Changes in breathing are a common and natural part of the body’s final transition in the end-of-life process. Witnessing these alterations can be unsettling for loved ones, but they are typically a reflection of the body slowing down, not an indication of distress or pain for the person dying. As the body’s systems begin to fail, the regulation of respiration changes, leading to distinctive sounds and patterns. Acknowledging these changes helps caregivers focus on providing comfort and support.
Understanding the Distinct Sounds and Patterns
One of the most noticeable respiratory changes is noisy breathing, often referred to as terminal respiratory secretions or the “death rattle.” This sound is characterized by wet, gurgling, or crackling noises that occur as air passes over pooled saliva and mucus in the throat and upper airways. The sound can be quite loud and is heard on both inhalation and exhalation. This noisy pattern is much more distressing for the listener than for the patient, who is often in a state of decreased consciousness.
Another distinct change is Cheyne-Stokes respiration, a significant alteration in the rhythm and depth of breathing. This pattern involves a cycle where breathing gradually increases in depth and rate (crescendo phase), before becoming progressively shallower (decrescendo phase). The cycle concludes with a period of apnea, or a pause in breathing, that can last up to a minute before the pattern repeats itself. This waxing and waning pattern reflects the body’s diminishing ability to regulate its respiratory drive. These irregular patterns are a sign that the body’s involuntary systems are taking over, but they are usually reflexive and not a sign of conscious suffering.
The Physiological Mechanisms Behind Respiratory Changes
The noisy breathing, or terminal secretions, occurs because the muscles responsible for coughing and swallowing become weak. As consciousness decreases, the natural reflexes to clear saliva and mucus from the back of the throat are diminished or lost entirely. This means the normal secretions produced by the body accumulate in the upper respiratory tract rather than being swallowed or expelled. The resulting gurgling sound is simply the movement of air through this pool of fluid.
The cyclical nature of Cheyne-Stokes breathing is primarily driven by a change in the brain’s responsiveness to carbon dioxide levels in the blood. The respiratory center in the brainstem, which normally maintains a steady breathing rate, becomes less sensitive to the body’s chemical signals. During the apneic phase, carbon dioxide builds up until it triggers an exaggerated, rapid breathing response. The body then over-breathes, dropping the carbon dioxide level too low, which causes the respiratory center to pause again, perpetuating the cycle. This mechanism is often linked to decreased blood flow to the brain, making the respiratory center less efficient.
Comfort Measures and Caregiver Support
For the noisy breathing caused by secretions, the primary non-medical intervention is a simple change in the person’s position. Gently turning the individual onto their side or slightly elevating the head of the bed utilizes gravity to help drain secretions away from the vocal cords and upper throat. This adjustment can reduce the intensity of the gurgling sound, making the environment calmer for all present. Caregivers should avoid suctioning the mouth or throat, as this aggressive intervention can cause distress and agitation without effectively clearing deeper secretions.
Medical staff may use specific pharmacological treatments, such as anticholinergic medications, which work to dry up the production of new secretions. These medications manage the symptom and reduce the auditory effect of the secretions. For caregivers witnessing the irregular patterns, maintaining a calm and reassuring presence is important. It is helpful to remember that the person is typically unaware of the pattern changes, and the sounds do not indicate that the person is choking or in pain. Speaking softly, holding a hand, or playing gentle music provides emotional support and reassurance for both the patient and the family.