Randomized Double-Blind Trial of Sublingual Atropine vs. Placebo for the Management of Death Rattle

Context. Noisy breathing because of respiratory tract secretions (RTS), often referred to as death rattle, occurs in up to half of all dying patients. Despite a lack of evidence showing benefit compared with placebo, antimuscarinic medications have been used in an attempt to decrease noise associated with RTS and to decrease family distress. Objectives. The goal of this study was to compare the efficacy of the antimuscarinic medication atropine with that of placebo in reducing noise associated with death rattle. Methods. Terminally ill adult hospice inpatients who developed noisy breathing as a result of RTS were randomized to double-blind treatment with atropine or placebo. Study drug was given as a single sublingual dose. Noise from breathing was monitored at baseline and at two and four hours. Results. One hundred thirty-seven participants were randomized to atropine or placebo. Reduction in noise score from baseline to two hours after dose occurred in 37.8% and 41.3% of subjects treated with atropine and placebo, respectively (P = 0.73). Noise score reduction at four hours occurred in 39.7% and 51.7% of subjects treated with atropine and placebo, respectively (P = 0.21). Differences between groups were not significant at either time point. Atropine was well tolerated. Heart rate increased slightly in both groups (+1.1/minute for atropine and +3.1/minute for placebo) but not significantly. Conclusion. Sublingual atropine given as a single dose was not more effective than placebo in reducing the noise associated with death rattle. J Pain Symptom Manage 2013;45:14e22. (C) 2013 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved.