n e w e ng l a n d j o u r na l


m e dic i n e

1. Larach MG, Localio AR, Allen GC, et al. A clinical grading

Eva Morava, M.D., Ph.D. Tulane University Medical School New Orleans, LA

Stephan Rust, Ph.D. Leibniz-Institut für Arterioskleroseforschung Münster, Germany Since publication of their article, the authors report no further potential conflict of interest.

scale to predict malignant hyperthermia susceptibility. Anesthesiology 1994;80:771-9. 2. Gurnaney H, Brown A, Litman RS. Malignant hyperthermia and muscular dystrophies. Anesth Analg 2009;109:1043-8. 3. Romero A, Joshi GP. Neuromuscular disease and anesthesia. Muscle Nerve 2013;48:451-60. DOI: 10.1056/NEJMc1403446

Fundamentals of Lung Auscultation To the Editor: We wish to complain (râler in French slang)1 that Bohadana and colleagues (Feb. 20 issue)2 have breathed life into the term “rhonchus,” which is as redundant as terms such as “phthisis.” Robertson and Coope3 suggested that lung sounds be divided primarily into continuous sounds, which they labeled wheezes, and interrupted (discontinuous) sounds, which they called crackles. Forgacs4 emphasized that wheezes are musical and crackles are not. The binary distinction is easy to teach and to use in practice. Bohadana et al. describe the rhonchus as a variant of the wheeze, indicate that its frequency is approximately 150 Hz, and liken it to snoring. Earlier distinctions between mucous, sibilant, and sonorous rhonchi5 are ignored; the frequency of wheeze — 100 to almost 5000 Hz — encompasses 150 Hz; since snores are inspiratory and rhonchi are usually expiratory, this might be misleading. It is time to dispense with “rhonchus” as well as with “rale” (which means “death rattle”).1 Jamie J. Coleman, M.D. Robin E. Ferner, M.D. University of Birmingham Birmingham, United Kingdom [email protected] No potential conflict of interest relevant to this letter was reported. 1. Rey A, ed. Le Petit Robert micro. Paris: Dictionnaires Le

Robert, 2013.

2. Bohadana A, Izbicki G, Kraman SS. Fundamentals of lung

auscultation. N Engl J Med 2014;370:744-51.

3. Robertson AJ, Coope R. Rales, rhonchi, and Laennec. Lancet


4. Forgacs P. Crackles and wheezes. Lancet 1967;2:203-5. 5. Thompson T. Hints on auscultation, with a view to the sim-

plification of terms and arrangement. Assoc Med J 1853;1:364-6. DOI: 10.1056/NEJMc1403766

To the Editor: The review of lung auscultation has two easily overlooked lessons that are par-


ticularly important in the examination of children.1 First, no noise is pathognomonic of a particular disease (or anatomical site). For example, stridor is not diagnostic of laryngeal obstruction. Obstruction at other sites can mimic the sound. Second, the “musical” sounds of airway obstruction — stridor, wheeze, stertor, and snore — form part of a continuous sound spectrum and cannot be distinguished from one another by means of any objective criterion. Their frequency spectra overlap, and their waveforms lack unique features. What matters most in children is not whether a noise can be called snoring, stridor, or wheeze but whether the sound is inspiratory or expiratory. Airway obstruction above the chest is worst and noise is loudest during inspiration. By contrast, intrathoracic airway obstruction is worst and noise is loudest during expiration. The site of airway obstruction in children with noisy breathing can be pinpointed by answering only two questions — without having to put a name to any sound. First, is airway obstruction worse during inspiration or expiration? Depending on the answer to the first question, the second question is either “Does obstruction occur when the child is breathing through the mouth or crying?” or “Is bilateral air trapping present?” The figure in the Supplementary Appendix, available with the full text of this letter at, shows an algorithm of the diagnostic process. Max Klein, M.B., Ch.B. University of Cape Town Rondebosch, South Africa [email protected] No potential conflict of interest relevant to this letter was reported. 1. Mellis C. Respiratory noises: how useful are they clinically?

Pediatr Clin North Am 2009;56:1-17, ix.

DOI: 10.1056/NEJMc1403766

n engl j med 370;21 may 22, 2014

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To the Editor: Bohadana et al. do not note a major and common obstacle to the accuracy of auscultation. In this country, auscultation is often attempted while the patient is wearing a shirt, blouse, or sweater. Although this is the standard of care in advertisements on television that portray physicians examining patients, it somehow has evolved into the common practice of both younger and older internists and subspecialists. Attenuation of lung sounds has been reported when auscultation is performed through even light clothing,1 and acoustic artifacts due to clothing may impair interpretation of sounds. Placing the stethoscope on bare skin remains the preferred technique.

eliminate the use of “rhonchus” from medical wards. Klein raises the important point that no lung sound is pathognomonic of a particular disease — an opinion that we share. This is not a weakness of auscultation, however, since few physical findings or single laboratory tests are absolutely specific; accurate diagnosis instead depends on combinations of abnormal findings. Regarding his comment about determining the site of airway obstruction in children by assessing only the relative amplitude of breathing noise during inspiration and expiration, we agree that this makes sense, although we are not aware of any published objective test of this finding and caution that lung sounds do not always appear as Raymond S. Koff, M.D. would be predicted. Since none of us are pediaUniversity of Connecticut School of Medicine tricians, we have little personal experience with Farmington, CT [email protected] this question. Koff brings up an important issue that one of No potential conflict of interest relevant to this letter was reported. us has previously studied.5 We agree that the 1. Kraman SS. Transmission of lung sounds through light practice of auscultation over clothing has become commonplace. We also agree that the physical clothing. Respiration 2008;75:85-8. examination is best performed when the patient DOI: 10.1056/NEJMc1403766 is unclothed. We can offer no solution to this problem but do recognize that the completeThe Authors Reply: With regard to the com- ness and accuracy of the physical examination ments by Coleman and Ferner: the term “rhon- is a physician’s professional duty, regardless of chus” has been retained in the nomenclature of possible inconvenience. the International Lung Sounds Association.1 In Abraham Bohadana, M.D. addition, it is very popular among general physi- Gabriel Izbicki, M.D. cians. The longevity of the term stems from its Shaare Zedek Medical Center origin. Laennec2 coined the term “râle” to de- Jerusalem, Israel scribe “all noises produced by the passage of air [email protected] during breathing” detected with his newly in- Steve S. Kraman, M.D. vented stethoscope. Given its similarity with the University of Kentucky School of Medicine death rattle, in clinical wards Laennec preferred Lexington, KY its Latin equivalent “rhonchus.” When translatSince publication of their article, the authors report no furing Laennec’s writing, Forbes3 used “rale” to de- ther potential conflict of interest. scribe discontinuous sounds, and he translated 1. Cugell DW. Lung sound nomenclature. Am Rev Respir Dis “rhonchus” as “wheeze,” with both terms used 1987;136:1016. Laennec RTH. De l’auscultation mediate. Paris: Brosson et to describe musical sounds. To illustrate how 2. Chaude, 1819. “rhonchus” became synonymous with “musical,” 3. Idem. A treatise on the diseases of the chest. John Forbes, almost two centuries later, a popular dictio- translator. London: Underwood, 1821. Merriam-Webster Dictionary. Definition of rhonchus (http:// nary 4 defines it as “a whistling or snoring sound 4. heard on auscultation of the chest when the air 5. Kraman SS. Transmission of lung sounds through light channels are partly obstructed.” In our opinion, clothing. Respiration 2008;75:85-8. a couple more centuries will be necessary to DOI: 10.1056/NEJMc1403766

n engl j med 370;21 may 22, 2014


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