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Wednesday, November 4, 2009

How to hear bronchospasm

It has been said that it takes a trained ear to hear bronchospasm. There is much truth to this statement. So, that in mind, I have decided to create a lesson here on how to hear bronchospasm. This might be good for all nurses, respiratory therapists, students and even doctors to review.

First of all, the patient has to be breathing. If you are hearing no lung sounds then you know you are not hearing bronchospasm. Likewise, if a patient is breathing normal, is not short of breath, and has good air movement with clear lungsounds, you are also not dealing with bronchospasm.

Many people believe if you hear a wheeze it's automatically bronchospasm and a bronchodilator breathing treatment is indicated. They jump the gun and scream, "Hey Respiratory! Give this guy a treatment!"

The truth is, not all that wheezes is bronchospasm. Heart failure and pneumonia cause more wheezes than bronchospasm. The fluid from heart failure or pneumoonia causes increased pressure in the lungs and squeezes the air passages from the outside causing a wheeze that is quite often heard in the throat. This, my friends, is called a Cardiac Wheeze and must not be confused with a bronchospasm wheeze.

Here are some tips to help you learn to hear bronchospasm:

  1. Shortness of breath alone does not indicate bronchospasm. Or, stated another way: All that wheezes is not bronchospasm. Before you rush to call an RT for a bronchodilator you should assess the patient further to determine WHY the patient is short of breath.
  2. If patient is not short of breath there is no bronchospasm, and no bronchodilator is indicated. Nuff said.
  3. If it's an audible wheeze it's not bronchospasm. Usually if it's audible what you are hearing is fluid sitting on the vocal cords. Many experts consider an audible wheeze stridor, and stridor is not a wheeze at all. If you hear an audible wheeze consider pneumonia or heart failure and check or watch the patients fuid intakes and outtakes.
  4. A bronchospasm wheeze is NEVER audible. True bronchospasm wheezes are within the air passages of the lungs and can only be heard by auscultation. They will also NOT be heard in the throat. (Yes, I know I repeated myself. This is an important point.)
  5. Listen to the throat. If you hear the wheeze by auscultating the neck area it's an upper airway wheeze, and is usually associated with excessive secretions or pulmonary edema (again think heart failure or pneunomia). If you hear this watch this patient for signs of fluid overload. Sometimes you will hear a "throat wheeze" radiating throughout the lungfields.
  6. Have patient breath normal. When a patient is taking a deep breath you are more likely to hear upper airway noises that overshadow underlying bronchospasm. A true bronchospasm wheeze is best heard with normal, slow, laminar inspiration and expiration.
  7. Have patient relax. This sort of goes along with #3 above, but it had to be said. Many times a patient is anxious and breathing fast and this moves secretions around causing dyspnea and wheeze. Usually the cause of dyspnea with exertion is cardiac related and what a patient needs is an oxygen boost and/or rest -- not Albuterol.
  8. Have patient breath through pursed lips. If you really want to tell if a patient actually has bronchospasm, have them breathe through pursed lips. This forces them to breathe normal and you will not hear the upper airway component, and are more likely to hear the bronchospasm wheeze if it exists. You may need to listen closely, because a bronchospasm wheeze can sound very distant. This is a great trick.
  9. Listen for diminished lungsounds. Bronchospasm usually results in diminished or decreased air movement in the lungfields. If a patient has good air movement even with other adventitious lungsounds, the odds are that the noises are not caused by bronchospasm. (Click here to learn why I think diminished lungsounds is better indicator of bronchospasm than wheezes.)
  10. As a rule of thumb, bronchospasm wheezes are usually expiratory. If you hear an expiratory wheeze you can consider bronchospasm. If you hear an inspiratory wheeze chances are you're hearing bronchitis.
  11. Exceptions to the rule. Sometimes the patient can have an upper airway wheeze or cardiac wheeze and also have an underlying bronchospasm component. In this case you may want to try one bronchodilator treatment and see if the patient gets better. If it doesn't work don't be the fool who orders continuous breathing treatments for no reason and overlooks what the patient really needs (perhaps some Lasix?).
  12. If you hear increased lungsounds after the treatment you had bronchospasm to begin with. However, if the patient had good aeration before and after therapy, consider no bronchospasm existed and tell the nurse and doctor to try something else (if they'll listen to you).
  13. Quite often, the best inidcator of bronchospasm is no wheeze at all. This is especially true with adults. So don't assume just because a patient isn't wheezing that he's not having bronchospasm.

For more information check out the following posts:

Indications for breathing treatments.
SOB not always caused by bronchospasm

1 comment:

Anne said...

Your last comment interested me. I have been asked about wheezing too many times, when no, I didn't think I had been wheezing, but I absolutely positively without question had (or had had) much too much shortness of breath.