1. Epidemiology and Incidence

Death rattle—the noisy, gurgling sound from pooled oropharyngeal and bronchial secretions—affects roughly one-third to one-half of patients in the final hours to days of life. Incidence varies by setting, primary diagnosis, and measurement methods.

• Prevalence Range: 12%–92%, with a weighted mean of approximately 35%–50%.
• Setting Differences: Incidence is highest in hospice settings (~60%), followed by acute care wards (~40%) and intensive care units (~30%).
• Higher Rates Associated With: Advanced thoracic or abdominal malignancies and prolonged sedation.
• Patient and Family Impact: While patients are often unaware of the sound, up to 80% of families find it distressing.

2. Pathophysiology of Secretion Accumulation

Normal airway clearance relies on an effective cough, swallowing reflexes, mucociliary transport, and a sufficient level of consciousness. In terminal illness, central nervous system depression and the loss of protective reflexes lead to pooled secretions that generate audible gurgling during respiration.

The fluid balance of the patient can also influence the character of secretions. Dehydration may lead to thickened, tenacious secretions, while overhydration can increase the volume of pooled fluid.

3. Chronic Disease as a Risk Modifier

Pre-existing neurological, pulmonary, and head/neck comorbidities significantly increase a patient’s susceptibility to secretion pooling by either impairing protective reflexes or increasing the baseline secretion burden.

4. Social Determinants of Health

The management of death rattle and the resulting family experience are profoundly shaped by social and environmental factors, including access to care, caregiver literacy, and cultural beliefs.

• Resource Access: The availability of anticholinergic medications, portable suction devices, and humidifiers can differ greatly between home, hospice, and hospital settings.
• Health Literacy: A caregiver’s ability to understand that death rattle is a natural part of the dying process, rather than a sign of suffering, is crucial for reducing their anxiety and preventing requests for potentially burdensome interventions.
• Care Setting: Home and hospice care typically emphasize non-invasive, comfort-focused measures like repositioning. In contrast, an ICU setting allows for more aggressive interventions like deep suctioning, which may not improve patient comfort and can be distressing to observe.
• Cultural Beliefs: Family and cultural perspectives on the dying process influence goals of care and the acceptance of non-interventionist approaches.

5. Clinical Presentation and Goals of Care

Death rattle typically appears as low-pitched, bubbling respirations in a minimally responsive patient who shows no signs of active distress. Distinguishing this sound from true dyspnea is essential to avoid unnecessary and potentially harmful interventions.

• Audible Signs: Gurgling or rattling sounds are heard at the bedside, often on both inspiration and expiration.
• Absence of Distress: Crucially, there is minimal change in respiratory rate, no tachypnea, no use of accessory muscles, and no patient agitation.
• Goals of Care: The primary goal is to support the family and honor patient preferences. This involves clarifying wishes regarding suctioning, medication use, and non-pharmacologic measures like repositioning the head.
• Communication: A core intervention is explaining to observers that death rattle is not believed to be painful or distressing for the patient, even though it may be upsetting to hear.