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Thursday, August 22, 2013

The 9 different types of wheezes

As you guys know I am an ardent opponent to the idea that a wheeze is an indication for a bronchodilator.  I say this because about 90 percent of people who work in a hospital, and that includes nurses, doctors, (yes, doctors) and even some respiratory therapists have no idea what a wheeze is.

That might be a shocking statement to some of you, but it's true.  Just because someone has a "wheeze" does not mean it is bronchospasm.

So, for that matter, let us describe bronchospasm:

Bronchospasm:  Narrowing of the brochioles due to spasming of the bronchial muscles.  Or, worded so that non medical people can understand: Narrowing of the air passages in the lungs due to spasming of the muscles that wrap around them.  When this occurs, a wheeze may occur due to the narrowed airway, although a wheeze is not always present.

Okay, that's a simple enough definition.  So if you hear a wheeze it's bronchospasm then, right? Well, not necessarily.  There is a variety of other conditions that cause a wheeze, and many of them occur way more frequently than bronchospasm.

The following are things that may cause a wheeze:
  1. Laryngospasm:  Spasming of the larynx causes an upper airway wheeze
  2. Dry throat:  Dehydration may cause an upper airway wheeze
  3. Secretions:  Increased secretions may cause an upper airway wheeze as it sits on the voice box
  4. Inflammation in throat:  Narrowed upper air passages cause a wheeze, and it's usually audible
  5. Heart failure: Increased secretions cause a wheeze, it's often harsh and loud, and often heard audible, and it usually is noisier (not better) after b2 agonist therapy
  6. Kidney failure: Same as heart failure
  7. Upper airway obstruction: Causes an asthma-like sounding wheeze
All of the wheezes listed here can produce an audible upper airway wheeze. If you listen to the throat you will hear it. Also, you may also hear it in the lung fields because it radiates throughout the lung fields.

However, it must be noted here that just because you hear a sound in the lung fields, does not mean it's in the lung fields. This is why I recommend taking your stethoscope and placing it over the neck. If you hear the wheeze loudly there, then that's where the noise is coming from. If you still hear it throughout the lungfields, it's because the wheeze is radiating throughout. The wheeze is not coming from the bronchioles, it's radiating from the upper airways. And yes, the upper airway is going to cause a louder, more likely to be audible, wheeze, becasue they are in essence larger than bronchioles.

Here are some more types of wheezes.

8.  Cardiac wheeze:  This is the audible, upper airway, harsh wheeze you hear with heart and kidney failure. About 70 percent of wheezes heard by nurses and doctors are actually cardiac wheezes, not bronchospasm.  
The final thing that may cause a wheeze is bronchospasm

9.  Bronchospasm:  It's a wheeze due to bronchospasm and it can only be heard with a stethoscope.  

Technically speaking, all the wheezes described in this post, with the exception of true bronchospasm wheezes (#9) can technically be called rhonhi as opposed to wheeze. Rhonchi is the sound of air moving through secretions, and if it's audible, those secretions are sitting right around the vocal cords.

Thoughts? 

5 comments:

Anonymous said...

Great description of the various causes of a 'wheeze!. I frequently asked my peers to listen to the neck but none of them would...they could have learned a lot!

Unknown said...

Great info. This RT student thanks you.

Unknown said...

Great info. This RT student thanks you.

Anonymous said...

My 10 year old son has asthma. Sometimes, I can hear him wheeze when he walks in the room. I put my stethoscope on him and hear wheezes throughout. He says it's hard to breathe. He uses his albuterol inhaler and feels better. I can't hear the wheezes anymore. I put my stethoscope back on him and hear improvement. So what am I hearing when I can hear him wheezing without my stethoscope? That wheezing is not his asthmatic bronchospasm?

john bottrell said...

Great question. I observed the same thing in myself when I was a kid, that I would sometimes audibly wheeze when I was having asthma symptoms. My theory is you can't hear bronchospasm without the aid of a stethoscope. However, asthmatics also produce excessive amounts of mucus from an abnormally high number of goblet cells. This mucus makes it's way to upper airways, obstructing them. As air moves through these airways, an audible wheeze may be heard. I had many nurses tell me when I was a kid that my wheezes were audible, so they can't be bronchospasm. She was right. But what she failed to consider was that you can have both upper airway and lower airway (it's bronchospasm) wheezes at the same time. Keep in mind this is just my theory. However, I have also been living with this disease, and studying this disease, for over 40 years. I hope this answers your question. John. Site Moderator.