Administration of prophylactic scopolamine butylbromide significantly reduced the occurrence of noisy breathing, a symptom common in dying patients and a cause of distress to patients’ loved ones. Commonly known as the death rattle, the study found the sound can be prevented in almost half the cases by the administration of scopolamine butylbromide without adverse events.

Noisy breathing is a common symptom accompanying impending death, and is caused by excessive mucus and muscle relaxation in the upper airway. The unpleasant sound can make family and other relatives anxious as they fear their loved one is suffocating. Attending to a patient's family is also part of care, and reducing their discomfort at this distressing time may help reduce future post-traumatic symptoms that can result from such negative experiences.

Current management guidelines include the administration of anticholinergic drugs, which decrease mucus production but do not affect mucus that is currently present. In other words, once symptoms begin, these drugs may not be effective. A research collaboration between Erasmus MC and several hospice facilities in the Netherlands was formed to investigate if the prophylactic administration of scopolamine butylbromide prior to the onset of upper airway secretions could prevent their formation and decrease the occurrence of the symptom.

Between April 2017 and January 2020, patients (162) who gave advance written consent were randomized to receive scopolamine butylbromide or a placebo upon recognition of the dying phase. The occurrence of noisy breathing and side effects (restlessness, dry mouth and urinary problems) were assessed and reported by a healthcare provider every four hours.

Preventive administration of scopolamine butylbromide at the beginning of the dying phase significantly reduced the incidence of the death rattle (13% versus 27%, p=.02), without an increase in adverse effects. The research strongly supports the administration of prophylactic anticholinergic medications for dying patients, with the goal of reducing distress and discomfort especially for the patient's family.

People involved affiliated with Amsterdam UMC:  Lia van Zuylen, Professor of Palliative Care at Cancer Center Amsterdam.

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Read the accompanying editorial by JAMA

The study was funded by ZonMW.