What is the appropriate management for patients presenting with abnormal respiratory sounds?

Management of Abnormal Respiratory Sounds

For patients presenting with abnormal respiratory sounds, immediately assess for respiratory distress or stridor—if present, initiate emergency protocols and perform expedited laryngeal evaluation; if absent, determine whether symptoms are acute or chronic and perform targeted diagnostic evaluation based on anatomic localization of the sound abnormality. 1

Immediate Assessment and Risk Stratification

Emergency Red Flags Requiring Immediate Intervention

• If the patient is unconscious with abnormal or absent breathing, assume cardiac arrest and initiate emergency protocols immediately. 1 Do not mistake agonal breathing for normal respiration—this is a common pitfall that delays resuscitation. 1

• Respiratory distress or stridor requires immediate intervention and expedited laryngeal evaluation. 1 These findings indicate potential upper airway obstruction that may progress to complete airway compromise. 2

• Assess airway patency first, particularly in patients found face-down or with suspected spinal injury. 1

High-Risk Features Requiring Expedited Evaluation (Within Days)

The following factors mandate expedited laryngeal evaluation regardless of symptom duration 2, 3, 1:

• Recent surgical procedures involving head, neck, or chest 2, 1
• Recent endotracheal intubation (causes vocal fold pathology in >50% of cases) 2, 1
• Presence of concomitant neck mass 2, 1
• History of tobacco or alcohol abuse (increases risk 2-3 fold for malignancy) 2, 1
• Professional voice users (teachers, singers, clergy) with significant impairment 1
• Accompanying symptoms: hemoptysis, dysphagia, odynophagia, otalgia, or unexplained weight loss 3, 1
• Neurologic symptoms suggesting amyotrophic lateral sclerosis or other progressive conditions 2
• Immunocompromised status 1
• Hoarseness in a neonate 1
• Worsening or unresolving symptoms after surgery 1

Diagnostic Approach Based on Clinical Presentation

For Voice-Related Abnormal Sounds (Hoarseness, Dysphonia, Stridor)

Perform laryngoscopy or refer to a specialist who can perform it when dysphonia fails to resolve within 4 weeks, or immediately if a serious underlying cause is suspected. 2, 3, 1

Critical Timing Guidelines:

• Do NOT delay laryngoscopy beyond 4 weeks in persistent hoarseness—this is a major pitfall that increases healthcare costs from $271 to $711 and risks missing critical diagnoses including laryngeal cancer. 3
• 56% of primary care diagnoses change after specialist laryngoscopy, so avoid treating symptoms as "laryngitis" or "reflux" without confirming the diagnosis. 3

What NOT to Do Before Laryngoscopy:

• Do not prescribe antibiotics routinely for dysphonia (strong recommendation against). 2, 1
• Do not prescribe antireflux medications for isolated dysphonia based on symptoms alone without visualization of the larynx. 2, 3, 1
• Do not prescribe corticosteroids routinely prior to laryngoscopy. 2, 1
• Do not obtain CT or MRI for primary voice complaints before visualizing the larynx. 2, 3, 1

For Respiratory Sounds Suggesting Parenchymal or Airway Disease (Wheezes, Crackles, Rhonchi)

Obtain standard posteroanterior and lateral chest radiographs for patients with suspected pneumonia or parenchymal disease. 1

Anatomic Localization Strategy:

The diagnostic approach depends on suspected anatomic origin 4:

• Airways: Consider oral examination, cervical and thoracic radiographs, fluoroscopy, and bronchoscopy. 4
• Pulmonary parenchyma: Use thoracic radiographs, echocardiography, ultrasound of thorax, and transtracheal or endotracheal wash. 4
• Pleural space: Perform thoracocentesis (both diagnostic and therapeutic); chest tube placement may be necessary. 4
• Exercise-induced disorders: Consider spirometry and laryngoscopy with sound recording during exercise. 1

Comprehensive History and Physical Examination Elements

Key Historical Features to Document:

• Duration of symptoms: Acute versus chronic presentation 1
• Quality of breathing and voice: Perform perceptual evaluation 1
• Abnormal breathing patterns: Gasping, wheezing, impaired breathing 1
• Occupational history: Professional voice users are at higher risk 1
• Tobacco and alcohol use: Document quantity and duration 2, 1
• Recent procedures: Any head, neck, chest surgery or intubation 2, 1

Physical Examination Priorities:

• Inspection and palpation of neck for masses or lesions 1
• Assessment for concomitant symptoms: Hemoptysis, dysphagia, odynophagia, otalgia, weight loss 1
• Minimize stress during examination—patients with respiratory distress can decompensate easily, leading to respiratory arrest. 4

Treatment Approach After Diagnosis

Voice Therapy Indications:

Advocate for voice therapy in patients with dysphonia from causes amenable to voice therapy (strong recommendation). 2 Voice therapy is effective for nonorganic dysphonia and many benign pathologic vocal cord lesions. 3

• Perform diagnostic laryngoscopy before prescribing voice therapy and document/communicate results to the speech-language pathologist. 2

Surgical Indications:

Advocate for surgery as a therapeutic option for patients with conditions amenable to surgical intervention, including suspected malignancy, symptomatic benign vocal fold lesions unresponsive to conservative management, or glottic insufficiency. 2

Monitoring and Follow-Up

• Document resolution, improvement, or worsening of symptoms after treatment or observation. 3
• Educate patients about vocal hygiene and control/preventive measures. 3
• Serial physical examination, pulse oximetry, and arterial blood gas analysis may be necessary for monitoring respiratory patients. 4

Common Pitfalls to Avoid

• Failure to recognize agonal breaths as cardiac arrest leads to delayed resuscitation. 1
• Delaying laryngoscopy beyond 4 weeks in persistent hoarseness doubles costs and risks missing diagnoses. 3
• Empiric treatment without visualization of the larynx (antibiotics, corticosteroids, proton pump inhibitors). 3, 1
• Ordering imaging studies before laryngoscopy for voice complaints. 3, 1
• Overlooking occupational voice demands when developing treatment plans. 3
• Failing to recognize that most viral laryngitis resolves in 1-3 weeks—symptoms persisting beyond this require further evaluation. 3