What are the appropriate steps to take when concerned about abnormal breath sounds?

Approach to Abnormal Breath Sounds

When concerned about abnormal breath sounds, clinicians should first determine if the patient is unconscious with abnormal breathing, which may indicate cardiac arrest requiring immediate resuscitation, and if not, proceed with a systematic assessment to identify the underlying cause and determine if expedited laryngeal evaluation is needed.1

Initial Assessment

Emergency Evaluation

• If the patient is unconscious with abnormal or absent breathing, assume cardiac arrest and initiate emergency protocols immediately 1
• Look for signs of respiratory distress or stridor which require immediate intervention 1
• Assess for airway patency, especially in patients found face-down or with suspected spinal injury 1

History Taking

• Determine duration of symptoms - acute vs chronic 1
• Document any recent surgical procedures involving head, neck, or chest 1
• Note any recent endotracheal intubation which can cause vocal fold pathology in over 50% of cases 1
• Ask about occupation, especially for professional voice users (teachers, singers, clergy) who are at higher risk for voice disorders 1
• Record tobacco and alcohol use history as these increase risk of laryngeal pathology 1

Physical Examination

• Listen carefully to the quality of breathing and voice (perceptual evaluation) 1
• Note any abnormal breathing patterns such as:
  • Gasping, wheezing, impaired breathing 1
  • Occasional, barely/hardly breathing 1
  • Heavy, labored or noisy breathing 1
  • Thoracic dominant breathing or forced abdominal expiration 2
• Perform inspection and palpation of the neck for masses or lesions 1
• Assess for concomitant symptoms such as hemoptysis, dysphagia, odynophagia, otalgia, or weight loss 1

Diagnostic Approach

Imaging

• Obtain standard posteroanterior (PA) and lateral chest radiographs for patients with suspected pneumonia 1
• Do not obtain CT or MRI for patients with primary voice complaints prior to visualization of the larynx 1

Laryngoscopy

• Perform laryngoscopy or refer to a specialist who can perform it in the following situations:
  • When dysphonia fails to resolve within 4 weeks 1
  • Immediately when a serious underlying cause is suspected 1
  • When the patient has risk factors requiring expedited evaluation 1

Special Considerations

• For suspected exercise-induced laryngeal disorders, consider:
  • Spirometry and laryngoscopy with sound recording during exercise 1
  • Continuous laryngoscopy during exercise challenge for vocal cord dysfunction 1
• For computerized breath sound analysis, note that normal breath sounds have different acoustic properties based on:
  • Recording location (highest frequencies at trachea) 3
  • Patient characteristics (women and infants have higher frequencies) 3
  • Respiratory phase (inspiratory sounds generally more intense) 3

Indications for Expedited Evaluation

Expedited laryngeal evaluation is indicated in patients with the following risk factors:1

• Recent surgical procedures involving head, neck, or chest
• Recent endotracheal intubation
• Presence of concomitant neck mass
• Respiratory distress or stridor
• History of tobacco abuse
• Professional voice user with significant impairment
• Hoarseness with hemoptysis, dysphagia, odynophagia, or otalgia
• Hoarseness with accompanying neurologic symptoms
• Unexplained weight loss
• Worsening hoarseness
• Immunocompromised host
• Possible aspiration of a foreign body
• Hoarseness in a neonate
• Unresolving hoarseness after surgery

Common Pitfalls and Caveats

• Failure to recognize agonal breaths as a sign of cardiac arrest can lead to delayed resuscitation 1
• Most dysphonia is self-limited and related to upper respiratory tract infection, which usually resolves in 7-10 days regardless of treatment 1
• Do not prescribe antireflux medications to treat isolated dysphonia without visualization of the larynx 1
• Absence of breath sounds must be treated as a clinical emergency requiring immediate medical assistance 4
• Computerized breath sound analysis shows promise for distinguishing pneumonia or pleural effusion from normal lungs (sensitivity 82.5-90%, specificity 80-88%) 5