What is the best approach for an adult patient with abnormal breathing sounds and no known medical history?

Approach to Adult Patient with Abnormal Breathing Sounds and No Known Medical History

First, immediately assess if the patient is responsive and breathing normally—if they are unresponsive with abnormal or absent breathing, assume cardiac arrest and initiate CPR immediately. 1

Immediate Life-Threatening Assessment

The most critical first step is determining whether this represents a cardiac arrest scenario, as abnormal breathing in an unresponsive patient has a high likelihood of being cardiac arrest. 1

Emergency Recognition Protocol

• Check responsiveness by shouting and tapping the patient 1
• Simultaneously assess breathing and pulse (healthcare providers only) within 10 seconds to avoid delay 1
• If unresponsive with abnormal or absent breathing, assume cardiac arrest and begin chest compressions immediately at a rate of at least 100/min and depth of at least 2 inches 2
• Activate emergency response system while beginning resuscitation 1

Critical Warning About Agonal Breathing

Agonal gasps are frequently misinterpreted as normal breathing, occurring in 40-60% of cardiac arrest cases. 3 These appear as slow, irregular gasping respirations and should be treated as absent breathing. 1, 3 Failure to recognize agonal breaths as a sign of cardiac arrest leads to delayed resuscitation and increased mortality. 4

If Patient is Responsive: Systematic Evaluation

Immediate Triage for Expedited Evaluation

Certain presentations require immediate laryngeal visualization or specialist referral, not a "wait and see" approach. 1, 4

Perform expedited evaluation if any of the following are present:

• Respiratory distress or stridor (suggests airway compromise) 1, 4
• Recent surgical procedures involving head, neck, or chest 1, 4
• Recent endotracheal intubation (causes vocal fold pathology in >50% of cases) 4
• Concomitant neck mass 1, 4
• Hemoptysis, dysphagia, odynophagia, or otalgia 1, 4
• Accompanying neurologic symptoms 1, 4
• Unexplained weight loss 1, 4
• History of tobacco abuse (increases risk of laryngeal malignancy) 1, 4
• Immunocompromised status 1, 4

Focused History Elements

Document these specific factors that modify management:

• Duration of symptoms: acute versus chronic presentation 4
• Quality of breathing sounds: wheezing, stridor, gasping, or impaired breathing 4
• Tobacco and alcohol use: both increase risk of head and neck cancer 1, 4
• Occupation: professional voice users (teachers, singers, clergy) are at higher risk for voice disorders 4
• Voice quality changes: altered pitch, loudness, or vocal effort 1

Physical Examination Priorities

• Inspect and palpate the neck for masses or lesions 4
• Auscultate breath sounds to distinguish normal from adventitious sounds (crackles, wheezes, pleural rub) 5
• Assess for signs of inadequate ventilation: absent chest movement, cyanosis, decreasing oxygen saturation, hemodynamic changes, altered mental status 2

Diagnostic Approach Algorithm

For Upper Airway/Voice-Related Abnormal Sounds

Do NOT order CT or MRI before visualizing the larynx. 1, 4 This is wasteful and delays appropriate diagnosis.

• Perform laryngoscopy or refer for laryngoscopy within 4 weeks if dysphonia or abnormal breathing sounds persist 1, 4
• Perform immediate laryngoscopy if any red flag features listed above are present 1, 4

For Lower Respiratory Tract Sounds

• Obtain standard PA and lateral chest radiographs if pneumonia is suspected 4
• Consider spirometry and exercise laryngoscopy if exercise-induced laryngeal disorders are suspected 4

Critical Management Pitfalls to Avoid

Do NOT Do These Things

• Do NOT prescribe antireflux medications for isolated dysphonia without laryngeal visualization 1, 4
• Do NOT routinely prescribe corticosteroids before visualizing the larynx 1
• Do NOT routinely prescribe antibiotics to treat dysphonia 1
• Do NOT assume oxygen relief rules out serious causes—continue systematic evaluation even if initial oxygen improves symptoms 2

Common Diagnostic Errors

• Mistaking agonal gasps for normal breathing in cardiac arrest scenarios (occurs in 40-60% of cases) 4, 3
• Waiting too long for laryngoscopy when red flags are present 1, 4
• Ordering advanced imaging before basic laryngeal examination 1, 4

Special Considerations

Self-Limited Conditions

Most dysphonia is self-limited and related to upper respiratory tract infection, typically resolving in 7-10 days regardless of treatment. 4 However, this should not delay appropriate evaluation when red flags are present.

Risk of Delayed Diagnosis

The risk of missing serious pathology (malignancy, airway compromise) far outweighs the minimal risk of early laryngoscopy. 1, 4 Early cardiac arrest recognition with immediate CPR improves survival by 2- to 3-fold, while the risk of injury from CPR in patients not actually in cardiac arrest is only 1-2%. 3