Laryngospasm: It's often confused for a wheeze

Comics and writers like Stephen King can call it a wheeze.
But clinicians should know that if it's audible, it's laryngospasm.
For lack of a better description, you can call it rhonchi.
Oh, for crying out loud, call it a wheeze if you must,
but don't be fooled into thinking it's bronchospasm.

Clinicians don't learn about laryngospasm in nursing school, medical school, nor respiratory therapy school.  The reason is because most clinicians confuse it as bronchospasm, and call it a wheeze.  However, it is not bronchospasm, and it is not a wheeze: it's laryngospasm.  You should call it rhonchi.

So what is laryngospasm.  It's a harsh (coarse) audible sound during expiration. It's the sound of air moving through secretions sitting around the vocal cords, so when the patient exhales it is made audible.

Frequently it's caused by pulmonary edema and heart failure. Sometimes it is caused due to dehydration, such as when a patient suffers from detox or ETOH.

Many times it gives the appearance of airway obstruction, because the patient has a prolonged, forced, expiratory phase.  But when you ask these patients if they are short of breath they deny it.  This is because they are not experiencing bronchospasm, and the sound is perhaps "annoying" but it is not a wheeze.

If you don't want to call it "laryngospasm" you can call it rhonchi.  Rhonchi is the sound of air moving through secretions, and, more than likely, this is what you are hearing.  But you are certainly not hearing a "bronchospasmic wheeze," because a bronchospasmic wheeze is never audible. Bronchioles are teeny tiny airways, and you cannot possibly hear a wheeze produced by bronchospasm without the aid of a stethoscope.

What is a true bronchospasm wheeze?

A while back a fake buddy of mine made the observation that most people often confuse rhonchi for a wheeze.  He described it as "rhonchi-eeeeeeeeze."

Respiratory Therapists are often asked to give regularly scheduled breathing treatments that aren't needed because "the patient has a wheeze."  Sometimes the nurse says, "Can't you hear it?  I can hear it from here!"

My buddy also wrote a post about how what defines a wheeze is subjective, or that one person's wheeze is another person'a rhonchi or another person's coarse lung sounds.  Yet the bottom line is there is a lot of confusion regarding what a wheeze actually is.  This inspired the post "8 different types of wheezes."

My fake friend also wrote "Coarse lung sounds: the lazy clinician's lung sound." Here he wrote about how there is no such thing as a "coarse" lung sound, that what the clinician is actually hearing is rhonchi.  It's the sound of air moving through secretion filled air passages.  It was actually an NBRC test question once, proof that the experts who write the test were aware of the confusion long ago.

Sometimes rhonchi sounds bubbly on expiration.  A lazy clinician might confuse this as crackles or rhales, but it's actually rhonchi.  Coarse is rhonchi, and bubbly on expiration is rhonchi.  If you can hear it, it is rhonchi.  If you hear it over the throat, it's rhonchi.  Actually, if you place your stethoscope over the throat and you hear it, it's probably laryngospasm, but that's the subject of a future post.

Think of it this way.  If a person is having true bronchospasm, which is the true indication for bronchodilators such as Ventolin, Xopenex and Duoneb, the sound will not be coarse (i.e. rhonchi), and it will not be heard when you listen with the stethoscope over the neck where the vocal cords are, and it will definitely not be audible.

Think about it.  The air passages are tiny microscopic structures that can only be observed under the light of a microscope.  They are so tiny that there is no possible way that when they are obstructed the wheeze made will be heard unaided by a stethoscope.  It's simply not possible.

A wheeze is a high pitched sound, like eeeeeeeeeeeeeeee.  It even sounds like eeeeeeeeeeeeeee.  It can only be heard by auscultation.

A true wheeze (wheeeeeeze) is an indication for bronchodilator.  However, some people don't wheeze in the presence of bronchospasm, so another indication is no wheeze. So if you sit around waiting for a short of breath person to wheeze before you panic and order Ventolin, you may being your patient more harm than good.

So this is why it's important to know your lung sounds, as opposed to treating the patient with ventolin based on appearance and annoying audible noises coming from the patient.

Quote of the day -- Imaginary wheezes

I don't know about other hospitals, but where I work a ventilator is an indication for bronchodilator. It matters not if the patient has bronchospasm or not, because just being on a ventilator is indication enough.

So, today, when the third overdose patient in as many hours was put on a ventilator by your humble RT, and this patient too was ordered up on Ventolin Q6 hours, your humble RT approached the nursing supervisor with the quote of the day:

"Hey, Amanda, I was wondering if you'd fetch me -- at your convenience of course-- a Ventolin inhaler for this man's imaginary bronchospasms and imaginary wheezes."

Imaginary wheezes, bronchospasm, asthma, COPD and pneumonia seem to be on the prowl of late, so be on the lookout!!!