Clinical Usefulness of Breath Sounds

  • Sotirios Fouzas
  • Michael B. Anthracopoulos
  • Abraham Bohadana


Respiratory medicine relies both on clinical information and on complementary, laboratory tests results. However, despite today’s technological wonders, a proper history and a sound physical examination have no substitute as the initial step in making a correct diagnosis and, by consequence, providing the appropriate treatment. Respiratory complaints are frequently the cause that brings a patient to the doctor, and the respiratory system is the most commonly affected organ system in clinical practice. Consequently, respiratory sounds, either heard at a distance or auscultated over the chest, are integral to the evaluation of patients and may provide valuable clues. This chapter focuses on lung sounds as they are reported by patients (or by their guardians in the case of young children) and as a sign noted on chest auscultation performed with the stethoscope. The characteristics and the pathogenesis of adventitious breath sounds (stridor, wheeze, crackles, squawk) are briefly addressed and their clinical usefulness is discussed; voice-transmitted sounds and noisy breathing (grunt, snuffle, rattle, snore) are also presented. The four clinical cases included at the end of this chapter highlight the value of the proper understanding of breath sounds.


  1. 1.
    DeGowin EL (ed) (1987) Bedside diagnostic examination: a comprehensive pocket textbook. Macmillan, New YorkGoogle Scholar
  2. 2.
    Brown AM, von Mutius E, Morgan WJ (2008) Clinical assessment and diagnostic approach to common problems. In: Taussig LM, Landau LI, LeSouëf PN, Martinez FD, Morgan WJ, Sly PD (eds) Pediatric respiratory medicine, 2nd edn. Mosby-Elsevier, Philadelphia, pp 491–499Google Scholar
  3. 3.
    Anthracopoulos MB, Douros K, Priftis KN (2013) History and physical examination. In: Eber E, Midulla F (eds) ERS handbook paediatric respiratory medicine. HERMES ERS, Lausanne, pp 33–43Google Scholar
  4. 4.
    Bohadana A, Izbicki G, Kraman SS (2014) Fundamentals of lung auscultation. N Engl J Med 370(8):744–751PubMedPubMedCentralGoogle Scholar
  5. 5.
    Pasterkamp H, Kraman SS, Wodicka GR (1997) Respiratory sounds: advances beyond the stethoscope. Am J Respir Crit Care Med 156(3 Pt 1):974–987CrossRefGoogle Scholar
  6. 6.
    Pasterkamp H (2012) The history and physical examination. In: Wilmott RW, Boat TF, Bush A, Chernick V, Deterding RR, Ratjen F (eds) Kendig and Chernick’s disorders of the respiratory tract in children, 8th edn. Elsevier-WB Saunders, Philadelphia, pp 110–130CrossRefGoogle Scholar
  7. 7.
    Dalmay F, Antonini MT, Marquet P, Menier R (1995) Acoustic properties of the normal chest. Eur Respir J 8(10):1761–1769CrossRefGoogle Scholar
  8. 8.
    Sovijärvi AR, Dalmasso F, Vanderschoot J, Righini G, Stoneman SA (2000) Definition of terms for applications of respiratory sounds. Eur Respir Rev 10(77):597–610Google Scholar
  9. 9.
    Pasterkamp H, Brand PL, Everard M, Garcia-Marcos L, Melbye H, Priftis KN (2016) Towards standardisation of lung sound nomenclature. Eur Respir J 47(3):724–732CrossRefGoogle Scholar
  10. 10.
    Melbye H, Garcia-Marcos L, Brand P, Everard M, Priftis K, Pasterkamp H (2016) Wheezes crackles and rhonchi: simplifying description of lung sounds increases the agreement on their classification: a study of 12 physicians’ classification of lung sounds from video recordings. BMJ Open Respir Res 3(1):e000136CrossRefGoogle Scholar
  11. 11.
    Priftis KN, Douros K, Anthracopoulos MB (2013) Snoring hoarseness, stridor and wheezing. In: Eber E, Midulla F (eds) ERS handbook paediatric respiratory medicine. HERMES ERS, Lausanne, pp 57–64Google Scholar
  12. 12.
    Mellis C (2008) Respiratory noises: how useful are they clinically? Pediatr Clin N Am 56(1):1–17CrossRefGoogle Scholar
  13. 13.
    Meslier N, Charbonneau G, Racineux JL (1995) Wheezes. Eur Respir J 8(11):1942–1948CrossRefGoogle Scholar
  14. 14.
    Grotberg JB, Gavriely N (1989) Flutter in collapsible tubes: a theoretical model of wheezes. J Appl Physiol 66(5):2262–2273CrossRefGoogle Scholar
  15. 15.
    Sly PD, Collins RA (2006) Physiological basis of respiratory signs and symptoms. Paediatr Respir Rev 7(2):84–88CrossRefGoogle Scholar
  16. 16.
    Solway J, Fredberg JJ, Ingram RH, Pedersen OF, Drazen JM (1987) Interdependent regional lung emptying during forced expiration: a transistor model. J Appl Physiol 62(5):2013–2025CrossRefGoogle Scholar
  17. 17.
    Elphick HE, Sherlock P, Foxall G et al (2001) Survey of respiratory sounds in infants. Arch Dis Child 84(1):35–39CrossRefGoogle Scholar
  18. 18.
    Davies MJ, Cane R, Ranganathan S, McKenzie SA (1998) Cough, wheeze and sleep. Arch Dis Child 79(5):465CrossRefGoogle Scholar
  19. 19.
    Cane RS, Ranganathan S, McKenzie SA (2000) What do parents of wheezy children understand by “wheeze”? Arch Dis Child 82(4):327–332CrossRefGoogle Scholar
  20. 20.
    Cane RS, McKenzie SA (2001) Parents’ interpretations of children’s respiratory symptoms on video. Arch Dis Child 84(1):31–34CrossRefGoogle Scholar
  21. 21.
    Chong Neto HJ, Rosario N, Dela Bianca AC, Solé D, Mallol J (2007) Validation of a questionnaire for epidemiologic studies of wheezing in infants. Pediatr Allergy Immunol 18(1):86–87CrossRefGoogle Scholar
  22. 22.
    Lowe L, Murray CS, Martin L et al (2004) Reported versus confirmed wheeze and lung function in early life. Arch Dis Child 89(6):540–543CrossRefGoogle Scholar
  23. 23.
    Michel G, Silverman M, Strippoli MP et al (2006) Parental understanding of wheeze and its impact on asthma prevalence estimates. Eur Respir J 28(6):1124–1130CrossRefGoogle Scholar
  24. 24.
    Anthracopoulos MB, Liolios E, Panagiotakos DB, Triantou K, Priftis KN (2007) Prevalence of asthma among schoolchildren in Patras, Greece: four questionnaire surveys during 1978–2003. Arch Dis Child 92(3):209–212CrossRefGoogle Scholar
  25. 25.
    Asher MI, Keil U, Anderson HR et al (1995) International study of asthma and allergies in childhood (ISAAC): rational and methods. Eur Respir J 8(3):483–491CrossRefGoogle Scholar
  26. 26.
    Elphick HE, Ritson S, Rodgers H, Everard ML (2000) When a wheeze is not a wheeze: acoustic analysis of breath sounds in infants. Eur Respir J 16(4):593–597CrossRefGoogle Scholar
  27. 27.
    Elphick HE, Lancaster GA, Solis A, Majumdar A, Gupta R, Smyth RL (2004) Validity and reliability of acoustic analysis of respiratory sounds in infants. Arch Dis Child 89(11):1059–1063CrossRefGoogle Scholar
  28. 28.
    Elphick HE, Ritson S, Everard ML (2002) Differential response of wheezes and ruttles to anticholinergics. Arch Dis Child 86(4):280–281CrossRefGoogle Scholar
  29. 29.
    Netuveli G, Hurwitz B, Sheikh A (2007) Lineages of language and the diagnosis of asthma. J R Soc Med 100(1):19–24CrossRefGoogle Scholar
  30. 30.
    Shim CS, Williams MH Jr (1983) Relationship of wheezing to the severity of obstruction in asthma. Arch Intern Med 143(5):890–892CrossRefGoogle Scholar
  31. 31.
    Holleman DR, Simel DL, Goldberg JS (1993) Diagnosis of obstructive airways disease from the clinical examination. J Gen Intern Med 8(2):63–68CrossRefGoogle Scholar
  32. 32.
    Badgett RG, Tanaka DJ, Hunt DK et al (1994) The clinical evaluation for diagnosing obstructive airways disease in high-risk patients. Chest 106(5):1427–1431CrossRefGoogle Scholar
  33. 33.
    Bohadana AB, Peslin R, Uffholtz H (1978) Breath sounds in the clinical assessment of airflow obstruction. Thorax 33(3):345–351CrossRefGoogle Scholar
  34. 34.
    Purohit A, Bohadana A, Kopferschmitt-Kubler MC, Mahr L, Linder J, Pauli G (1997) Lung auscultation in airway challenge testing. Respir Med 91(3):151–157CrossRefGoogle Scholar
  35. 35.
    Yong SC, Smith CM, Wach R, Kurian M, Primhak RA (1999) Methacholine challenge in preschool children: methacholine-induced wheeze versus transcutaneous oximetry. Eur Respir J 14(5):1175–1178CrossRefGoogle Scholar
  36. 36.
    Springer C, Godfrey S, Picard E et al (2000) Efficacy and safety of methacholine bronchial challenge performed by auscultation in young asthmatic children. Am J Respir Crit Care Med 162(3 Pt 1):857–860CrossRefGoogle Scholar
  37. 37.
    Godfrey S, Uwyyed K, Springer C, Avital A (2004) Is clinical wheezing reliable as an endpoint for bronchial challenges in preschool children? Pediatr Pulmonol 37(3):193–200CrossRefGoogle Scholar
  38. 38.
    Bohadana AB, Peslin R, Uffholtz H, Pauli G (1995) Potential for lung sound monitoring during bronchial provocation testing. Thorax 50(9):955–961CrossRefGoogle Scholar
  39. 39.
    Bohadana AB, Michaely JP (2006) Does the inclusion of wheeze detection as an outcome measure affect the interpretation of methacholine challenge tests? A study in workers at risk of occupational asthma. Lung 184(3):151–157CrossRefGoogle Scholar
  40. 40.
    Global Initiative for Asthma (GINA) (2016) Global strategy for asthma management and prevention.
  41. 41.
    National Institute for Health and Care Excellence (NICE) (2016) Bronchiolitis in children: diagnosis and management. NICE guideline. Published: 1 June 2015.
  42. 42.
    Piirilä P, Sovijärvi AR (1995) Crackles: recording, analysis and clinical significance. Eur Respir J 8(12):2139–2148CrossRefGoogle Scholar
  43. 43.
    Nath AR, Capel LH (1974) Inspiratory crackles and mechanical events of breathing. Thorax 29(6):695–698CrossRefGoogle Scholar
  44. 44.
    Fredberg JJ, Holford SK (1983) Discrete lung sounds: crackles (rales) as stress-relaxation quadruples. J Acoust Soc Am 73(3):1036–1046CrossRefGoogle Scholar
  45. 45.
    Vyshedskiy A, Alhashem RM, Pciej R et al (2009) Mechanism of inspiratory and expiratory crackles. Chest 135(1):156–164CrossRefGoogle Scholar
  46. 46.
    Munakata M, Ukita H, Doi I et al (1991) Spectral and waveform characteristics of fine and coarse crackles. Thorax 46(9):651–657CrossRefGoogle Scholar
  47. 47.
    Metlay JP, Kapoor WN, Fine MJ (1997) Does this patient have community-acquired pneumonia? Diagnosing pneumonia by history and physical examination. JAMA 287(17):1440–1445CrossRefGoogle Scholar
  48. 48.
    Lim WS, Baudouin SV, George RC et al (2009) BTS guidelines for the management of community-acquired pneumonia in adults: update 2009. Thorax 64(Suppl 3):iii1–iii55CrossRefGoogle Scholar
  49. 49.
    Bradley JS, Byington CL, Shah SS et al (2011) Executive summary: the management of community-acquired pneumonia in infants and children older than 3 months of age: clinical practical guidelines by the Pediatric Infectious Diseases Society of America. Clin Infect Dis 53(7):617–630CrossRefGoogle Scholar
  50. 50.
    Wipf JE, Lipsky BA, Hirshmann JV et al (1999) Diagnosing pneumonia by physical examination: relevant or relic? Arch Intern Med 159(10):1082–1087CrossRefGoogle Scholar
  51. 51.
    Margolis P, Gadomski A (1998) Does this infant have pneumonia? JAMA 279(4):308–313CrossRefGoogle Scholar
  52. 52.
    Vyshedskiy A, Bezares F, Paciej R, Ebril M, Shane J, Murphy R (2005) Transmission of crackles in patients with interstitial pulmonary fibrosis, congestive heart failure, and pneumonia. Chest 128(3):1468–1474CrossRefGoogle Scholar
  53. 53.
    Ponte DF, Moraes R, Hizume DC, Alencar AM (2013) Characterization of crackles from patients with fibrosis, heart failure and pneumonia. Med Eng Phys 35(4):448–456CrossRefGoogle Scholar
  54. 54.
    Paciej R, Vyshedskiy A, Bana D, Murphy R (2004) Squawks in pneumonia. Thorax 59(2):177–178CrossRefGoogle Scholar
  55. 55.
    Bilavsky E, Shouval DS, Yarden-Bilavsly H, Ashkenazi S, Amir J (2008) Are grunting respirations a sign of serious bacterial infection in children? Acta Paediatr 97(8):1086–1089CrossRefGoogle Scholar
  56. 56.
    Beck R, Odeh M, Oliven A, Gavriely N (1995) The acoustic properties of snores. Eur Respir J 8(12):2120–2128CrossRefGoogle Scholar
  57. 57.
    Jennum P, Riha RL (2009) Epidemiology of sleep apnoea/hypopnoea syndrome and sleep-disordered breathing. Eur Respir J 33(4):907–914CrossRefGoogle Scholar
  58. 58.
    Witmans M, Young R (2011) Update on pediatric sleep-disordered breathing. Pediatr Clin N Am 58(3):571–589CrossRefGoogle Scholar
  59. 59.
    Au CT, Li AM (2009) Obstructive sleep breathing disorders. Pediatr Clin N Am 56(1):243–259CrossRefGoogle Scholar
  60. 60.
    Li Z, Celestin J, Lockey RF (2016) Pediatric sleep apnea syndrome: an update. J Allergy Clin Immunol Pract 4(5):852–861CrossRefGoogle Scholar
  61. 61.
    Liistro G, Stanescu D, Veriter C (1991) Pattern of simulated snoring is different through mouth and nose. J Appl Physiol 70(6):2736–2741CrossRefGoogle Scholar
  62. 62.
    Dalmasso F, Prota R (1996) Snoring: analysis, measurement, clinical implications and applications. Eur Respir J 9(1):146–159CrossRefGoogle Scholar
  63. 63.
    Perez-Padilla JR, Slawinski E, Difrancesco LM, Feige RR, Remmers JE, Whitelaw WA (1993) Characteristics of the snoring noise in patients with and without occlusive sleep apnea. Am Rev Respir Dis 147(3):635–644CrossRefGoogle Scholar
  64. 64.
    Riha RL (2015) Diagnostic approaches to respiratory sleep disorders. J Thorac Dis 7(8):1373–1384PubMedPubMedCentralGoogle Scholar
  65. 65.
    Kaditis AG, Alonso Alvarez ML, Boudewyns A et al (2016) Obstructive sleep disordered breathing in 2- to 18-year-old children: diagnosis and management. Eur Respir J 47(1):69–94CrossRefGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Sotirios Fouzas
    • 1
  • Michael B. Anthracopoulos
    • 1
  • Abraham Bohadana
    • 2
  1. 1.Department of PediatricsUniversity Hospital of PatrasPatrasGreece
  2. 2.Pulmonary InstituteShaare Zedek Medical CenterJerusalemIsrael

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