This study looked at the efficacy of drug treatment in managing death rattl
e in a 30-bedded specialist palliative care unit. The study was conducted i
n two phases. In the first, patients received hyoscine hydrobromide as the
antimuscarinic; glycopyrrolate was used in the second phase. The patients i
n the two phases were well matched for diagnosis, age, sex and duration of
death rattle. A noise score scale of 0-3 was used, which was separately val
idated using a verbal rating scale and noise-meter readings. Noise scores w
ere taken at the start; 30 min after an antimuscarinic drug was administere
d: an hour after the initial injection if a repeat dose was given at 30 min
; and 4-hourly thereafter. Drug charts of all patients with death rattle we
re analysed to ascertain the amount of each drug given and the cost. The in
cidence of death rattle was 44% in phase I, and 36% in phase II. The percen
tage of patients with reduced noise scores 30 min after one injection of hy
oscine was significantly greater than after one dose of glycopyrrolate (56%
vs 27%, P = 0.002). The need for a second injection after 30 min was less
using hyoscine (33% vs 50%, P = 0.03). There was no statistically significa
nt difference in improvement at 1 h, or at the last recorded score before d
eath. A comparison of the cost of drug treatment using hyoscine or glycopyr
rolate was made, and the potential reduction in cost per patient in the gly
copyrrolate group was largely offset by increased expenditure on other drug
s, especially diamorphine, midazolam and levomepromazine. The results of th
is study suggest that: (1) glycopyrrolate 0.2 mg is less effective at reduc
ing death rattle than hyoscine hydrobromide 0.4 mg when assessed at 30 min,
(2) the use of glycopyrrolate may lead to an increased need for other seda
tive or anti-emetic medication such as diamorphine, midazolam or levomeprom
azine, and (3) the cost benefit of using glycopyrrolate over hyoscine hydro
bromide is a small part of the total drug budget, and may be less than anti
cipated due to the increased need of these other drugs.