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Added sounds

There are three common added sounds: wheezes, crackles

and rubs. Wheeze is a musical whistling sound accompanying

airflow and usually originates in narrowed small airways. It is

most commonly expiratory, due to dynamic airway narrowing

on expiration, but can also occur on inspiration. Usually, multiple

wheezing sounds are heard together (polyphonic wheeze); this

sign is common in asthma, bronchitis and exacerbation of COPD.

A solitary wheeze that is present consistently with each breath and

does not clear with coughing suggests a possible fixed bronchial

obstruction and can be an important sign of underlying cancer.

Crackles accompanying deep breathing are thought to

represent the sudden opening of small airways but sometimes

may indicate secretions in the airways or underlying lung fibrosis.

In healthy people, gravitational compression of the dependent

lung bases often causes a few crackles on the first few deep

breaths; these are of no pathological significance. Crackles that

persist after several breaths and do not clear with a deliberate

cough are pathological. They are graded as ‘fine’, meaning soft,

multiple crackles, to ‘coarse’, indicating loud, scanty crackles

that tend to change with each breath. Showers of fine crackles

during inspiration, resembling the sound made by peeling a

Velcro fastener, are characteristic of interstitial pulmonary fibrosis,

and are most commonly heard at the lung bases posteriorly

and laterally. Fine crackles also occur in pulmonary oedema and

some viral pneumonias. Coarse crackles are generally heard in

patients with significant purulent airway secretions such as those

with bronchopneumonia or bronchiectasis. Inspiratory crackles

are also often heard over the areas of incompletely inflated lung

immediately above a pleural effusion.

Pleural rub is a rasping, grating sound occurring with each

breath and sounding superficial, just under the stethoscope, like

two sheets of sandpaper rubbing together. It indicates pleural

inflammation, usually due to infection, and is often accompanied

by pleuritic chest pain.

Vocal resonance

Breath sounds normally reveal the presence of consolidation or

fibrosis (bronchial breath sounds) or pleural air or fluid (absent

5.6 Categories of respiratory disease and associated features on history and examination

Category of problem Suggestive features on history Suggestive features on examination

Infection: Fever

Acute bronchitis Wheeze, cough, sputum Wheeze

Exacerbation of chronic obstructive

pulmonary disease

Acute-on-chronic dyspnoea Hyperinflation

Pneumonia Pleuritic pain, rusty sputum, rigors If lobar, dull to percussion and bronchial breathing

Malignancy Insidious onset, weight loss, persisting pain

or cough

Cervical lymphadenopathy, clubbing, signs of lobar/lung

collapse ± effusion

Pulmonary fibrosis Progressive dyspnoea Tachypnoea, inspiratory fine crackles at bases, cyanosis

Pleural effusion Progressive dyspnoea Unilateral basal dullness and reduced breath sounds

Pulmonary embolism:

Large Sudden, severe dyspnoea Normal breath sounds

Medium Episodes of pleural pain, haemoptysis Pleural rub, swollen leg if deep vein thrombosis, crackles

if infarct

Multiple small Progressive dyspnoea Raised jugular venous pressure, right ventricular heave,

loud pulmonary second sound

Asthma Atopy, hay fever, pet ownership, variable

wheeze, disturbance of sleep

Polyphonic expiratory wheeze, eczema

90 • The respiratory system

5.7 Selecting investigations for different respiratory presentations

Likely problem from history and examination Appropriate initial investigations Diagnostic value

Infection

(e.g. acute bronchitis, exacerbation of COPD

and pneumonia)

Chest X-ray

O2 saturation or ABG

Sputum and blood culture

Respiratory function

WCC, CRP

Consolidation in pneumonia

Assessment of respiratory failure

Causal infection

Quantification of any COPD

Degree of inflammation

Malignancy Chest X-ray Identification of masses

CT scan thorax + abdomen Staging of extent

Bronchoscopy if central Diagnostic pathology

CT-guided biopsy if peripheral Diagnostic pathology

Respiratory function Fitness for radical therapies

Pulmonary fibrosis/interstitial lung disease Chest X-ray Bi-basal reticular shadows

High-resolution CT thorax Extent and type of disease

Respiratory function Quantification; identification of restrictive pattern

Autoantibodies Identification of any associated connective tissue disease

Pleural effusion Chest X-ray Dense basal fluid pool

Ultrasound-guided aspiration Culture for infection

pH low in empyema

Glucose low in infection

Cytology to identify malignancy

Protein to identify transudate or exudate

CT thorax + abdomen Identification of underlying tumour

Pulmonary embolism d-Dimer Normal if not pulmonary embolism

CT pulmonary angiogram Detection of emboli

Echocardiogram Detection of right ventricular strain

O2 saturation or ABG Assessment of respiratory failure

Asthma Respiratory function:

Peak flow diary

FEV1 /reversibility

Variable obstruction

Reversible obstruction

O2 saturation or ABG Assessment of respiratory failure

IgE, allergen skin tests Detection of allergic stimuli

ABG, arterial blood gas; COPD, chronic obstructive pulmonary disease; CRP, C-reactive protein; CT, computed tomography; FEV1, forced expiratory volume in 1 second;

IgE, immunoglobulin E; WCC, white cell count.

OSCE example 1: Respiratory history

Mrs Walker, 55 years old, presents to the respiratory clinic with cough and wheeze.

Please take a history

• Introduce yourself and clean your hands.

• Ask an open question about why this person has come to the clinic.

• Explore each presenting symptom:

• Cough:

– Onset, duration?