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Response to “Hyoscine Butylbromide for the Management of Death Rattle: Sooner Rather Than Later”

Open ArchivePublished:November 26, 2018DOI:https://doi.org/10.1016/j.jpainsymman.2018.11.018
      We read with interest the article “Hyoscine Butylbromide for the Management of Death Rattle: Sooner Rather Than Later” by Mercadante et al.,
      • Mercadante S.
      • Marinangeli F.
      • Masedu F.
      • et al.
      Hyoscine butylbromide for the management of death rattle: Sooner rather than Later.
      comparing pre-emptive hyoscine butylbromide for the management of noisy upper respiratory tract secretions (RTS) in patients in the last days of life with treatment of RTS when they occurred. Previous studies have administered anticholinergic drugs to treat already formed noisy RTS rather than preventing their formation, but anticholinergic drugs are unable to remove secretions already formed.
      • Mercadamte S.
      Death rattle: critical review and research agenda.
      • Star A.
      • Boland J.W.
      Updates in palliative care - recent advancements in the pharmacological management of symptoms.
      This exploratory study presents promising effects; however, the data should be interpreted in the context of its methodological limitations. The natural history of RTS is poorly described, so attribution of outcomes is difficult in an unblinded trial. In addition, no power calculations were reported, making it difficult to evaluate the significance of the findings. Importantly, harms were not reported, but it is vital to know about toxicity when proposing a prophylactic treatment (potentially for the benefit of family and staff rather than the patient)
      • Wee B.L.
      • Coleman P.G.
      • Hillier R.
      • Holgate S.H.
      The sound of death rattle I: are relatives distressed by hearing this sound?.
      • Wee B.
      • Coleman P.
      • Hillier R.
      • Holgate S.
      Death rattle: its impact on staff and volunteers in palliative care.
      • Campbell M.L.
      • Yarandi H.N.
      Death rattle is not associated with patient respiratory distress: is pharmacologic treatment indicated?.
      where a significant number of people would never develop noisy RTS (40% in comparator arm of present study) but nevertheless have now been exposed to a drug with a significant harm profile (including dry mouth, constipation, and urinary retention).
      • Mercadamte S.
      Death rattle: critical review and research agenda.
      • Star A.
      • Boland J.W.
      Updates in palliative care - recent advancements in the pharmacological management of symptoms.
      In particular, anticholinergics are known to contribute to delirium—of concern in this high-risk population.
      • Hosie A.
      • Davidson P.M.
      • Agar M.
      • Sanderson C.R.
      • Phillips J.
      Delirium prevalence, incidence, and implications for screening in specialist palliative care inpatient settings: a systematic review.
      To make clinical judgments, we must be able to evaluate the net-benefit (harms-benefit balance) of exposing patients to a medication they might not need but might cause clinically important harms. Furthermore, we cannot identify and target patients at higher risk of developing RTS.
      • Likar R.
      • Michenthaler M.C.
      • Traar R.
      • Molnar M.
      • Neuwersch S.
      Clinical factors influencing death rattle breathing in palliative care cancer patients: Non-interventional study.
      These data are useful to inform a subsequently adequately powered double-blinded randomized placebo-controlled trial, but until high quality data are available (of both effectiveness and harms), a change in practice cannot be recommended.

      Disclosures and Acknowledgments

      This research received no specific funding/grant from any funding agency in the public, commercial, or not-for-profit sectors. None of the authors have any conflicts of interest.

      References

        • Mercadante S.
        • Marinangeli F.
        • Masedu F.
        • et al.
        Hyoscine butylbromide for the management of death rattle: Sooner rather than Later.
        J Pain Symptom Manage. 2018;
        • Mercadamte S.
        Death rattle: critical review and research agenda.
        Support Care Cancer. 2014; 22: 571-575
        • Star A.
        • Boland J.W.
        Updates in palliative care - recent advancements in the pharmacological management of symptoms.
        Clin Med (lond). 2018; 18: 11-16
        • Wee B.L.
        • Coleman P.G.
        • Hillier R.
        • Holgate S.H.
        The sound of death rattle I: are relatives distressed by hearing this sound?.
        Palliat Med. 2006; 20: 171-175
        • Wee B.
        • Coleman P.
        • Hillier R.
        • Holgate S.
        Death rattle: its impact on staff and volunteers in palliative care.
        Palliat Med. 2008; 22: 173-176
        • Campbell M.L.
        • Yarandi H.N.
        Death rattle is not associated with patient respiratory distress: is pharmacologic treatment indicated?.
        J Palliat Med. 2013; 16: 1255-1259
        • Hosie A.
        • Davidson P.M.
        • Agar M.
        • Sanderson C.R.
        • Phillips J.
        Delirium prevalence, incidence, and implications for screening in specialist palliative care inpatient settings: a systematic review.
        Palliat Med. 2013; 27: 486-498
        • Likar R.
        • Michenthaler M.C.
        • Traar R.
        • Molnar M.
        • Neuwersch S.
        Clinical factors influencing death rattle breathing in palliative care cancer patients: Non-interventional study.
        Z Gerontol Geriatr. 2017; 50: 332-338

      Linked Article

      • Author's Response
        Journal of Pain and Symptom ManagementVol. 57Issue 3
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          Thanks again for the further comments. The debate continues and I'm happy that this paper has raised such interest, giving me the occasion to further clarify its meaning.
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