Using anti-muscarinic drugs in the management of death rattle: evidence-based guidelines for palliative care

The management of 'death rattle' was reviewed by a task group on behalf of the Association for Palliative Medicine's Science Committee. Evidence was searched for the effectiveness of various anti-muscarinic drugs in drying oropharyngeal and bronchial secretions in dying patients. Clinical guidelines were constructed based on evidence from volunteer and clinical studies. Death rattle occurs in half of all dying patients and some response occurs in around 80% of treated patients. Clinical studies demonstrate that subcutaneous hyoscine hydrobromide 400 mug is more effective at improving symptoms at 30 min than glycopyrronium 200 mug by the same route. Volunteer studies demonstrate that intramuscular glycopyrronium 400 mug is as effective in drying secretions at 30 min as a dose of 200 mug given intravenously. Duration of response is shortest for hyoscine butylbromide (1 h) and longest for glycopyrronium (more than 6 h). There is insufficient evidence to support the use of one drug over another in a continuous infusion and prescribers should base decisions on different characteristics of each anti-muscarinic drug.