Lung Sound Nomenclature Survey* Robert L. Wilkins, M.A., R.R.7:;t James R. Dexter; M.D., F.C.C.R;t Raymond L. H. Murphy, Jr., M.D., F.C.C.R;* and Elizabeth A. DeiBono, M.RH.§
We report the terms used by 223 pulmonary physicians and 54 physicians in other specialties to describe eight recorded examples of lung sounds. The participants listened to the lung sounds at the 1988 American College of Chest Physicians annual convention and wrote "free form" answers. Pulmonary physicians used the terms "crackles" and "rales" with equal frequency to describe discontinuous adventitious lung sounds (ALS) and not at all to describe continuous ALS. Other physicians preferred the term "rales" in describing discontinuous ALS. The terms "wheeze" and "stridor" were used only in describing continuous ALS; however, the term "rhonchi" was frequently used to de-
scribe continuous and discontinuous ALS. The majority of participants recognized the normal breath sounds but not the pleural friction rub. Most did not use a qualifying adjective to describe ALS, and there was little agreement among those who did. The lung sound terminology used by physicians is not well standardized and the recommendations of the ATS/ACCP nomenclature subcommittee are not (Chest 1990; 98:886-89) widely accepted.
The clinical value of chest auscultation would be enhanced by the use of a consistent nomenclature for lung sounds. An Ad Hoc Subcommittee on Pulmonary Nomenclature established by the American College of Chest Physicians and the American Thoracic Society has made recommendations in an attempt to achieve this goal. 1•2 The committee most recently suggested that discontinuous adventitious lung sounds be described as "crackles," high-pitched continuous ALS be described as "wheezes," and low-pitched continuous ALS be described as "rhonchi." The term "rales" was considered undesirable because it had historically been used to describe both continuous and discontinuous ALS. In addition to the basic terms used to describe ALS, qualifying adjectives may improve or confuse communication. The nomenclature committee recommended the terms "fine" and "coarse" be used to qualify crackles following the suggestion by Forgacs" that adjectives with a physiologic or acoustic basis (eg, low-pitched, high-pitched, fine, coarse) be used rather than the traditional terms (eg, dry, wet, sonorous, sibilant, etc). Studies of lung sound nomenclature in published case reports have identified that lung sound terminology varies widely and that the term "rales" remains
popular despite a decline in its use from 1978 to 1982.4•5 It is not clear, however, if the decrease in use of the term "rales" was due to author preference or to editorial policy influencing the terms used. In 1987, Pasterkamp et al6 reported significant differences between groups of health care professionals in the preferred terms used to describe tape recorded breath sounds of asthmatic patients. The investigation was limited by the small sample size (only 40 Canadian professionals were studied) and the lack of variety in the breath sound samples (continuous ALS from asthmatics were predominant in the selection of examples). In 1989, we reported the terms preferred by respiratory care practitioners (Rep) to describe recorded ALS heard through the use of a cassette player and earphones at a national meeting." We found that the terms "rales" and "crackles" were used exclusively for discontinuous ALS, with "rales" approximately twice as popular as "crackles." The terms "wheeze" and "stridor" were used primarily for high-pitched continuous ALS; however, the term "rhonchi" was used frequently to describe both continuous and discontinuous ALS. While this study provides information regarding RC~ it did not provide data about physician use of terminology for lung sounds. The purpose of our current study was to answer the following questions: (a) What terms are physicians in the United States using to describe lung sounds? (b) Are there significant differences in nomenclature based on demographic factors such as region of practice, type of practice or age? (c) Are pulmonary physicians and other physicians using similar terms to describe lung sounds? To answer these questions, we asked physicians at a national meeting to describe
*From the Department of Respiratory Therapy, School of Allied Health Professions, and the School of Medicine, Lorna Linda University, Lorna Linda, CA; Tufts University School of Medicine, and the Pulmonary Departments, Faulkner and Lemuel Shattuck Hospitals, Boston. t Associate Professor, Lorna Linda University. tProfessor of Medicine, Tufts University School of Medicine. §Research Assistant, Faulkner Hospital. Manuscript received October 17, revision accepted March 14. Reprint requests: Mr. Walkins, Rm 1926 NichOL Hall, Loma Linda University, Loma Linda,CA 92350
188
ALS = adventitious lung sounds; Rep = respiratory care practitioner; PP = pulmonary physicians; NPP = nonpulmonary physicians
Lung Sound NomencIabn Survey(WIlkins et 81)
A
:v1W.
J"., v ....... "'-
'VV~"""'-oojIlW'oo...,..
-""'
__
,..
...
~
-""'~
. _.,.,.",."".,
~
",..•.,
~
-
q,
:
s'* Ai'~ "~rM~
~~.Lf~'~Y~ ••••••
B
E
~_J.k"'.'l
~
, l
.......
t
j
I
I
I
l
••
I
~
.. . J
I
l
......
~
l
- .. I
~
I
I
...... I
,
nat
c o
500
1000
1500 HZ
FIGURE 1. Examples of the waveforms used to evaluate the lung sound samples. In the interest of brevity, not all the samples are presented. Analysis of sample 1 and sample 5 (A and 8, respectively) in the time domain. I denotes the beginning of inspiration and E denotes the beginning of exhalation. The plot is read top to bottom and left to right. Each line represents 0.34 seconds and the entire sample is approximately 4 seconds in length. (C). Analysis of sample 5 in the frequency domain. Inspiration begins at the bottom left corner and the plot is read bottom to top and left to right. Each line represents 260 ms increments.
tape-recorded lung sounds. MATERIAL AND METHODS
We surveyed 277 North American physicians in the exhibit hall of the 1988 ACCP Annual Meeting in Anaheim, California. Participants completed a data sheet to identify background information and then wrote "free form" answers while listening to eight recorded
lung sounds using stethophones. Sonograms" and wave-form analysis" in the time domain were used to substantiate the nature of the recorded chest sounds (Fig 1, upper and center). For the continuous type of ALS (samples 3 to 5), analysis in the frequency domain was done to evaluate the pitch (Fig 1, lower). A description of each sound sample based on interpretation of the wave-forms is presented in Table 1. CHEST I 98 I 4 I OCTOBER, 1990
887
Table l-Deacription afthe Sound Sample. Sample No.
Description
1 2
Pan-inspiratory fine crackles Inspiratory and expiratory coarse crackles and rhonchi (secretion sounds) Inspiratory crackles and expiratory polyphonic wheezes Expiratory rhonchi Inspiratory stridor and expiratory highpitched wheeze (monophonic) Pleural friction rub Normal breath sounds Coarse, early-inspiratory crackles
3 4
5 6 7
8
RESULTS
Of the 277 North American physicians surveyed, 223 were pulmonary physicians (PP) and 54 were
physicians with a specialty other than pulmonary which will be referred to as nonpulmonary physicians (NPP). Most of the physicians used "crackles" or "rales" to describe sample 1 with NPP favoring the term "rales" over "crackles" and PP not showing a preference between the two terms (Table 2). Sample 2 was described most often as "rales," "rhonchi," or "crackles." Almost 90 percent of the PP and nearly 80 percent of the NPP used "wheezes" in their description of sample 3. Some noted the inspiratory crackles in sample 3 and thus wrote "crackles and wheezes" or "rales and wheezes." Sample 4 elicited a variety of responses from both groups with "rhonchi," "bronchial breath sounds," "wheeze," and "rub" being the most popular. Most of the physicians described sample 5 as "stridor" or "wheezes" with the PP preferring "stridor" and the NPP using both terms equally Sample 6 was recognized as a rub by 32 percent of the PP and 11 percent of the NPE Those who did not recognize the rub frequently describe sample 6 as "rales," "crackles," or "rhonchi." Sample 7 was recognized as
normal breath sounds by nearly 80 percent of the physicians. For sample 8, "rales," "crackles," and "rhonchi" were used by both groups; however, "crackles" was more popular with the PE Table 2 identifies the terms in which there were significant differences between the pulmonary and other physicians for the description of the sound samples. We did not find statistically significant differences among the physicians in the selection of terms based on region of practice, time since the completion of residency, age, or type of practice (clinical vs research). The majority of physicians did not use a qualifying adjective to describe the seven abnormal sound samples. For those who did use a qualifying adjective, a variety of terms were used. For the discontinuous ALS samples (1, 2, and 8), the terms "fine," "coarse," "Velcro," "dry," and "wet/moist" among others were used. For the continuous ALS samples (3, 4, and 5), qualifying adjectives were used less frequently. "Coarse" or "harsh," "high-pitched," and "lowpitched" were the only terms used as qualifiers by at least 5 percent of the participants. Since the physicians completed this survey while listening to an audiotape, we did not tabulate the frequency in which the terms "inspiratory" or "expiratory" were used. DISCUSSION
The PP use the terms "rales" and "crackles" with approximately equal frequency for describing discontinuous ALS and not at all for describing continuous ALS. This suggests that the two terms are synonyms and neither this survey nor our Rep survey previously reported? substantiate concerns regarding the lack of specificity in the use of the term "rales." Although NPP use "rales" more often than P~ they also only use this term to describe discontinuous ALS. Musical (polyphonic) wheezes represent a sound
Table 2- Tenns Used by Physiciam to De.cribe the Sound Samples Sound Samples
3
2
5
4
6
7
8
Term(s)
PP
NP
PP
NP
PP
NP
pp
NP
PP
NP
PP
NP
PP
NP
PP
NP
Rales Crackles Rhonchi Wheeze Stridor Rub Bales/crackles & rhonchi Bales/crackles & wheezes Normal Bronchial Other
.40 .44
.63* .19* 0 0 0 0 0 0 0 0 .18
.24 .22 .24
.20
0 0
0 0
0 0
0 0
0 0
0 0
.31
.26
.05
.04
.39 0 0
.16 0 0 0 0 0
.28 .09· .22
0 0
0 0 0 0 0 0 0 0 .79 .10 .10
0 0
0 0
.19 .18 .18 0 0 .32 0 0 0 0 .13
.28
.17
0 0 0 0 0 0 0 0 .16
.05 .09 0 0
.02 .14
.04 .07 0 0 .07 .19
.03 .38 0 0 .15
.07
.54 .02 0 0 .19· 0 0 .18
.30
.30
.04
.07
.13
.11
.05 .09
.04
.27 .49 0 0 0 0 0 .21
.37 .37 0 0 0 0
0 0 0 .21
.23
.02 0 0 .02 .13
.39
.04 .15
.13
.30 0 0 .11·
.06 0 0
.02 .10
0 0
.02 0 0 .78
.30
.06
.03 .04
.10
.17
0 0
.06 .02 0
.02 .06 .25
·Difference significant at the 1 percent level in comparing pulmonary physicians (PP) to other physicians (NP).
888
Lung SoundNomenclature Survey(W1Ikins et 81)
that most physicians agree should be described as "wheezes," as more than 80 percent of those surveyed used the term "wheeze" in their description of sample 3. Even though sample 3 had briefinspiratory crackles in addition to the loud, expiratory polyphonic wheeze, only 38 percent of the PP and 19 percent of the NPP described this sample as "rales and wheezes" or "crackles and wheezes." The ability to identify and document such details is an important part of auscultation. The term "rhonchi" was used with less precision than other terms as it was frequently used to describe samples 2, 4, 6, and 8. Rhonchi are defined as lowpitched continuous sounds with a snoring quality and are commonly heard in patients with airway secretions. This association between rhonchi and secretion sounds may explain why some described the coarse crackles of samples 2 and 8 with the term "rhonchi" and may indicate that the term needs clarification among many clinicians. Sample 4 was a rhonchus and was described inaccurately by more than 50 percent of the physicians. This suggests that a rhonchus is not easily recognized which we believe could be due to its lack of distinctive sound characteristics. While the majority of physicians identified sample 5 as "stridor" or "wheeze," only 54 percent of the PP and 43 percent of the NPP used "stridor" in their description. Because this sound was recorded over the neck of a patient with laryngeal obstruction, which represents a potentially life-threatening problem, precise recognition is important. The majority of participants did not use a qualifying adjective to describe the ALS samples. These results are consistent with the findings of Bunin and Loudon" and with our Rep survey 7 Since certain characteristics of ALS (eg, fine vs coarse crackles) can be of diagnostic value,!" a precise and uniform qualifying adjective terminology based on acoustical logic would be a marked improvement over present practice. In conclusion, our survey results indicate that physicians apply the terms "rales" and "crackles" specifically to discontinuous ALS. While PP use the
two terms equally NPP prefer the term "rales," Physicians consistently describe the musical sounds typical of asthma as "wheezes" and the continuous ALS typical of laryngeal obstruction as "stridor" or "wheeze." Rhonchi are frequently identified incorrectly and the term "rhonchi" is often applied to continuous and discontinuous ALS. While PP recognize a pleural friction rub more often than NPl: neither group excelled at identifying this sound from an audiotape. Most physicians do not use qualifying adjectives to describe ALS and there is little agreement among those who do. In general, the recommendations of the Ad Hoc Subcommittee on Pulmonary Nomenclature are not followed. ACKNOWLEDGMENTS: We thank Robert Loudon, MB, ChB, of the University of Cincinnati and Hans Pasterkamp, MD, of the Health Sciences Center, Winnipeg, Canada, for their analysis of the sound samples, and Jerry W Lee ofLoma Linda University for his assistance with the statistical analysis of the data. We also are grateful to Alfred Soffer, MD, for his support of this project and to the ACCP members who participated in the survey.
REFERENCES 1 ACCP-ATSJoint Committee on Pulmonary Nomenclature: pulmonary terms and symbols. Chest 1975; 67:583-93 2 Report of the ACCP-ATS ad hoc subcommittee on pulmonary nomenclature. ATS News 1977; 3:5-6 3 Forgacs f! The functional basis of pulmonary sounds. Chest 1978; 73:399-405 4 Bunin NJ, Loudon RG. Lung sound tenninology in case reports. Chest 1979; 76:690-92 5 Wilkins RL, Dexter JR, Smith JR. Survey of adventitious lung sound tenninology in case reports. Chest 1984; 85:523-25 6 Pasterkamp H, Montgomery M, Wiebicke W Nomenclature used by health care professionals to describe breath sounds in asthma. Chest 1987; 92:346-52 7 Wilkins RL, Dexter JR, Smith M~ Marshak AB. Lung-sound terminology used by respiratory care practitioners. Respir Care 1989; 34:36-41 8 Pasterkamp H, Carson C, Daien D, Oh Y. Digital respirosonography-new images of lung sounds. Chest (in press). 9 Murphy RLH, Holford SIC, Knowler WC. Lung sound characterization by time-expanded wavefonn analysis. N Eng) J Med 1977; 296:968-71 10 Epler GR, Carrington CB, Gaensler EA. Crackles (rales) in the interstitial lung diseases. Chest 1978; 73:333-39
CHEST I 98 I 4 I OClOSER, 1990
889
We report the terms used by 223 pulmonary physicians and 54 physicians in other specialties to describe eight recorded examples of lung sounds. The participants listened to the lung sounds at the 1988 American College of Chest Physicians annual convention and wrote "free form" answers. Pulmonary physicians used the terms "crackles" and "rales" with equal frequency to describe discontinuous adventitious lung sounds (ALS) and not at all to describe continuous ALS. Other physicians preferred the term "rales" in describing discontinuous ALS. The terms "wheeze" and "stridor" were used only in describing continuous ALS; however, the term "rhonchi" was frequently used to de-
scribe continuous and discontinuous ALS. The majority of participants recognized the normal breath sounds but not the pleural friction rub. Most did not use a qualifying adjective to describe ALS, and there was little agreement among those who did. The lung sound terminology used by physicians is not well standardized and the recommendations of the ATS/ACCP nomenclature subcommittee are not (Chest 1990; 98:886-89) widely accepted.
The clinical value of chest auscultation would be enhanced by the use of a consistent nomenclature for lung sounds. An Ad Hoc Subcommittee on Pulmonary Nomenclature established by the American College of Chest Physicians and the American Thoracic Society has made recommendations in an attempt to achieve this goal. 1•2 The committee most recently suggested that discontinuous adventitious lung sounds be described as "crackles," high-pitched continuous ALS be described as "wheezes," and low-pitched continuous ALS be described as "rhonchi." The term "rales" was considered undesirable because it had historically been used to describe both continuous and discontinuous ALS. In addition to the basic terms used to describe ALS, qualifying adjectives may improve or confuse communication. The nomenclature committee recommended the terms "fine" and "coarse" be used to qualify crackles following the suggestion by Forgacs" that adjectives with a physiologic or acoustic basis (eg, low-pitched, high-pitched, fine, coarse) be used rather than the traditional terms (eg, dry, wet, sonorous, sibilant, etc). Studies of lung sound nomenclature in published case reports have identified that lung sound terminology varies widely and that the term "rales" remains
popular despite a decline in its use from 1978 to 1982.4•5 It is not clear, however, if the decrease in use of the term "rales" was due to author preference or to editorial policy influencing the terms used. In 1987, Pasterkamp et al6 reported significant differences between groups of health care professionals in the preferred terms used to describe tape recorded breath sounds of asthmatic patients. The investigation was limited by the small sample size (only 40 Canadian professionals were studied) and the lack of variety in the breath sound samples (continuous ALS from asthmatics were predominant in the selection of examples). In 1989, we reported the terms preferred by respiratory care practitioners (Rep) to describe recorded ALS heard through the use of a cassette player and earphones at a national meeting." We found that the terms "rales" and "crackles" were used exclusively for discontinuous ALS, with "rales" approximately twice as popular as "crackles." The terms "wheeze" and "stridor" were used primarily for high-pitched continuous ALS; however, the term "rhonchi" was used frequently to describe both continuous and discontinuous ALS. While this study provides information regarding RC~ it did not provide data about physician use of terminology for lung sounds. The purpose of our current study was to answer the following questions: (a) What terms are physicians in the United States using to describe lung sounds? (b) Are there significant differences in nomenclature based on demographic factors such as region of practice, type of practice or age? (c) Are pulmonary physicians and other physicians using similar terms to describe lung sounds? To answer these questions, we asked physicians at a national meeting to describe
*From the Department of Respiratory Therapy, School of Allied Health Professions, and the School of Medicine, Lorna Linda University, Lorna Linda, CA; Tufts University School of Medicine, and the Pulmonary Departments, Faulkner and Lemuel Shattuck Hospitals, Boston. t Associate Professor, Lorna Linda University. tProfessor of Medicine, Tufts University School of Medicine. §Research Assistant, Faulkner Hospital. Manuscript received October 17, revision accepted March 14. Reprint requests: Mr. Walkins, Rm 1926 NichOL Hall, Loma Linda University, Loma Linda,CA 92350
188
ALS = adventitious lung sounds; Rep = respiratory care practitioner; PP = pulmonary physicians; NPP = nonpulmonary physicians
Lung Sound NomencIabn Survey(WIlkins et 81)
A
:v1W.
J"., v ....... "'-
'VV~"""'-oojIlW'oo...,..
-""'
__
,..
...
~
-""'~
. _.,.,.",."".,
~
",..•.,
~
-
q,
:
s'* Ai'~ "~rM~
~~.Lf~'~Y~ ••••••
B
E
~_J.k"'.'l
~
, l
.......
t
j
I
I
I
l
••
I
~
.. . J
I
l
......
~
l
- .. I
~
I
I
...... I
,
nat
c o
500
1000
1500 HZ
FIGURE 1. Examples of the waveforms used to evaluate the lung sound samples. In the interest of brevity, not all the samples are presented. Analysis of sample 1 and sample 5 (A and 8, respectively) in the time domain. I denotes the beginning of inspiration and E denotes the beginning of exhalation. The plot is read top to bottom and left to right. Each line represents 0.34 seconds and the entire sample is approximately 4 seconds in length. (C). Analysis of sample 5 in the frequency domain. Inspiration begins at the bottom left corner and the plot is read bottom to top and left to right. Each line represents 260 ms increments.
tape-recorded lung sounds. MATERIAL AND METHODS
We surveyed 277 North American physicians in the exhibit hall of the 1988 ACCP Annual Meeting in Anaheim, California. Participants completed a data sheet to identify background information and then wrote "free form" answers while listening to eight recorded
lung sounds using stethophones. Sonograms" and wave-form analysis" in the time domain were used to substantiate the nature of the recorded chest sounds (Fig 1, upper and center). For the continuous type of ALS (samples 3 to 5), analysis in the frequency domain was done to evaluate the pitch (Fig 1, lower). A description of each sound sample based on interpretation of the wave-forms is presented in Table 1. CHEST I 98 I 4 I OCTOBER, 1990
887
Table l-Deacription afthe Sound Sample. Sample No.
Description
1 2
Pan-inspiratory fine crackles Inspiratory and expiratory coarse crackles and rhonchi (secretion sounds) Inspiratory crackles and expiratory polyphonic wheezes Expiratory rhonchi Inspiratory stridor and expiratory highpitched wheeze (monophonic) Pleural friction rub Normal breath sounds Coarse, early-inspiratory crackles
3 4
5 6 7
8
RESULTS
Of the 277 North American physicians surveyed, 223 were pulmonary physicians (PP) and 54 were
physicians with a specialty other than pulmonary which will be referred to as nonpulmonary physicians (NPP). Most of the physicians used "crackles" or "rales" to describe sample 1 with NPP favoring the term "rales" over "crackles" and PP not showing a preference between the two terms (Table 2). Sample 2 was described most often as "rales," "rhonchi," or "crackles." Almost 90 percent of the PP and nearly 80 percent of the NPP used "wheezes" in their description of sample 3. Some noted the inspiratory crackles in sample 3 and thus wrote "crackles and wheezes" or "rales and wheezes." Sample 4 elicited a variety of responses from both groups with "rhonchi," "bronchial breath sounds," "wheeze," and "rub" being the most popular. Most of the physicians described sample 5 as "stridor" or "wheezes" with the PP preferring "stridor" and the NPP using both terms equally Sample 6 was recognized as a rub by 32 percent of the PP and 11 percent of the NPE Those who did not recognize the rub frequently describe sample 6 as "rales," "crackles," or "rhonchi." Sample 7 was recognized as
normal breath sounds by nearly 80 percent of the physicians. For sample 8, "rales," "crackles," and "rhonchi" were used by both groups; however, "crackles" was more popular with the PE Table 2 identifies the terms in which there were significant differences between the pulmonary and other physicians for the description of the sound samples. We did not find statistically significant differences among the physicians in the selection of terms based on region of practice, time since the completion of residency, age, or type of practice (clinical vs research). The majority of physicians did not use a qualifying adjective to describe the seven abnormal sound samples. For those who did use a qualifying adjective, a variety of terms were used. For the discontinuous ALS samples (1, 2, and 8), the terms "fine," "coarse," "Velcro," "dry," and "wet/moist" among others were used. For the continuous ALS samples (3, 4, and 5), qualifying adjectives were used less frequently. "Coarse" or "harsh," "high-pitched," and "lowpitched" were the only terms used as qualifiers by at least 5 percent of the participants. Since the physicians completed this survey while listening to an audiotape, we did not tabulate the frequency in which the terms "inspiratory" or "expiratory" were used. DISCUSSION
The PP use the terms "rales" and "crackles" with approximately equal frequency for describing discontinuous ALS and not at all for describing continuous ALS. This suggests that the two terms are synonyms and neither this survey nor our Rep survey previously reported? substantiate concerns regarding the lack of specificity in the use of the term "rales." Although NPP use "rales" more often than P~ they also only use this term to describe discontinuous ALS. Musical (polyphonic) wheezes represent a sound
Table 2- Tenns Used by Physiciam to De.cribe the Sound Samples Sound Samples
3
2
5
4
6
7
8
Term(s)
PP
NP
PP
NP
PP
NP
pp
NP
PP
NP
PP
NP
PP
NP
PP
NP
Rales Crackles Rhonchi Wheeze Stridor Rub Bales/crackles & rhonchi Bales/crackles & wheezes Normal Bronchial Other
.40 .44
.63* .19* 0 0 0 0 0 0 0 0 .18
.24 .22 .24
.20
0 0
0 0
0 0
0 0
0 0
0 0
.31
.26
.05
.04
.39 0 0
.16 0 0 0 0 0
.28 .09· .22
0 0
0 0 0 0 0 0 0 0 .79 .10 .10
0 0
0 0
.19 .18 .18 0 0 .32 0 0 0 0 .13
.28
.17
0 0 0 0 0 0 0 0 .16
.05 .09 0 0
.02 .14
.04 .07 0 0 .07 .19
.03 .38 0 0 .15
.07
.54 .02 0 0 .19· 0 0 .18
.30
.30
.04
.07
.13
.11
.05 .09
.04
.27 .49 0 0 0 0 0 .21
.37 .37 0 0 0 0
0 0 0 .21
.23
.02 0 0 .02 .13
.39
.04 .15
.13
.30 0 0 .11·
.06 0 0
.02 .10
0 0
.02 0 0 .78
.30
.06
.03 .04
.10
.17
0 0
.06 .02 0
.02 .06 .25
·Difference significant at the 1 percent level in comparing pulmonary physicians (PP) to other physicians (NP).
888
Lung SoundNomenclature Survey(W1Ikins et 81)
that most physicians agree should be described as "wheezes," as more than 80 percent of those surveyed used the term "wheeze" in their description of sample 3. Even though sample 3 had briefinspiratory crackles in addition to the loud, expiratory polyphonic wheeze, only 38 percent of the PP and 19 percent of the NPP described this sample as "rales and wheezes" or "crackles and wheezes." The ability to identify and document such details is an important part of auscultation. The term "rhonchi" was used with less precision than other terms as it was frequently used to describe samples 2, 4, 6, and 8. Rhonchi are defined as lowpitched continuous sounds with a snoring quality and are commonly heard in patients with airway secretions. This association between rhonchi and secretion sounds may explain why some described the coarse crackles of samples 2 and 8 with the term "rhonchi" and may indicate that the term needs clarification among many clinicians. Sample 4 was a rhonchus and was described inaccurately by more than 50 percent of the physicians. This suggests that a rhonchus is not easily recognized which we believe could be due to its lack of distinctive sound characteristics. While the majority of physicians identified sample 5 as "stridor" or "wheeze," only 54 percent of the PP and 43 percent of the NPP used "stridor" in their description. Because this sound was recorded over the neck of a patient with laryngeal obstruction, which represents a potentially life-threatening problem, precise recognition is important. The majority of participants did not use a qualifying adjective to describe the ALS samples. These results are consistent with the findings of Bunin and Loudon" and with our Rep survey 7 Since certain characteristics of ALS (eg, fine vs coarse crackles) can be of diagnostic value,!" a precise and uniform qualifying adjective terminology based on acoustical logic would be a marked improvement over present practice. In conclusion, our survey results indicate that physicians apply the terms "rales" and "crackles" specifically to discontinuous ALS. While PP use the
two terms equally NPP prefer the term "rales," Physicians consistently describe the musical sounds typical of asthma as "wheezes" and the continuous ALS typical of laryngeal obstruction as "stridor" or "wheeze." Rhonchi are frequently identified incorrectly and the term "rhonchi" is often applied to continuous and discontinuous ALS. While PP recognize a pleural friction rub more often than NPl: neither group excelled at identifying this sound from an audiotape. Most physicians do not use qualifying adjectives to describe ALS and there is little agreement among those who do. In general, the recommendations of the Ad Hoc Subcommittee on Pulmonary Nomenclature are not followed. ACKNOWLEDGMENTS: We thank Robert Loudon, MB, ChB, of the University of Cincinnati and Hans Pasterkamp, MD, of the Health Sciences Center, Winnipeg, Canada, for their analysis of the sound samples, and Jerry W Lee ofLoma Linda University for his assistance with the statistical analysis of the data. We also are grateful to Alfred Soffer, MD, for his support of this project and to the ACCP members who participated in the survey.
REFERENCES 1 ACCP-ATSJoint Committee on Pulmonary Nomenclature: pulmonary terms and symbols. Chest 1975; 67:583-93 2 Report of the ACCP-ATS ad hoc subcommittee on pulmonary nomenclature. ATS News 1977; 3:5-6 3 Forgacs f! The functional basis of pulmonary sounds. Chest 1978; 73:399-405 4 Bunin NJ, Loudon RG. Lung sound tenninology in case reports. Chest 1979; 76:690-92 5 Wilkins RL, Dexter JR, Smith JR. Survey of adventitious lung sound tenninology in case reports. Chest 1984; 85:523-25 6 Pasterkamp H, Montgomery M, Wiebicke W Nomenclature used by health care professionals to describe breath sounds in asthma. Chest 1987; 92:346-52 7 Wilkins RL, Dexter JR, Smith M~ Marshak AB. Lung-sound terminology used by respiratory care practitioners. Respir Care 1989; 34:36-41 8 Pasterkamp H, Carson C, Daien D, Oh Y. Digital respirosonography-new images of lung sounds. Chest (in press). 9 Murphy RLH, Holford SIC, Knowler WC. Lung sound characterization by time-expanded wavefonn analysis. N Eng) J Med 1977; 296:968-71 10 Epler GR, Carrington CB, Gaensler EA. Crackles (rales) in the interstitial lung diseases. Chest 1978; 73:333-39
CHEST I 98 I 4 I OClOSER, 1990
889
