Approach to Abnormal Breath Sounds

Initial Assessment

• The American Heart Association recommends that if the patient is unconscious with abnormal or absent breathing, assume cardiac arrest and initiate emergency protocols immediately 1
• The American Academy of Otolaryngology-Head and Neck Surgery suggests looking for signs of respiratory distress or stridor which require immediate intervention 3
• Assess for airway patency, especially in patients found face-down or with suspected spinal injury, as recommended by the American Heart Association 2
• Determine duration of symptoms - acute vs chronic, as suggested by the American Academy of Otolaryngology-Head and Neck Surgery 4
• Document any recent surgical procedures involving head, neck, or chest, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 3
• Note any recent endotracheal intubation which can cause vocal fold pathology in over 50% of cases, according to the American Academy of Otolaryngology-Head and Neck Surgery 4
• Ask about occupation, especially for professional voice users (teachers, singers, clergy) who are at higher risk for voice disorders, as suggested by the American Academy of Otolaryngology-Head and Neck Surgery 4
• Record tobacco and alcohol use history as these increase risk of laryngeal pathology, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 4, 5
• Listen carefully to the quality of breathing and voice (perceptual evaluation), as suggested by the American Academy of Otolaryngology-Head and Neck Surgery 5
• Note any abnormal breathing patterns such as gasping, wheezing, impaired breathing, as recommended by the American Heart Association 6
• Perform inspection and palpation of the neck for masses or lesions, as suggested by the American Academy of Otolaryngology-Head and Neck Surgery 5
• Assess for concomitant symptoms such as hemoptysis, dysphagia, odynophagia, otalgia, or weight loss, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 4

Diagnostic Approach

• Obtain standard posteroanterior (PA) and lateral chest radiographs for patients with suspected pneumonia, as recommended by the American Thoracic Society 7
• Do not obtain CT or MRI for patients with primary voice complaints prior to visualization of the larynx, as suggested by the American Academy of Otolaryngology-Head and Neck Surgery 3
• Perform laryngoscopy or refer to a specialist who can perform it when dysphonia fails to resolve within 4 weeks, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 3
• Perform laryngoscopy or refer to a specialist who can perform it immediately when a serious underlying cause is suspected, as suggested by the American Academy of Otolaryngology-Head and Neck Surgery 3, 4
• For suspected exercise-induced laryngeal disorders, consider spirometry and laryngoscopy with sound recording during exercise, as recommended by the American Academy of Allergy, Asthma, and Immunology 8

Indications for Expedited Evaluation

• Expedited laryngeal evaluation is indicated in patients with recent surgical procedures involving head, neck, or chest, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 3
• Expedited laryngeal evaluation is indicated in patients with recent endotracheal intubation, as suggested by the American Academy of Otolaryngology-Head and Neck Surgery 3
• Expedited laryngeal evaluation is indicated in patients with presence of concomitant neck mass, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 3
• Expedited laryngeal evaluation is indicated in patients with respiratory distress or stridor, as suggested by the American Academy of Allergy, Asthma, and Immunology 8
• Expedited laryngeal evaluation is indicated in patients with history of tobacco abuse, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 4
• Expedited laryngeal evaluation is indicated in patients with professional voice user with significant impairment, as suggested by the American Academy of Otolaryngology-Head and Neck Surgery 5
• Expedited laryngeal evaluation is indicated in patients with hoarseness with hemoptysis, dysphagia, odynophagia, or otalgia, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 4
• Expedited laryngeal evaluation is indicated in patients with hoarseness with accompanying neurologic symptoms, as suggested by the American Academy of Otolaryngology-Head and Neck Surgery 4
• Expedited laryngeal evaluation is indicated in patients with unexplained weight loss, as recommended by the American Academy of Allergy, Asthma, and Immunology 8
• Expedited laryngeal evaluation is indicated in patients with worsening hoarseness, as suggested by the American Academy of Otolaryngology-Head and Neck Surgery 4
• Expedited laryngeal evaluation is indicated in patients with immunocompromised host, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 4
• Expedited laryngeal evaluation is indicated in patients with hoarseness in a neonate, as suggested by the American Academy of Otolaryngology-Head and Neck Surgery 4
• Expedited laryngeal evaluation is indicated in patients with unresolving hoarseness after surgery, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 4

Common Pitfalls and Caveats

• Failure to recognize agonal breaths as a sign of cardiac arrest can lead to delayed resuscitation, as warned by the American Heart Association 1, 6
• Most dysphonia is self-limited and related to upper respiratory tract infection, which usually resolves in 7-10 days regardless of treatment, as noted by the American Academy of Otolaryngology-Head and Neck Surgery 5
• Do not prescribe antireflux medications to treat isolated dysphonia without visualization of the larynx, as warned by the American Academy of Otolaryngology-Head and Neck Surgery 3