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.

Coarse lung sounds: The lazy clinician's lung sound

Most students don't like it when they follow me, because I don't accept lazy reporting of lung sounds.  When I have a student, I don't let them describe lung sounds as "coarse."  There is no such thing as coarse lung sounds.  I want a real lungsound, such as wheezes, or crackles or rhonchi.  I want specifics.  I also want location.  Do you hear crackles in the left lower lobe?  Do you hear sibilant wheezes in the left lower lobe?  Do you hear inspiratory wheezes inspiratory and expiratory (a bad sign)?  Do you hear rhonchi? 

Coarse lung sounds are most often rhonchi.  Yes, I think most people, including many of my fellow respiratory therapists, have no idea what rhonchi even is.  Most of them think it's secretions in the upper airway, but secretions in the upper airway are probably coarse crackles.  Coarse crackles is the sound fluid makes as it "rumbles" when a person inhales and exhales.  Rhonchi is the sound of air moving through air passages filled with secretions, and sound coarse.  It is most often air moving through secretion narrowed upper air passages, and this is why it is often audible.  Wheezes, if they are true bronchospasm wheezes, are almost always only audible with the aid of a stethoscope. 

Folks: There is no such thing as coarse lung sounds.  Do not be lazy and chart "Coarse." Do not be like my ignorant, lazy coworkers. 

Further reading:

1. There is no such thing as coarse lung sounds
2. Why do we listen to lung sounds?
3. Lungsound Lexicon
4. Lungsounds for Dunderheads (this might be a good read for you if you like to chart "coarse"

Where to listen to lung sounds

A question I get quite a bit by nursing and respiratory students is where to listen to lung sounds. I have also learned that nursing schools and RT schools may teach a different method, depending on the experience of the teacher.

In this post, however, I will teach you the ideal way to listen to lung sounds. Note, however, that it is up to you to find the method that works best for you. As with anything in the medical field, it's an art based on a science, and therefore the final decision is up to the individual.

I notice a lot of nurses and doctors will tell you to take in a deep breath for each place the stethoscope is placed on your back. While this is a good method of hearing adventitious lung sounds, it's not the best way to listen.

Here is how I do it.

First, I tell the patient to breathe normal. This way you will hear how the lungs sound with normal breathing. Now you take your stethoscope and place it over the right base of the lung on the back of the patient. Then you listen to the left base. Then the right middle lobe. Then the right upper lobe, and then the left upper lobe. All of this while the patient is taking normal breaths.

Basically, all you want to do here is see if the lung sounds are equal on each side and if the air movement is normal, increased, or decreased.

Normal air movement: This is where you hear airflow throughout the lungs fields. If the patient is short of breath and you hear normal air flow, you can surmise there is a low chance of it being due to bronchospasm. However, you still cannot rule bronchospasm out.

Diminished lungsounds: If all the lungfields are diminished, this is often indicative of bronchospasm, loss of lung elasticity (emphysema) or other diseases that diminish air flow such as cystic fibrosis or pulmonary fibrosis. If in one lobe, it may be indicative of something blocking airflow in that lobe, such as pneumonia or lung cancer.

Increased air movement: Usually you will only hear increased air movement over one lobe of the lungs, and usually in the bases. This is indicative of fluid in that lobe. Note here that sound travels better through water, and sounds louder. This may be a sign of possible pneumonia or pleural effusion.

Equal air movement: If the air flow is the same on both sides of the lungs this is good. If airflow is diminished on the right and normal on the left, then you know you have some disease process going on and it's up to you and the doctor to determine what it is.

Bronchospasm: This is best heard during normal laminar flow, and this is why you will want the patient to breath normal. If you hear wheezes during normal breathing, chances are increased that it might be bronchospasm.

All of this should be done in only a few short moments.

Second you will want to place the stethescope back on the right base and tell the patient to take in a deep breath. During a deep breath you will hear other adventitious lung sounds, such as a cardiac wheeze, crackles, rhonchi and rhales. Or, better yet, the air movement will be good with no adventitious sounds.

Here you will hear any fine crackles you missed when the patient was taking in a normal respiration (alveoli popping open). You will also be more likely to hear rhonchi or secretions that are rolling around. This is because the deep breath causes more turbulence and this may knock secretions around.

Likewise, these secretions, or other fluid, are likely to cause a wheeze that is not a bronchospasm wheeze. This is where you will here your cardiac wheeze or your wheeze due to secretions sitting on the vocal cords. These wheezes are often audible.

If you hear a wheeze, particularly one that is audible or present with good air movement, you should then proceed to listen to the throat. If you hear a wheeze in the throat you do not have bronchospasm, but a throat wheeze (stridor) that is radiating throughout the lungfields.

You can work your way up the patients back by the standard stethoscope spots as shown in the picture. Yet, ideally, when you are having a patient take in deep breaths, all you have to do is listen to the bases. That's where you'll hear your crackles.

Hence, if you hear crackles during normal respirations, chances are you'll hear them during deep inspirations. And, if you hear crackles during normal respirations, chances are what you are hearing is secretions or fluid as opposed to fine inspiratory crackles.

Third, once you have listened to all the lung fields you will want to listen to the throat. If you hear a wheeze in the throat you know the wheeze is not bronchospasm. More than likely it's secretions sitting on or near the vocal cords. This often occurs with cardiac patients, such as CHF.

Likewise, many times if you hear a wheeze throughout the lungfields and you have good throat wheeze.

Fourth, use common sense. While good airmovement and a throat wheeze may increase the chance it's caused by secretions or fluid, it does not always rule out bronchospasm. I have heard COPD patients and asthma patients with a throat wheeze and good air movement.

Like I said, the medical field is an art based on a science.

Check out my lung lexicon for more on the lung sounds, or check out this post on how to listen to lung sounds. To learn how to hear bronchospasm, click here.

My answers to your RT queries

Every week I check my statcounter to see who's typing things into Google or Yahoo and being linked to my RT Cave blog. Assuming the queries were not answered, I provide in this spot each week my humble responses.

And, hey, if the query is comical, it deserves a comical response. If it's serious, I treat it as serious. That in mind, here are this weeks queries:

1. career change respiratory therapist to rn : While I think that RT is a noble profession just like RN, we RTs are still working on developing the same kind of respect RNs have in the medical profession. We have made major strides just in the 10 years I've been an RT. But we have much farther to go. That in mind, there are some struggles in the RT community. Likewise, pay is not as great as for RNs. Fair? Well, if you don't think so, you can always become an RN yourself. Still, can you go from a mucus sucker, frivolous Scrubblin-Bubblin giver, roamer of the entire hospital to a poop scooper person who has to take care of the same patient all night. For the advantages and disadvantages of being an RT, click here.

2. how to break up wet lungs: Despite the myth that aerosolized sulfate will bind to the fluid particles in the lungs forcing the body to "exhale" the fluid, this IS -- my friends -- just a myth. Actually, if you have a patient with wet lungs, a diuretic is the best method of getting fluid from the lungs to the Kidneys and out of the body through the urinary tract. For more information about diuretics, click here. If by "break up" you are referring to pneumonia, the only thing that will "break up" pneumonia is the human body's defense system, and sometimes with a little assistance of an antibiotic.

3. what is the indication for albuterol with atrovent? It's basically the preference of the doctor. Some studies do indicate slight improvements when Atrovent is used in conjunction with Albuterol in emergency rooms. Others show that it works well for COPD to improve lung function long term (click here for more). Most studies show Atrovent is not beneficial for asthma patients. Whether they want to believe every study that's out there is up to the discretion of each individual doctor. Out of the hospital Atrovent is no longer used as a rescue bronchodilator. It is used as a "preventative" asthma medication. For more information about Atrovent as a bronchodilator click here and here.

4. coarse lung sounds: There is no such thing as coarse lung sounds. If you are hearing coarse, then what you are really hearing is rhonchi. Click here for more information.

5. dont give incentive spirometer to copd patietns: This is a fallacy. There is no reason a COPD patient couldn't benefit from good old fashioned deep breath with a breath hold followed by a cough. In fact, I would recommend it.

6. will unprescribed ventolin hurt children? Not any more than prescribed Ventolin, unless it was obtained by some illegal source; or unless it is outdated. Still, if you decide to use some other person's prescription, you should at the very least call your or your child's doctor.

7. baby's chest caves in while crying: This could be a sign of respiratory distress. Click here and check the other signs of respiratory distress.

8. atrovent pulmonary oedema: I have not seen any studies that show Atrovent does anything for pulmonary edema. If you find any studies to the contrary I would love to read about it.

9. when to stop singulair for asthmatics: Of course I'm no doctor, but I think the general consensus is you do not ever stop taking medications that are preventative in nature unless some better and safer med comes along, OR if you experience side effects that effect your quality of life. Singulair is a medication that works to prevent you from responding to your allergens, and there fore if you stop taking it you could have trouble with allergies and asthma. Asthma medicine should never be stopped without the explicit direction of a physician.

10. dummies guide to respiratory care: Sometimes that's how I think of this blog. However, none of my readers are dummies. You are all brilliant.

My answers to your querries

One of my favorite things to do on this RT cave is to answer your questions. What follows are web queries that lead someone to my blog, and my humble responses. I hope this can be of help to someone.

1. how does the hypoxic drive affects the brain? Lack of oxygen can kill brain cells.

2. atrovent doses to lower potassium: No.

3. use unprescribed ventolin inhaler: Unwise.

4. coarse vs snoring lung sounds: Snoring is defined well by Wikipedia: "Snoring is the vibration of respiratory structures and the resulting sound, due to obstructed air movement during breathing while sleeping. Coarse lung sounds are caused by fluid or secretions in lower or upper passageways in the lungs. If in the upper airway, the fluid may cause an audible snoring sound, hence the confusion.

5. allergy to ventolin: A very small percentage of patients claim to be allergic to ventolin, but I think most of the time someone makes this claim it is false. Most of the patients I've seen make this claim became "coincidentally" nauseous while using Ventolin and blames the Ventolin. However, nausea is not caused by allergies.

6. nebulizer tx q1 for pediatrics: If indicated it is safe for most patients. Yet this should only be done under in the hospital under the care of a physician.
7. ippb sucks: I bet. It sucks for the RT too that we know it only works to overdistend the good alveoli and doctors still order it, but more often than not at the insistence of older RTs who still believe old and outdated research.

8. do you get less respect as a respiratory therapist if you don't work in a hospital: That's a good question. I don't know. Of course, are you assuming RTs in hospital are respected? While RT respect is growing, we still lag behind respect of doctors for their nurse. But, some nurses aren't respected either, so the cycle continues.

9. nurses and respiratory therapists get paid the same: Not usually. Where I work RNs get paid way better.

10. breathing treatments one year old baby second hand smoke: Anyone who smokes in front of their kids is a pinhead. And smoking in front of kids can increase the chance of breathing complications and the need for meds like Ventolin.

Any further questions let me know: Freadom1776@yahoo.com.

There's no such thing as coarse lung sounds

The rest of this week I thought I would discuss some of the basic lungsounds. I know this might sound hilarious, but there are some people who have listened to lungs for 20 years and still have no clue how to describe them.

To be fair, however, different books can describe the same sounds differently. Lets take crackles for instance. Some books say that a crackle is either fine, medium or coarse, while others say it's rhonchi, rhales and fine crackles.

On a side note, someone in my RT department (we won't name names) keeps charting "Coarse" under lungsounds. Allow me to share this information with you: there is no such lung sound as coarse.

What is coarse? Is it a coarse wheeze? Is is rhonchi? Actually, it could be both. It could be a coarse wheeze or coarse rhonchi. But, so, where is it? RUL? RML? RLL? LUL? LLL?

So we need to be more specific.

The majority of the time, however, a coarse wheeze is actually rhonchi. if you can isolate it to one particular lobe, its more likely a wheeze. But if it's continuous throught all the lungfields, it is probably not a wheeze.

Why do I say this? Because rhonchi is usually heard over a wheeze and is usually hard throughout the lungs. The low pitched coarseness of rhonchi is usually in the upper, larger airways where sound travels better, and it produces a noise that is more easily heard.

A wheeze, for definition purposes, is not a low pitched coarse sound but high pitched whistling sound. And because it comes from the small bronchial tubes in the lungs, it is NEVER heard audibly. I will discuss wheezes at a later date.

Today I want to discuss rhonchi and coarse.

There was a practice NBRC test that asked this question: You are listening to lung sounds and you hear a coarse sound throughout on inspiration and expiration. How do you best describe this sound? a) a wheeze b) rhonchi c) crackles d) a and c.

Do you want to know what the answer was? It was (drum roll please) "b" rhonchi.

If you are charting coarse, you should actually be charting rhonchi. In a lot of patients you have that loud sound on inspiratory and expiratory. It may even sound like snoring. This is not a wheeze, it is rhonchi. What you are hearing is secretions rumbling on inspiratoin and expiration.

This is probably the toughest lung sound to pick out because it's not taught very well in school. Even many doctors chart this is coarse or as a wheeze and assume it is bronchospasm.

Yet, as soon as the RT does the STAT breathing treatment, the patient feels no better and the peek flow is the same before and after. Yet, three weeks later and after the insurance company is out $10,000 because of useless breathing treatments, the patient still has those treatments ordered.

And all of that because the doctor heard rhonchi and had no idea it was not a wheeze.

Rhonchi can also produce a bubbly sound over the throat and upper airway, which almost sounds like fluid is in there. You have the patient cough and usually this goes away. However, sometimes those secretions are further embedded in the upper airway, and this causes the COARSE sound you hear.

Sometimes these secretions are embedded by the vocal cords, and produce an audible sound. As I wrote in my last post, any lung sound that is audible is not a wheeze: it is rhonchi. Either that, or it is stridor.

Stridor is usually an audible inspiratory high-pitched sound. It is usually caused because of swelling near the vocal cords. It can be the result of croup or post extubation. It can be caused due to laryngospasms. And, despite contrary belief, it is a common lung sound in adults too. Only, it usually gets charted as a wheeze, so no one ever talks about it.

However, some RT books describe stridor as any noise inspiratory and expiratory that is heard in the throat. (Dana Oakes, "Clinical Practitioner's Pocket Guide to Respiratory Therapy," describes it this way).

To hear this noise, all you have to do is take your stethoscope and set it over the throat. If you hear it loud and clear their, then the noise you heard in the lower airways was this same sound.

Yet, it is true, many times doctors only listen to the posterior lungs and hear this high pitched sound and call it a wheeze, when it is actually upper airway stridor or rhonchi. A lot of older patients get secretions stuck right up behind the vocals, and they produce this high pitched sound. This happens sometimes for no reason on healthy adults, or it can happen on those with NGs, or simply OTL (Out To Lunch) patients or SGD (She's gonna die) patients.

I'm to the point now that I get so irritated when a doctor orders a treatment because a patient has upper airway swelling or secretions and no otherwise signs of shortness of breath, that if the doctor is still standing there, I will listen to the throat and say, "What you hear isn't a wheeze, it's stridor."

"Don't you know a wheeze by now," a doctor said to me once.

"Yes, and that's a stridor."

Of course I don't do that very often, only when I'm extremely busy and don't have time for such nonsensical treatments, very tired, or simply irritated. Unfortunately that doesn't happen enough around here, so our doctors continue to go uneducated.

Now I say doctors, I know there are some nurses and even a few RTs who have no clue what lung sounds are actually bronchospasm and which are secretions. I suppose this will be a continual battle.

However, there are some really smart doctors and RNs that I work with who know the difference, and don't call me every time they hear "COARSE" lung sounds.

Tomorrow I will expound a little about crackles and then maybe wheezes.

How to listen to lung sounds

As he places the stethoscope on your back, the doctor says, "Take a deep breath."

As an RT who has listened to the lung sounds of over 10,000 patients, I will tell you that having a patient take in a deep breath is not the ideal way to listen to lung sounds.

Ideally, you want the patient to breath normal. The reason is you want to hear what a patent's lungs sound like when he is breathing normal.

When a patient is taking in a deep breath, you will have more turbulence in the lungs, and you will hear a lot of extra noises, particularly upper airway noises, and secretions sitting in the throat. Throat noises are often mistaken for wheezes caused by bronchospasm.

So, here is an RT 101 coarse on how to listen to lung sounds. If I disagree with what you learned in RT, RN or DR school I apologize. But this is how you hear lung sounds.

First, you listen to the apices while the patient is breathing normal. Many times, though, the patient could have the worse lung sounds and still sound clear in the front, so this should never be the only place you listen.

Second, while the patient is still breathing normal, you'll want to listen to the right upper lobe and then left upper lobe, and then right lower lobe and left lower lobe. You do this because you want to make sure the lung sounds are equal on both sides.

If lung sounds are not equal, this may be indicative of whatever illness is ailing the patient. For example, crackles in one part of lung may be indicative of pneumonia. Diminished in one lobe may be indicative of pneumonia or pleural effusion or pneumo.

If a patient has fine crackles in the bases, you sometimes will not hear them unless the patient takes a deep breath. So, third, you have the patient take a deep breath while you listen to the bases for those fine crackles. This is how you hear your fine crackles.

Many times these crackles get missed by nurses, doctors and probably even some RTs. But never me.

Many times, if the crackles are equal in both bases, this may be a normal sound, particularly in COPD and CHF patients. However, fine crackles in the bases can be an early sign that the lungs are getting wet, and you should check the patients urinary output to see if he is retaining fluid.

See, by your proper lung assessment, you can easily prevent a patient from ever getting short-of-breath due to wet lung. And the Dr. and RN might even be impressed with you (or their faces might be red because they failed to listen at all).

Okay, by now you have heard all your lung sounds right? Wrong. When you listened you heard a loud wheeze throughout the lungfields. This "wheeze" may also even be audible.

Here is something I learned by experience and not through school: If the wheeze is audible it is not bronchospasm: it is a throat wheeze. Many times when a patient is wet he has a throat
wheeze, so when I hear this I assess for wet lungs while auscultating.

So, we have to add a fourth step that most doctors miss.

Fourth, listen to the patient's throat. If you hear the wheeze loud in the throat, there is a high likelihood that it is not a bronchospasm wheeze. It is probably a wheeze caused by phlegm in throat, or a dry throat, or snoring, or maybe even stridor.

Many times, doctors order breathing treatments just because a patient has throat wheezes that are RADIATING throughout the lungfields mimicking a bronchospasm wheeze. Many times this throat wheeze is laryngospasm, such as you might hear after a bronchoscopy or extubation.

If you follow these four simple steps you will always get accurate lung sounds. Then you go look at the chart to see what the doctor charted: "wheezes." Then the order says, "Albuterol Nebs Q4 ATC."

As a smart RT or smart RT student or smart RN you question the doctor: "What kind of wheezes? Where are the wheezes?"

You know that they are not bronchospasm wheezes, but the doctor doesn't. While you once thought a doctor could do no wrong, you now know better. You may even snicker.