Sunday, January 23, 2011

Gurgling or Death Rattle? Does it predict pneumonia?

The physical exam is an important skill for the practitioner of palliative medical arts because we may be working with patients in their home where technical diagnostic options are limited or in a treatment mode that has been defined by avoiding further diagnostic tests.  So I am particularly interested by any article that discusses clinical examination skills relevant to palliative medicine.  Of course the title did not hurt in causing me to pause.  "Gurgling Breath Sounds May Predict Hospital Acquired Pneumonia" by Dr. Rodrigo Vasquez et al. published in Chest (article behind paywall) is one of only 6 articles in all of PubMed that have 'gurgling' in the title.

The research team from Bridgeport Hospital in Conencticut, examined patients in the 24 hours near admission by auscultating over the throat (glottis) during quiet breathing and speech.  Interestingly they mention examination near admission but they also include this caveat: 'or at any time during admission.'  How often people were diagnosed on admission versus during the admission is not presented which may affect some of the results.  For example is gurgling a cause or an effect of hospital acquired pneumonia?  And if you are studying gurgling being a risk factor for the acquisition of hospital acquired pneumonia I think it would be important to just evaluate on admission.  Moving on....

They compared demopgraphics, residence co-morbidities, treatments, and outcomes to see what was asosicatied with gurgle on admission (or at any time during admission).  They enrolled 80 patients (20 with gurgle and 60 matched cohorts) on the same day of admission.  Those who were found to have a gurgle had higher incidence of hospital acquired pneumonia (55% v 1.7%), intubation, transfer to ICU and were associated with a increased age (78.5 v 65.2), nursing home residence, treatment with opioids or antipsychotics.

In Table 2 I do have some concerns about their conclusions since they leave out some key details, in particular the timing of events.

The authors write:
"In multivariate analysis, dementia (OR = 23.4; 95% CI, 4.2-131.9) and recent (within 24 h) treatment with opiates (OR = 14.7; 95% CI, 2.2-97.5) emerged as the only statistically significant independent predictors of gurgle (Table 2)."
But could a reasonable conclusion also be that patients with dementia, of an advanced age, who acquire a pneumonia in the hospital and stay in the ICU and hospital an average of 14 days, may at some point receive opioids as the goals change away from a fading chance at recovery and more towards comfort measures only?

The main finding was that gurgling was far and away the biggest predictor (or associated symptom) of hospital-acquired pneumonia.

So what can we take away form this? Well if we hear gurgling in a patient it is important to document it, and to add in your notes this may be a risk factor for hospital acquired pneumonia and counsel the patient and family appropriately.  I am not sure we need to auscultate over the larynx.  Thoughts?

Another thing we can do is take this study, improve upon it and try and complete it from a hospice setting, or maybe in your own hospital.  I think the fundamentals are good, but some of the conclusions may be a bit premature.  Hopefully this also proves an important point of not relying on the summary from the authors and reading the article fully if you are going to change your practice.  Heck don't even trust me, go read it for yourself.  Apparently the writers of The Hospitalist didn't.  I originally saw this article highlighted in a clinical summary there.  They also agreed with the conclusion that opioid were also a predictor of gurgles, which I do not agree with.

I do have to compliment the authors on bringing up this important topic and for the following paragraph on the history of 'gurgling' in medical literature (emphasis mine).
Although the exact origins of the term “death rattle” are not clear, in 1853, Barclay attributed it to Laennec, who also described “gargouillement” (gurgling). Laennec initially used the term “rale” (French for rattle) in his writings but recognized it might frighten patients familiar with the term “death rattle.” In 1859, Thomas Inman indicated that “…an abundant perspiration, and the ‘death rattle’ in the throat, have long been recognized in many diseases as immediate harbingers of death.” Although many have studied or discussed the acoustics and pathogenesis of adventitious sounds, gurgling does not fit authoritative descriptions of rales, wheezes, or ronchi. So, although gurgling has been appreciated by clinicians for centuries, its technical features and pathophysiology have not been well studied. Ours is the first study, to our knowledge, to suggest that not all seriously ill patients who gurgle die and that this examination finding is associated with HAP.
It seems they tried hard to avoid the term 'death rattle' as the mere use of the term presupposes the outcome, much like terminal delirium.  Both of these I feel should be used more in a retrospective manner when discussing about a particular patient or in a tone that discusses them as a possibility not a certainty.  I am curious why they didn't go for my term of choice and the much more clinical/academic sounding 'oropharyngeal secretions?'

ResearchBlogging.orgVazquez, R., Gheorghe, C., Ramos, F., Dadu, R., Amoateng-Adjepong, Y., & Manthous, C. (2010). Gurgling Breath Sounds May Predict Hospital-Acquired Pneumonia Chest, 138 (2), 284-288 DOI: 10.1378/chest.09-2713

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