My question involves scientific background on snoring if you have it. We have had this uptrend in snoring being confused with agonal breathing. It seems to be getting lumped in with “making funny noises.” My understanding is that snoring alone is not agonal breathing, but it’s the time in between these snores that we need to focus on. For example, if a caller provides a weird snoring noise but it’s very sporadic with a long pause in between, then that’s agonal. But if it’s like they are sleeping/snoring, then it’s not. Obviously, every situation of snoring is different, but the best way to determine this is with the Breathing Verification Diagnostic Tool if no other indicators of agonal breathing were provided earlier.
From what I’ve been told this is typical with diabetic problems (unconscious patients.) Would you be able to confirm whether my understanding is correct and provide some scientific insight on this concept? I’m thinking this may be helpful to include in our training so that they know exactly what to do in these situations.
EMD Quality Performance Improvement Coordinator
Weld County Regional Communications
Greeley, Colorado (USA)
Perhaps it would be useful to study at the dispatch level calls described as simply snoring versus other descriptions.
Regular snoring (and I mean regular both in the sense it is the most common type, and it presents in regular intervals), is known and familiar to most callers. Therefore, a simple report of snoring in the diabetic or stroke patient is common and not usually alarming to the caller. Things get more interesting when the snoring is described as unusual, bearing in mind that many terms may be used to describe abnormal snoring. While there are significant variations of chronic and non-immediately life-threatening snoring, such as irregular snoring due to sleep apnea, let’s stick to snoring in unresponsive patients that we can generally classify as two types—unremarkable and everything else.
Snoring is simply caused by a flaccid or altered airway and, when there is no other clinical cause for the snoring itself, it is usually benign unless the airway becomes compromised (keep in mind we are talking about unresponsive patients so aspiration and positioning can actually prove deadly). For this reason, we always provide airway support to unconscious patients, regardless of the snoring. Incidentally, the head-tilt maneuver is a temporary remedy for classic snoring and, therefore, is somewhat diagnostic.
The “everything else” group includes seriously blocked airways by foreign material or severe loss of muscle tone, and agonal respirations, the latter being characterized by an irregular, gasping, and deteriorating breathing pattern that may or may not include snoring. Interestingly, but probably not supported by research, the “snoring” associated with agonal respirations I have heard over the years usually occurs after a gasp, during passive exhalation, unlike the more typical inhalation sounds associated with regular snoring. This makes sense since regular snoring is more associated with the airway than the dying gasps associated with agonal respirations.
Other than this basic pathophysiology, I think experience is the best way to learn this distinction. Fortunately, most EMDs have heard “regular” snoring and are already familiar with it. Agonal respirations, literally from the word “agony,” is much less familiar to most and needs to be heard to be properly explained. To complicate things a bit more, it may differ from patient to patient, time passed after the arrest, and fluids present in the airway, among other factors I’m sure. Fortunately, we have numerous examples to share in curriculum, and most agencies share examples discovered during the internal ED-Q process.
To summarize, snoring in and of itself is generally regular and familiar, and strange or unusual snoring is a red flag. When in doubt, use the Breathing Verification Diagnostic Tool (BVDxT) to confirm what the caller hears as simple snoring, and go straight to CPR for strange or unusual snoring, especially when irregular or when associated with gasping.
Brett A. Patterson
Academics & Standards Associate
Chair, Medical Council of Standards
International Academies of Emergency Dispatch
Brett Patterson is Academics & Standards Associate and Chair of the Medical Council of Standards for the IAED. His role involves protocol standards and evolution, research, training, curriculum, and quality improvement. Prior to working with the IAED, he spent 10 years working in the Pinellas County EMS System, Florida. He answers members’ protocol questions in the Journal FAQ column. (firstname.lastname@example.org)