Essays And Articles Are A Type Of Rhonchi

Lung Sounds Made Easy

From the general practice nurse to the ICU nurse, lung sounds tell you a great deal about a patient and their relative health. However, knowing the difference between rales, a crackle, and a wheeze is sometimes still a confusing proposition for many nurses, especially new nurses.

Part of the reason for that is that some of the language is interchangeable. For instance, crackles actually are rales, and the large amount of words can leave anyone’s head spinning. Knowing what to call what you hear on the other end of the stethoscope can tell you – and the doctor – quite a bit about a patient’s condition.

Rhonchi

What was once called rhonchi are now called a sonorous wheeze, and this is because they have a snoring, gurgling quality to them. Rhonchi are often a low-pitched moan that is more prominent on exhalation. It differs from wheezes in that wheezes are high and squeaky while these are low and dull. Rhonchi are caused by blockages to the main airways by mucous, lesions, or foreign bodies. Pneumonia, chronic bronchitis, and cystic fibrosis are patient populations that commonly present with rhonchi. Coughing can sometimes clear this breath sound and make it change to a different sound.

Crackles (Rales)

Crackles are the sounds you will hear in a lung field that has fluid in the small airways. As stated before, crackles and rales are the same thing, and this can often lead to confusion among health care providers. Crackles come in two flavours: fine and coarse. Fine crackles sound like salt heated on a frying pan or the sound of rolling your hair between your fingers next to your ear. Coarse crackles sound like pouring water out of a bottle or like ripping open Velcro. This lung sound is often a sign of adult respiratory distress syndrome, early congestive heart failure, asthma, and pulmonary oedema.

Rhonchi, rales, wheezes, rubbing or stridor? – Listening for lung sounds.

Wheezes

Wheezes and rhonchi are actually very closely related. They are so closely related that the terminology for them has changed, too. Wheezes are now known as sibilant wheezes to distinguish them from rhonchi. Sibilant wheezes are high-pitched and shrill sounding breath sounds that occur when the airway becomes narrowed. They often have a musical quality to them. These are the typical wheezes heard when listening to an asthmatic patient. Sibilant wheezes are caused by asthma, congestive heart failure, chronic bronchitis, and COPD (see ‘Understanding COPD and the Hypoxic Drive to Breathe‘).

Stridor

Stridor is an unusual sound that not many adult patients will have, but it bears mentioning. It is a high-pitched, musical sound that is heard over the upper airway. It usually indicated a foreign body obstruction of the larger airways, such as the trachea or a main bronchus, and requires immediate attention. It is also the most common type of breath sound heard in children with croup, though it is important to differentiate between croup and a foreign body airway obstruction.

Rub

A pleural friction rub is caused by the inflammation of the visceral and parietal pleurae. These membranes are usually coated in a protective fluid, but when inflamed, they stick together and make a sound like leather creaking against itself. It often causes a great deal of pain, and the patient will splint their chest and resist breathing deeply to help mitigate the pain. A pericardial rub and a pleural rub will often sound similar, and the best way to distinguish between the two is to make the patient hold their breath. If you still hear the rubbing sound, then the patient has a pericardial rub and requires different treatment. Pleural effusion and pneumothorax are two diagnoses that can cause a pleural friction rub.

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1. Loudon R, Murphy RL Jr. Lung sounds. Am Rev Respir Dis 1984;130:663–73. doi:10.1164/arrd.1984.130.4.663[PubMed]

2. Osmer JC, Cole BK. The stethoscope and roentgenogram in acute pneumonia. South Med J 1966;59:75–7. doi:10.1097/00007611-196601000-00014[PubMed]

3. Wang CS, FitzGerald JM, Schulzer M et al. Does this dyspneic patient in the emergency department have congestive heart failure?JAMA 2005;294:1944–56. doi:10.1001/jama.294.15.1944[PubMed]

4. Vestbo J, Hurd SS, Agustí AG et al. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary. Am J Respir Crit Care Med 2013;187:347–65. doi:10.1164/rccm.201204-0596PP[PubMed]

5. Reddel HK, Bateman ED, Becker A et al. A summary of the new GINA strategy: a roadmap to asthma control. Eur Respir J 2015;46:622–39. doi:10.1183/13993003.00853-2015[PMC free article][PubMed]

6. van Vugt SF, Verheij TJ, de Jong PA et al. Diagnosing pneumonia in patients with acute cough: clinical judgment compared to chest radiography. Eur Respir J 2013;42:1076–82. doi:10.1183/09031936.00111012[PubMed]

7. Oshaug K, Halvorsen PA, Melbye H. Should chest examination be reinstated in the early diagnosis of chronic obstructive pulmonary disease?Int J Chron Obstruct Pulmon Dis 2013;8:369–77. doi:10.2147/COPD.S47992[PMC free article][PubMed]

8. Mikami R, Murao M, Cugell DW et al. International Symposium on Lung Sounds. Synopsis of proceedings. Chest 1987;92:342–5. doi:10.1378/chest.92.2.342[PubMed]

9. ERS Task Force Report, ed Sovijarvi A VJEJ. Computerized Respiratory Sound Analysis (CORSA): recommended standards for terms and techniques. Eur Respir Rev 10 2000;77:585–649.

10. Bohadana A, Izbicki G, Kraman SS. Fundamentals of lung auscultation. N Engl J Med 2014;370:744–51. doi:10.1056/NEJMra1302901[PubMed]

11. Benbassat J, Baumal R. Narrative review: should teaching of the respiratory physical examination be restricted only to signs with proven reliability and validity?J Gen Intern Med 2010;25:865–72. doi:10.1007/s11606-010-1327-8[PMC free article][PubMed]

12. Francis NA, Melbye H, Kelly MJ et al. Variation in family physicians’ recording of auscultation abnormalities in patients with acute cough is not explained by case mix. A study from 12 European networks. Eur J Gen Pract 2013;19:77–84. doi:10.3109/13814788.2012.733690[PubMed]

13. Jakobsen KA, Melbye H, Kelly MJ et al. Influence of CRP testing and clinical findings on antibiotic prescribing in adults presenting with acute cough in primary care. Scand J Prim Health Care 2010;28:229–36. doi:10.3109/02813432.2010.506995[PMC free article][PubMed]

14. Patra S, Singh V, Pemde HK et al. Antibiotic prescribing pattern in paediatric in patients with first time wheezing. Ital J Pediatr 2011;37:40 doi:10.1186/1824-7288-37-40[PMC free article][PubMed]

15. Pasterkamp H, Montgomery M, Wiebicke W. Nomenclature used by health care professionals to describe breath sounds in asthma. Chest 1987;92:346–52. doi:10.1378/chest.92.2.346[PubMed]

16. Pasterkamp H, Brand PL, Everard M et al. Towards the standardisation of lung sound nomenclature. Eur Respir J 2016;47:724–32. doi:10.1183/13993003.01132-2015[PubMed]

17. Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics 1977;33:159–74. doi:10.2307/2529310[PubMed]

18. Spiteri MA, Cook DG, Clarke SW. Reliability of eliciting physical signs in examination of the chest. Lancet 1988;1:873–5. doi:10.1016/S0140-6736(88)91613-3[PubMed]

19. Mulrow CD, Dolmatch BL, Delong ER et al. Observer variability in the pulmonary examination. J Gen Intern Med 1986;1:364–7. doi:10.1007/BF02596418[PubMed]

20. Holleman DR Jr, Simel DL, Goldberg JS. Diagnosis of obstructive airways disease from the clinical examination. J Gen Intern Med 1993;8:63–8. doi:10.1007/BF02599985[PubMed]

21. Badgett RG, Tanaka DJ, Hunt DK et al. Can moderate chronic obstructive pulmonary disease be diagnosed by historical and physical findings alone?Am J Med 1993;94:188–96. doi:10.1016/0002-9343(93)90182-O[PubMed]

22. Badgett RG, Tanaka DJ, Hunt DK et al. The clinical evaluation for diagnosing obstructive airways disease in high-risk patients. Chest 1994;106:1427–31. doi:10.1378/chest.106.5.1427[PubMed]

23. Wang EE, Milner RA, Navas L et al. Observer agreement for respiratory signs and oximetry in infants hospitalized with lower respiratory infections. Am Rev Respir Dis 1992;145:106–9. doi:10.1164/ajrccm/145.1.106[PubMed]

24. Wipf JE, Lipsky BA, Hirschmann JV et al. Diagnosing pneumonia by physical examination: relevant or relic?Arch Intern Med 1999;159:1082–7. doi:10.1001/archinte.159.10.1082[PubMed]

25. Brooks D, Thomas J. Interrater reliability of auscultation of breath sounds among physical therapists. Phys Ther 1995;75:1082–8. [PubMed]

26. Elphick HE, Lancaster GA, Solis A et al. Validity and reliability of acoustic analysis of respiratory sounds in infants. Arch Dis Child 2004;89:1059–63. doi:10.1136/adc.2003.046458[PMC free article][PubMed]

27. Gajdos V, Beydon N, Bommenel L et al. Inter-observer agreement between physicians, nurses, and respiratory therapists for respiratory clinical evaluation in bronchiolitis. Pediatr Pulmonol 2009;44:754–62. doi:10.1002/ppul.21016[PubMed]

28. Prodhan P, Dela Rosa RS, Shubina M et al. Wheeze detection in the pediatric intensive care unit: comparison among physician, nurses, respiratory therapists, and a computerized respiratory sound monitor. Respir Care 2008;53:1304–9. [PubMed]

29. Puder LC, Fischer HS, Wilitzki S et al. Validation of computerized wheeze detection in young infants during the first months of life. BMC Pediatr 2014;14:257 doi:10.1186/1471-2431-14-257[PMC free article][PubMed]

30. Kiyokawa H, Greenberg M, Shirota K et al. Auditory detection of simulated crackles in breath sounds. Chest 2001;119:1886–92. doi:10.1378/chest.119.6.1886[PubMed]

31. Bekhof J, Reimink R, Bartels IM et al. Large observer variation of clinical assessment of dyspnoeic wheezing children. Arch Dis Child 2015;100:649–53. doi:10.1136/archdischild-2014-307143[PubMed]

32. Williams GJ, Macaskill P, Kerr M et al. Variability and accuracy in interpretation of consolidation on chest radiography for diagnosing pneumonia in children under 5 years of age. Pediatr Pulmonol 2013;48:1195–200. doi:10.1002/ppul.22806[PubMed]

33. Walsh SL, Calandriello L, Sverzellati N et al. Interobserver agreement for the ATS/ERS/JRS/ALAT criteria for a UIP pattern on CT. Thorax 2016;71:45–51. [PubMed]

34. Piirila P, Sovijarvi AR, Kaisla T et al. Crackles in patients with fibrosing alveolitis, bronchiectasis, COPD, and heart failure. Chest 1991;99:1076–83. doi:10.1378/chest.99.5.1076[PubMed]

35. Piirila P, Sovijarvi AR. Crackles: recording, analysis and clinical significance. Eur Respir J 1995;8:2139–48. doi:10.1183/09031936.95.08122139[PubMed]

36. Meslier N, Charbonneau G, Racineux JL. Wheezes. Eur Respir J 1995;8:1942–8. doi:10.1183/09031936.95.08111942[PubMed]

37. Wilkins RL, Dexter JR, Murphy RL Jr et al. Lung sound nomenclature survey. Chest 1990;98:886–9. doi:10.1378/chest.98.4.886[PubMed]

38. Shim CS, Williams MH Jr. Relationship of wheezing to the severity of obstruction in asthma. Arch Intern Med 1983;143:890–2. doi:10.1001/archinte.1983.00350050044009[PubMed]

39. Shirai F, Kudoh S, Shibuya A et al. Crackles in asbestos workers: auscultation and lung sound analysis. Br J Dis Chest 1981;75:386–96. doi:10.1016/0007-0971(81)90026-7[PubMed]

40. Elphick HE, Ritson S, Rodgers H et al. When a “wheeze” is not a wheeze: acoustic analysis of breath sounds in infants. Eur Respir J 2000;16:593–7. doi:10.1034/j.1399-3003.2000.16d04.x[PubMed]

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