symptom from the perspective of others merely than that of the patient.