Who Is Speaking Asthma? - Part 1

Medical terminology has held both a degree of fascination and intimidation for patients who are unfamiliar with it. Between health care professionals, the use of terminology is deliberate and easily understood. It aids communication and becomes a shorthand for conveying a volume of information in a few words. However, while it is helpful for health care professionals, one needs to carefully examine and even question its usage with patients. Many studies have clearly shown that parents, patients and health care professionals differ in their use of language when describing an asthma exacerbation.

Wheeze

Parents and patients with asthma have different understandings of what is meant by the word “wheeze”. Patients may use the word to describe a variety of respiratory sounds, few of which conform to the clinical definition of wheeze. Wheeze has been described as a whistle, a whistle that is not quite there yet, a quieter whistle, noisy breathing, strangled, rattle, gasping, crackly, squeaky, rasp, lisp, animal-sounding, air noise, high-pitched, rustle, musical sound, tight, rackle, breath catches, bubbling, and breathing through fluid. It has been compared to a tiger roaring, to a pair of bellows that’s not very efficient, to a Labrador, to a dirty phone call, to someone who smokes 40 a day, and to a little pig.1

Breathing sounds were compared to a bull, a snort, a coffee machine which has not been decalcified and a bellow.2 92 parents of infants with noisy breathing were interviewed in an attempt to investigate the terminology used by parents to describe their children’s breath sounds. Initially almost 60% chose wheeze to describe their child’s symptoms. After being given a detailed description and a video clip, only 36% of parents used ‘wheeze’ to describe their child’s symptoms. This degree of inaccuracy in the use of terms such as wheeze makes communication between parent and health provider difficult since both have different meanings for the same word. Patients may assume that wheeze is a medical term and use it to describe a variety of abnormal, audible respiratory sounds.3

In another study of 43 children under the age of 5 with reported wheeze, parents were shown a video clip of four different respiratory noises including wheeze and stridor.4 33 children had wheeze as the main symptom. Despite watching the video, among the 19 children with doctor-observed wheeze, only 9 parents identified the wheeze and 9 other parents identified the sounds as something other than wheeze.

Wheeze in any language?

In an attempt to overcome the difficulties of dealing with patients whose mother tongue is not English, video clips have been used to illustrate wheeze. This is a solution to the problem of translating wheeze into another language which lacks an adequate word substitute; and avoids bias due to language, literacy, culture or interviewing techniques. 190 parents were involved and given questionnaires which were available in English, Bengali, Turkish and Urdu. They were required to watch the video twice and were free to ask questions at the end. Those parents who had English as a first language were more adept at labelling each sound than other parents. 59% of parents could identify wheeze on a video clip. 30% of parents used other words for wheeze and a similar percentage of parents labelled other sounds – such as stridor, stertor (noisy inspiration occurring in coma or deep sleep that may be due to obstruction of the larynx or upper airways) or snoring – as wheeze.5

Cane and others used questionnaires for 160 parents of children with reported wheeze in an attempt to compare parents’ reports with epidemiological definitions. ‘Squeaking’ is the nearest equivalent to wheeze in Asian languages. Parents’ answers not only included squeaking but also hissing, whistle, rasp, sound and ‘what I hear’.6

As to where the wheeze occurs, parents varied in their answers. Parents in one study specified that the wheeze came not from the chest but from the throat.5 In another study involving Caucasians and African Americans, the latter felt that wheeze occurred in the upper airway, while the Caucasians stated that it came from the lower airway.7 Another study3 found that parents tend to be confused about the area within the respiratory system from which the different sounds originate.

Cough

Parents of children with asthma, and patients with asthma, have indicated that the cough they associate with asthma is distinct from the ‘normal’ cough. They used a variety of terms to describe the asthma cough such as short, dry, shallow, tickly, repetitive, wet, quite deep, and not a thick throaty cough.1 Cough is the most common symptom of asthma and parents use cough together with other symptoms to make judgements about handling the asthma. Cough alone as a symptom tends to be ignored unless it is combined with difficulty in breathing, which is a signal that medical attention is required.

Difficulty breathing

In the Cane study mentioned earlier, when parents were asked how they determined that their child was having difficulty in breathing, their answers included the following:

  • changes in breathing
  • irregular breathing
  • trouble breathing
  • heavy breathing
  • different from usual breathing.

Shortness of breaths is a subjective symptom and as such was not described by parents.1,6 Patients with asthma generally do not use this phrase to describe symptoms until repeated use by a health care professional leads them to connect this phrase with the appropriate physical sensation.

    . . . to be continued


References

  1. Young B, Fitch GE, et al. Parents’ accounts of wheeze and asthma related symptoms: a qualitative study. Arch Dis Child 2002; 87:131-4
  2. Ostergaard MS. Childhood asthma: parents' perspective--a qualitative interview study. Fam Pract. 1998 Apr;15(2):153-7.
  3. Elphick HE, Sherlock P, Foxall G, et al. Survey of respiratory sounds in infants. Arch Dis Child. 2001;84(1):35-39.
  4. Saglani S, McKenzie SA, Bush A, Payne DN. A video questionnaire identifies upper airway abnormalities in preschool children with reported wheeze. Arch Dis Child 2005; 90(9): 961-4
  5. Cane RS, McKenzie SA. Parents' interpretations of children's respiratory symptoms on video. Arch Dis Child. 2001;84(1):31-34.
  6. Cane RS, Ranganathan SC, McKenzie SA. What do parents of wheezy children understand by "wheeze"? Arch Dis Child. 2000;82(4):327-32.
  7. Hardie GE, Janson S, et al. Ethnic differences: word descriptors used by African-American and white asthma patients during induced bronchoconstriction. Chest. 2000;117(4):935-43.S