Rales sounds like that crinkly thin wrapping paper they use in gift bags being crumpled up but if you were listening to it from a long way away through wax.
Wheezes are high pitched sounds, kinda sound like a whistling windy noise like air moving through a floppy wet reed.
Coarse breath sounds is a bit less specific and is a good descriptor when listening to a big gross PNA with a bunch of pops and whistles and cracks and extraneous sounds.
For all of these sounds, it helps to understand the pathophysiology of what is physically causing the sounds. That may help to then rationalize what you are hearing by comparing to real-world examples, and to train your ear to the sounds. Go into your exam already knowing what you should expect to hear based on your history and what others before you have recorded and you will be able to better differentiate what you hear.
Good descriptors, I will add, wheezes sounds like an accordian or a harmonica. Because they're whistle-y and high pitched they are the easiest to distinguish.
Wheezing is on exhalation. Breathe out forcefully now and close your vocal cords a little. That is what wheezing sounds like. It is caused by resistance to outward air flow, obstructive lung disease like asthma or COPD.
Rales are an inspiratory sound. They can be āfineā and sound like walking on fresh snow, or ācoarseā and sound more like Velcro. Fine rales are more typical of pulmonary edema and coarse are more typical of pulmonary fibrosis.
āCoarseā breath sounds really doesnāt have a good definition and gets thrown around a lot as āit doesnāt sound as quiet as it should but I canāt really categorize it.ā
ā- old man rant ā-
Donāt they teach physical exam in medical school anymore? Fuck.
They do teach it in med school. Itās call CT chest.
Joke aside. The thing I hate about breath sound is itās very performer dependent, and in order to get good breathing sounds patient really have to take a nice deep breath in and really exhale out, but not all patients can actually do that well for various reasons.
Yes, patient effort matters. But the doctorās effort matters more. Laying your stethoscope on the front or side of someone lying down is not going to be as useful as making the patient sit up and getting a good listen.
Physical exam is a dying art and it is a sad development.
Instead of looking it as sad could we look at it as happy that technology has improved so much? My understanding is physical exam has more inter observer variability than reading imaging
I can get a ton of information with an exam before the imaging is even done. Iām not discounting the value of technology. What we have now is incredible. What Iām worried about is the replacement of clinical examination and judgement with āwhat does the scan show?ā The story is often more complex. The reason for medical education is to understand these complexities and then use the existing technology to enhance our understanding. I see a general move towards skipping the first few steps to get āthe answer.ā As though everything else is just a game to see if you can guess what the film will show. Relying too much on imaging will result in misdiagnosis and mistreatment. Learning to integrate that technology is the way to practice medicine.
Problem is, it isnāt a joke. I tell my residents that the only person in the entire hospital that knows nothing about your patient is the radiologist. Their reports do not contain ādiagnosesā. Had a case a few months ago. Presented with recent onset of dyspnea. No fever, not much cough, increasing leg swelling. CT was read as āmost consistent with multifocal pneumoniaā with patchy opacities and mediastinal adenopathy. Basic HPI was not suggestive of pneumonia. And, the patient has Sarcoidosis, which explains the adenopathy and is also a cause of CHF.
He spent 18 hours in the ER and then in the ICU. Saw him the following morning. Gave him lasix. Magic.
The ER believed the radiologist. The overnight icu team believed the ER. At no time was there any critical thinking applied. I still believe what I was taught in my Int Med rotation in Med School. You get a history and a physical. Then you can order one test. That should get you the diagnosis 95% or more of the time.
>The only person in the entire hospital that knows nothing about your patient is the radiologist.
As someone who works IR, can confirm. You best get your orders correct for the type/laterality of catheter or -ostomy the patient needs, cause IR ain't got time for sleuthing shit out.
And to be clear, Iām not criticizing the radiologist. I donāt like how ādefinitiveā their reports have become since it changes the whole paradigm from figuring out what is going on to just asking what the scan said.
Sounds like the dying art here is speaking with the radiologist. They have been siloed off. Ordering physician should chat with them on the phone more if not reading images side by side.
Yup. There is often no communication with radiology. I read my own chest films (Pulm/CC). I look at the images first, then I read the report. I regularly call or message when I have questions or disagreements. I donāt see a lot of that happening overall. Order film, read report, believe everything that is written. Those reports often donāt even have differentials and sound more definitive than they should be.
Question for the residents here: Do you ever have radiology rounds? Where you present your cases and the radiologist goes over the films with you? This was a regular part of my fellowship training (less so as a resident, but we still did meet with them).
I started radiology residency in 2019. Clinicians used to commonly come to the reading room and it was great. After COVID, people completely stopped that and it has never really bounced back. I just completely a musculoskeletal imaging fellowship - I don't think a doctor came to the reading once the entire year to go over anything I dictated.
New EM intern here. I learned the importance of reading your own scans to provide better patient care when during my second shift a 70 y/o F came in with cc of dyspnea with no major pmhx other than a hip surgery 6 months ago. Her O2sat was 88-92 on 4LNC but would drop into the 70s when she started talking. CXR was clear. I ordered a CTA PE and before the read even came back from the radiologist my senior and I went through the scans, saw her bilateral submissive PEs, started her on heparin and called IR. She could have easily coded if we would have waited for the read to come back. Lesson learned. Moving forward I will be looking at every study I order even before the reads come back.
Absolutely untrue. No one will be perfect every time. Anyway, The hospital team is supposed to do a separate evaluation, not get tunnel-visioned on what the ED said.
The ED is the gatekeeper for the hospital and their job is invaluable.
As a medical student going through it right now. I can without a doubt say that I do not get nearly enough practice with physical exams on my rotations. My school does a good job teaching it, but without seeing dozens to hundreds of patients its so hard to tell sounds apart.
I like to think I can tell when something doesn't sound or feel right, but I don't think I could tell fine or coarse rales apart on a physical exam
Not a real excuse. I was in med school during covid, assuming you have access to the internet there are thousands of hours of videos showing you what every exam finding imaginable looks/sounds like
Wheezing and rales can be heard in either exhalation or inhalation and the differential is different based on which part of the inspiratory cycle you hear the sound and auscultation location. Not sure if you were just simplifying the explanation to give an example or not but if I am hearing a new wheeze on a patient I am thinking about where that wheeze is originating from based on the phase of respiration.
There are inspiratory sounds which can mimic wheezing, but are better described as stridor. With very severe bronchospasm, you can have both inspiratory and expiratory wheezing.
Rales are only inspiratory. The sound is of thickened alveolar walls opening.
The characteristic honk/high pitched whistle that we characterize clinically as wheezing comes from disruption of laminar flow within the airway due to loss of airway diameter and vibrating of the walls. This can happen anywhere in the tracheal-bronchial tree or oropharynx resulting in wheezing and whether it happens during inspiration or expiration is related to the difference in pressures based on location during a particular part of the respiratory cycle. Stridor is a very specific type of wheeze which some clinicians very specifically say originates at the level of the glottis or just below it. There is another camp of clinicians that refers to stridor as any wheeze that originates from the upper airway which I do not believe is accurate. The following excerpt is copied directly from Steven McGee's Evidence-Based Physical Diagnosis" 5th ed, which people widely consider to be the gold standard for physical examination in medicine:
"Stridor is a loud, musical sound of definite and constant pitch (usually about 400Hz) that indicates upper airway obstruction. It is identical acoustically to wheezing in every way except for two characteristics: (1) stridor is confined to inspiration whereas wheezing is either confined entirely to expiration (30% to 60% of patients) or occurs during both expiration and inspiration (40% to 70% of patients) (2) stridor is always louder over the neck, whereas wheezing is always louder over the chest." (pg 263)
Because of the pathogenesis of wheeze, you can absolutely have an inspiratory wheeze that is not stridor. Plenty of both intra and extrathrocic sources, variable or fixed, can cause an inspiratory wheeze and not be specifically related to the glottis or oropharynx. Couple of examples include tracheal masses, tracheal impingement from thyroid masses, and proximal anterior mediastinal masses.
Additionally, you can have expiratory crackles as well. While you are correct that inspiratory crackles are from the opening of collapsed alveoli under the increased negative pressure of deep inspiration, you can have crackles from alveolar collapse at the end of expiration as well. A quick lit search will show this, but just to prove my point, Vyshedskiy et al 2009 published a article in Chest titled "Mechanism of inspiratory and expiratory crackles" which used a multichannel lung sound analyzer in patients with pneumonia, heart failure, or ILD and they identified both inspiratory and expiratory crackles in both patient populations. This one of a number of articles talking about the presence and pathogenesis of expiratory crackles.
Iāll buy all of that.
I agree that there can be inspiratory wheezing that is not stridor (provided that it is associated with expiratory wheeze as well). Any obstructing lesion large enough to cause inspiratory wheezing must also cause expiratory wheezing.
I canāt say that Iāve heard (or maybe Iāve never listened carefully for) expiratory rales. Not familiar with that article but how sensitive is their detection device? Were those sounds audible to the average human using a standard stethoscope?
Iāve started using an Eko amplifier for my stethoscope. As I get older, Iām finding amplification to be very valuable.
The technology Iād love to see would be in the stethoscope. Itās such a convenient tool, allows you to use multiple senses at the same time (ultrasound takes all of your attention, tough to watch or palpate the patient at the same time). Some form of audio filtering to boost the sounds of interest (which often come at difficult to hear frequencies) would be a great advance. Stethoscopes havenāt fundamentally changed since they were invented. The components have been improved and now there is amplification, but the basic idea is still the same.
The only scenario in which I have heard an isolated inspiratory wheeze that I would waffle about calling stridor was a patient with advanced thyroid cancer which had variable tracheal obstruction during inspiration as the mass was about 1 cm above the manubrium where it invaded the tracheal. But again that wouldn't be unreasonable and probably semantics to not call stridor in which case your point about not having isolated inspiratory wheeze is totally fair.
I would be curious about the sensitivity/specificity of that device used to identify crackles as well and admittedly do not know that. I will say I have definitely heard end expiratory crackles in patients myself. These were all patients whose closing capacity was definitely within their functional residual capacity (very young children, the elderly, pregnancy, morbid obesity). Basically, they were already predisposed to small airway and alveolar collapse and had a pathology which would add to this predisposition. I will say that as a now brand new board eligible Anesthesiologist I have a distinct advantage in that by the time patients get to me their pathology is either so advanced or so well characterized that I hear that strongest examples of each of these things. Mitral Valve Prolapse from a freshly ruptured chordae, bronchopleural fistulas, massive anterior mediastinal masses. Have had the honor of getting to hear them all. As one of the few that always has my stethoscope on me still because I want to be good at the skill, it is very depressing to see how few are good at it anymore.
I did want to sincerely thank you. I am in the heat of studying for boards and this stuff is always so hard to sit down and review and this was a great motivation to review it, as it really made me think about if I was misremembering what I learned about this stuff.
Good luck on your exam! This was a fun discussion. This stuff is what I still find I love about medicine and I fear that the next generation of doctors will miss out on it.
Coarse Velcro rales is the classic description of pulmonary fibrosis.
Another anecdotal example of imaging missing the diagnosis. One of my outpatients with IPF was in the ER and going to be admitted to the ICU that I was covering. The ER resident was telling me about his CHF exacerbation and need for diuretics. The CXR and CT were generally unchanged from prior. He was telling me about the B-lines he had seen on bedside ultrasound. And he was right. B-lines are a typical feature for CHF. But, he didnāt know that B-lines are also a typical feature of pulmonary fibrosis. So the patient with rales and b-lines doesnāt always have a CHF exacerbation. This stuff is hard. We need to think more, not less. Technology is great but it is only part of the story.
Thatās weird. I just rechecked Talley and OāConnor (kind of the bible of examination medicine here in Australia) and it definitely says fine, late/pan-inspiratory crackles.
As an aside, I agree with you about the importance of the physical exam. Itās heavily emphasised here.
Can confirm that both Bowenās Mechanisms of Clinical Signs and McGeeās Evidence Based Physical Diagnosis describe the crackles in pulmonary fibrosis as āfineā. They also use the term āVelcroā. Maybe youāre confusing Velcro with course crackles? It was my understanding that Velcro refers to fine crackles.
Because on the inpatient side which is where most of the pathology can be found, weāre in an era of high BMI and elderly deconditioned patients that canāt sit up easily for a posterior exam. Ā
You have to auscultate and percuss the chest simultaneously while asking the patient to repeat āHow now brown cowā.
Edit: In a comatose and ventilated patient you can replicate this with some specific vent maneuvers and in-line kazoo, ask your local RT for help.
Honestly just listen to it on YouTube, they are noticably different. Rales typically occur in inspiration(but can occur in expiration) and wheezes occur in expiration but have a very very distinct sound. Unlike other audios (e.g murmurs), I've found wheezes to be pretty much identical when listening to a recording and listening to a patient.
Rales sounds like you grab a two strand of your hair and rub it together on typically inspiration caused by alveolar edema while it's getting enlarged. If you are not sure whether or not they are fine rales make the patient cough a few times and listen again. If it's lost it's due to secretions rather than edema.
Wheezing is a melodical sound heard in exhalation it's like a messed up horn that shrinks when honked.
Coarse sounds has no definition and should not be used. Wheezes are typically expiratory (although they can be inspiratory). You can listen to a YouTube video of someone wheezing to get the sound. Rales there are several different causes but usually easier to hear on inspiration. If you pull some of your hair in front of your ear and roll it between your thumb and forefinger thatās the noise
>Coarse sounds has no definition and should not be used.
Eh, I'll disagree with you there from an anesthesia perspective.
Globs of mucus and congestion tend to make non-specific coarse sounds that can't be classified as rales/rhonchi/wheezes.
I've been told "the patient's lungs sound terrible," listened myself, woken them up to cough several times and suctioned them, and then it has cleared up with proper pulmonary toileting.
That's what coarse sounds like.
Yeah but as a pulmonologist thatās kind of my point. That definition youāre using makes sense in theory but everyone has their own definition so the term becomes meaningless. I canāt hear your patients but it sounds like diffuse ronchi with transmitted upper airway noise from secretions. Or even just saying the lungs sound congested with poor air movement would be more helpful. However, this isnāt a hill I care to die on itās not that important
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They are very distinct. Rales have a popping like sound and wheezes are squeaky. They are from different parts of the lungs too. Rales = alveolar (little popcorn buddies). Wheezes = bronchi and their sound is the air version of ohms law wherein the air flow and resistance in the tubes creates a pressure differential. That differential contributes to the noise. āCoarseā sounds I just chalk it up to some high / upper airway sounds ā think trachea and main bronchi.
Iām a neurologist though soā¦take that for what itās worth.
If this isnāt obvious to you then you probably arenāt listening right. When you put the stethoscope in your ears, make sure to rotate it to eye level so it lines up in your ear canals. Then give it one more push to really get in their ears. Listen under the shirt and have the patient inhale and exhale through their mouth. Listen in all frontal and posterior areas. Make sure you can hear the inspiratory and expiratory phase well, and that they have a normal I:e ratio.
If you have a cardiology 4, push down on it to activate the bell. This helps to hear high pitched wheezing.
Rales sounds like that crinkly thin wrapping paper they use in gift bags being crumpled up but if you were listening to it from a long way away through wax. Wheezes are high pitched sounds, kinda sound like a whistling windy noise like air moving through a floppy wet reed. Coarse breath sounds is a bit less specific and is a good descriptor when listening to a big gross PNA with a bunch of pops and whistles and cracks and extraneous sounds. For all of these sounds, it helps to understand the pathophysiology of what is physically causing the sounds. That may help to then rationalize what you are hearing by comparing to real-world examples, and to train your ear to the sounds. Go into your exam already knowing what you should expect to hear based on your history and what others before you have recorded and you will be able to better differentiate what you hear.
Good descriptors, I will add, wheezes sounds like an accordian or a harmonica. Because they're whistle-y and high pitched they are the easiest to distinguish.
Harmonica is a great descriptor for wheezes.
Yesš
Wheezing is on exhalation. Breathe out forcefully now and close your vocal cords a little. That is what wheezing sounds like. It is caused by resistance to outward air flow, obstructive lung disease like asthma or COPD. Rales are an inspiratory sound. They can be āfineā and sound like walking on fresh snow, or ācoarseā and sound more like Velcro. Fine rales are more typical of pulmonary edema and coarse are more typical of pulmonary fibrosis. āCoarseā breath sounds really doesnāt have a good definition and gets thrown around a lot as āit doesnāt sound as quiet as it should but I canāt really categorize it.ā ā- old man rant ā- Donāt they teach physical exam in medical school anymore? Fuck.
They do teach it in med school. Itās call CT chest. Joke aside. The thing I hate about breath sound is itās very performer dependent, and in order to get good breathing sounds patient really have to take a nice deep breath in and really exhale out, but not all patients can actually do that well for various reasons.
Yes, patient effort matters. But the doctorās effort matters more. Laying your stethoscope on the front or side of someone lying down is not going to be as useful as making the patient sit up and getting a good listen. Physical exam is a dying art and it is a sad development.
Instead of looking it as sad could we look at it as happy that technology has improved so much? My understanding is physical exam has more inter observer variability than reading imaging
I can get a ton of information with an exam before the imaging is even done. Iām not discounting the value of technology. What we have now is incredible. What Iām worried about is the replacement of clinical examination and judgement with āwhat does the scan show?ā The story is often more complex. The reason for medical education is to understand these complexities and then use the existing technology to enhance our understanding. I see a general move towards skipping the first few steps to get āthe answer.ā As though everything else is just a game to see if you can guess what the film will show. Relying too much on imaging will result in misdiagnosis and mistreatment. Learning to integrate that technology is the way to practice medicine.
Problem is, it isnāt a joke. I tell my residents that the only person in the entire hospital that knows nothing about your patient is the radiologist. Their reports do not contain ādiagnosesā. Had a case a few months ago. Presented with recent onset of dyspnea. No fever, not much cough, increasing leg swelling. CT was read as āmost consistent with multifocal pneumoniaā with patchy opacities and mediastinal adenopathy. Basic HPI was not suggestive of pneumonia. And, the patient has Sarcoidosis, which explains the adenopathy and is also a cause of CHF. He spent 18 hours in the ER and then in the ICU. Saw him the following morning. Gave him lasix. Magic. The ER believed the radiologist. The overnight icu team believed the ER. At no time was there any critical thinking applied. I still believe what I was taught in my Int Med rotation in Med School. You get a history and a physical. Then you can order one test. That should get you the diagnosis 95% or more of the time.
>The only person in the entire hospital that knows nothing about your patient is the radiologist. As someone who works IR, can confirm. You best get your orders correct for the type/laterality of catheter or -ostomy the patient needs, cause IR ain't got time for sleuthing shit out.
And to be clear, Iām not criticizing the radiologist. I donāt like how ādefinitiveā their reports have become since it changes the whole paradigm from figuring out what is going on to just asking what the scan said.
Sounds like the dying art here is speaking with the radiologist. They have been siloed off. Ordering physician should chat with them on the phone more if not reading images side by side.
Yup. There is often no communication with radiology. I read my own chest films (Pulm/CC). I look at the images first, then I read the report. I regularly call or message when I have questions or disagreements. I donāt see a lot of that happening overall. Order film, read report, believe everything that is written. Those reports often donāt even have differentials and sound more definitive than they should be. Question for the residents here: Do you ever have radiology rounds? Where you present your cases and the radiologist goes over the films with you? This was a regular part of my fellowship training (less so as a resident, but we still did meet with them).
I started radiology residency in 2019. Clinicians used to commonly come to the reading room and it was great. After COVID, people completely stopped that and it has never really bounced back. I just completely a musculoskeletal imaging fellowship - I don't think a doctor came to the reading once the entire year to go over anything I dictated.
New EM intern here. I learned the importance of reading your own scans to provide better patient care when during my second shift a 70 y/o F came in with cc of dyspnea with no major pmhx other than a hip surgery 6 months ago. Her O2sat was 88-92 on 4LNC but would drop into the 70s when she started talking. CXR was clear. I ordered a CTA PE and before the read even came back from the radiologist my senior and I went through the scans, saw her bilateral submissive PEs, started her on heparin and called IR. She could have easily coded if we would have waited for the read to come back. Lesson learned. Moving forward I will be looking at every study I order even before the reads come back.
Could just put a brief hpi in the order. More than just CT chest chief complaint: cough. CT abdomen: pain.
[ŃŠ“Š°Š»ŠµŠ½Š¾]
Absolutely untrue. No one will be perfect every time. Anyway, The hospital team is supposed to do a separate evaluation, not get tunnel-visioned on what the ED said. The ED is the gatekeeper for the hospital and their job is invaluable.
Sounds like something an idiot would say ālolā
As a medical student going through it right now. I can without a doubt say that I do not get nearly enough practice with physical exams on my rotations. My school does a good job teaching it, but without seeing dozens to hundreds of patients its so hard to tell sounds apart. I like to think I can tell when something doesn't sound or feel right, but I don't think I could tell fine or coarse rales apart on a physical exam
You shouldnāt be expected to. It takes years of practice and experience. Keep at it. It is a worthwhile skill to develop.
PGY2 means they were in med school during COVID. Some schools had online clinical rotations during that time lol
Not a real excuse. I was in med school during covid, assuming you have access to the internet there are thousands of hours of videos showing you what every exam finding imaginable looks/sounds like
Listening to rales on YT just doesnāt cement in your memory as well as real life
Wheezing and rales can be heard in either exhalation or inhalation and the differential is different based on which part of the inspiratory cycle you hear the sound and auscultation location. Not sure if you were just simplifying the explanation to give an example or not but if I am hearing a new wheeze on a patient I am thinking about where that wheeze is originating from based on the phase of respiration.
There are inspiratory sounds which can mimic wheezing, but are better described as stridor. With very severe bronchospasm, you can have both inspiratory and expiratory wheezing. Rales are only inspiratory. The sound is of thickened alveolar walls opening.
The characteristic honk/high pitched whistle that we characterize clinically as wheezing comes from disruption of laminar flow within the airway due to loss of airway diameter and vibrating of the walls. This can happen anywhere in the tracheal-bronchial tree or oropharynx resulting in wheezing and whether it happens during inspiration or expiration is related to the difference in pressures based on location during a particular part of the respiratory cycle. Stridor is a very specific type of wheeze which some clinicians very specifically say originates at the level of the glottis or just below it. There is another camp of clinicians that refers to stridor as any wheeze that originates from the upper airway which I do not believe is accurate. The following excerpt is copied directly from Steven McGee's Evidence-Based Physical Diagnosis" 5th ed, which people widely consider to be the gold standard for physical examination in medicine: "Stridor is a loud, musical sound of definite and constant pitch (usually about 400Hz) that indicates upper airway obstruction. It is identical acoustically to wheezing in every way except for two characteristics: (1) stridor is confined to inspiration whereas wheezing is either confined entirely to expiration (30% to 60% of patients) or occurs during both expiration and inspiration (40% to 70% of patients) (2) stridor is always louder over the neck, whereas wheezing is always louder over the chest." (pg 263) Because of the pathogenesis of wheeze, you can absolutely have an inspiratory wheeze that is not stridor. Plenty of both intra and extrathrocic sources, variable or fixed, can cause an inspiratory wheeze and not be specifically related to the glottis or oropharynx. Couple of examples include tracheal masses, tracheal impingement from thyroid masses, and proximal anterior mediastinal masses. Additionally, you can have expiratory crackles as well. While you are correct that inspiratory crackles are from the opening of collapsed alveoli under the increased negative pressure of deep inspiration, you can have crackles from alveolar collapse at the end of expiration as well. A quick lit search will show this, but just to prove my point, Vyshedskiy et al 2009 published a article in Chest titled "Mechanism of inspiratory and expiratory crackles" which used a multichannel lung sound analyzer in patients with pneumonia, heart failure, or ILD and they identified both inspiratory and expiratory crackles in both patient populations. This one of a number of articles talking about the presence and pathogenesis of expiratory crackles.
Iāll buy all of that. I agree that there can be inspiratory wheezing that is not stridor (provided that it is associated with expiratory wheeze as well). Any obstructing lesion large enough to cause inspiratory wheezing must also cause expiratory wheezing. I canāt say that Iāve heard (or maybe Iāve never listened carefully for) expiratory rales. Not familiar with that article but how sensitive is their detection device? Were those sounds audible to the average human using a standard stethoscope? Iāve started using an Eko amplifier for my stethoscope. As I get older, Iām finding amplification to be very valuable. The technology Iād love to see would be in the stethoscope. Itās such a convenient tool, allows you to use multiple senses at the same time (ultrasound takes all of your attention, tough to watch or palpate the patient at the same time). Some form of audio filtering to boost the sounds of interest (which often come at difficult to hear frequencies) would be a great advance. Stethoscopes havenāt fundamentally changed since they were invented. The components have been improved and now there is amplification, but the basic idea is still the same.
The only scenario in which I have heard an isolated inspiratory wheeze that I would waffle about calling stridor was a patient with advanced thyroid cancer which had variable tracheal obstruction during inspiration as the mass was about 1 cm above the manubrium where it invaded the tracheal. But again that wouldn't be unreasonable and probably semantics to not call stridor in which case your point about not having isolated inspiratory wheeze is totally fair. I would be curious about the sensitivity/specificity of that device used to identify crackles as well and admittedly do not know that. I will say I have definitely heard end expiratory crackles in patients myself. These were all patients whose closing capacity was definitely within their functional residual capacity (very young children, the elderly, pregnancy, morbid obesity). Basically, they were already predisposed to small airway and alveolar collapse and had a pathology which would add to this predisposition. I will say that as a now brand new board eligible Anesthesiologist I have a distinct advantage in that by the time patients get to me their pathology is either so advanced or so well characterized that I hear that strongest examples of each of these things. Mitral Valve Prolapse from a freshly ruptured chordae, bronchopleural fistulas, massive anterior mediastinal masses. Have had the honor of getting to hear them all. As one of the few that always has my stethoscope on me still because I want to be good at the skill, it is very depressing to see how few are good at it anymore. I did want to sincerely thank you. I am in the heat of studying for boards and this stuff is always so hard to sit down and review and this was a great motivation to review it, as it really made me think about if I was misremembering what I learned about this stuff.
Good luck on your exam! This was a fun discussion. This stuff is what I still find I love about medicine and I fear that the next generation of doctors will miss out on it.
Isnāt pulmonary fibrosis usually fine crackles?
Coarse Velcro rales is the classic description of pulmonary fibrosis. Another anecdotal example of imaging missing the diagnosis. One of my outpatients with IPF was in the ER and going to be admitted to the ICU that I was covering. The ER resident was telling me about his CHF exacerbation and need for diuretics. The CXR and CT were generally unchanged from prior. He was telling me about the B-lines he had seen on bedside ultrasound. And he was right. B-lines are a typical feature for CHF. But, he didnāt know that B-lines are also a typical feature of pulmonary fibrosis. So the patient with rales and b-lines doesnāt always have a CHF exacerbation. This stuff is hard. We need to think more, not less. Technology is great but it is only part of the story.
Thatās weird. I just rechecked Talley and OāConnor (kind of the bible of examination medicine here in Australia) and it definitely says fine, late/pan-inspiratory crackles. As an aside, I agree with you about the importance of the physical exam. Itās heavily emphasised here.
That is a little strange. Pulmonary fibrosis is typically louder/coarser than pulmonary edema.
Can confirm that both Bowenās Mechanisms of Clinical Signs and McGeeās Evidence Based Physical Diagnosis describe the crackles in pulmonary fibrosis as āfineā. They also use the term āVelcroā. Maybe youāre confusing Velcro with course crackles? It was my understanding that Velcro refers to fine crackles.
Because on the inpatient side which is where most of the pathology can be found, weāre in an era of high BMI and elderly deconditioned patients that canāt sit up easily for a posterior exam. Ā
You have to auscultate and percuss the chest simultaneously while asking the patient to repeat āHow now brown cowā. Edit: In a comatose and ventilated patient you can replicate this with some specific vent maneuvers and in-line kazoo, ask your local RT for help.
What residency are you in?
You can tell it's an Aspen by the way it looks
Wait yāall can actually hear shit?
Honestly just listen to it on YouTube, they are noticably different. Rales typically occur in inspiration(but can occur in expiration) and wheezes occur in expiration but have a very very distinct sound. Unlike other audios (e.g murmurs), I've found wheezes to be pretty much identical when listening to a recording and listening to a patient.
One sounds like Velcro and one sounds like wheezing.
EEEEEEEEEeeeee
Boom
Rales sounds like you grab a two strand of your hair and rub it together on typically inspiration caused by alveolar edema while it's getting enlarged. If you are not sure whether or not they are fine rales make the patient cough a few times and listen again. If it's lost it's due to secretions rather than edema. Wheezing is a melodical sound heard in exhalation it's like a messed up horn that shrinks when honked.
Get a CXR (partial /s)
You get a CXR/CT and decide from there
It will come with experience.
Who cares, just order a CTA PE study
Coarse sounds has no definition and should not be used. Wheezes are typically expiratory (although they can be inspiratory). You can listen to a YouTube video of someone wheezing to get the sound. Rales there are several different causes but usually easier to hear on inspiration. If you pull some of your hair in front of your ear and roll it between your thumb and forefinger thatās the noise
>Coarse sounds has no definition and should not be used. Eh, I'll disagree with you there from an anesthesia perspective. Globs of mucus and congestion tend to make non-specific coarse sounds that can't be classified as rales/rhonchi/wheezes. I've been told "the patient's lungs sound terrible," listened myself, woken them up to cough several times and suctioned them, and then it has cleared up with proper pulmonary toileting. That's what coarse sounds like.
Yeah but as a pulmonologist thatās kind of my point. That definition youāre using makes sense in theory but everyone has their own definition so the term becomes meaningless. I canāt hear your patients but it sounds like diffuse ronchi with transmitted upper airway noise from secretions. Or even just saying the lungs sound congested with poor air movement would be more helpful. However, this isnāt a hill I care to die on itās not that important
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Listen to a YouTube video :/
They are very distinct. Rales have a popping like sound and wheezes are squeaky. They are from different parts of the lungs too. Rales = alveolar (little popcorn buddies). Wheezes = bronchi and their sound is the air version of ohms law wherein the air flow and resistance in the tubes creates a pressure differential. That differential contributes to the noise. āCoarseā sounds I just chalk it up to some high / upper airway sounds ā think trachea and main bronchi. Iām a neurologist though soā¦take that for what itās worth.
If this isnāt obvious to you then you probably arenāt listening right. When you put the stethoscope in your ears, make sure to rotate it to eye level so it lines up in your ear canals. Then give it one more push to really get in their ears. Listen under the shirt and have the patient inhale and exhale through their mouth. Listen in all frontal and posterior areas. Make sure you can hear the inspiratory and expiratory phase well, and that they have a normal I:e ratio. If you have a cardiology 4, push down on it to activate the bell. This helps to hear high pitched wheezing.
Chest CT
1. You donāt 2. Because there is no difference and 3. Everyone is lying
CT chest abdomen pelvis without and with
Just grab the ultrasound bruh
by auscultating and thinking about the sound youāre hearing?
you look at the CXR you are ordering anyways for your dx