Crackles, an End to Civility and the timely diagnosis of pneumonia

Share
|

Rene Laënnec in 1816 fashioned a role of paper in order to listen to the heart sounds in an older obese woman in cardiac distress. Laennec later described the sounds of peripneumonia as rales at the left base of the lungs. Rales translate appropriately as rattles in English, and the term rales prevailed as the ausculatory sound of pneumonia. In referring to rales in front of a French patient, however, there was a problem. The French term for death rattle, `rales d mort,` was common knowledge, and known as a sign of imminent death. Thus, Laënnec substituted the word rhonchi when referencing rales in front of a patient. Both terms remained in common use in medicine and with some confusion between the two. 

I learned rales as the subtle rustling or faint bubbling sound of wet alveoli engorged with purulence during inspiration.  Rhonchi were a coarser sound emanating from more proximal bronchioli – not at all the interchangeable meaning of rales and ronchi as used by Laennec. The continuing confusion over these two terms lead the American Thoracic  Society and the American College of Chest Physicians in 1977 to change the name rales to crackles.

Crackles carry the suggestion of an onomatopoeia; Crackles implies the sound of Rice-Crispi’s. Crackles may mimic the sound of advanced pneumonia, but the sound of rales at the left base at the critically early onset of left lower lobe pneumonia sounds more like rubbing your hair above your ear. It is a subtle sound accompanied by respiratory lag and splinting of the diaphragm –to often missed.

Changes in curriculum, standardized patients, recorded sounds from a manikin, shorter clinical hours, the concern for overuse of antibiotics, the change in name of d-pneumococcus to streptococcus, the protocols for immunizations, cholesterol checks, colonoscopies, conspire to reduce the sensitivity for the seriousness of a patient’s early illness. Early onset pneumonia presents with a patient who is a whole lot sicker than he or she looks. Often the temperature is not so high and the protocols seem to suggest that anything that coughs is a virus. There is even a score called the Risk-Rating-Index that tries to quantify the risk of the patient actually having pneumonia. Without long hours in the middle of the night seeing such patients, the pattern recognition of early pneumonia is lost or never learned.

The treatment is wrong when the diagnosis is wrong. If we diagnose pneumonia only with the second Emergency Room visit after the treatment for the virus that is going around fails, and the patient becomes indeed critical, an easy early treatment with oral agents becomes a hospital admission treating a critical illness all for a failure to diagnose.

 So, crackles it is, but define them as fine, coarse, wet or dry and when in inspiration. Percuss the mobility of the diaphragm. Do a Gram stain and view it yourself. Recognize a critical diagnosis when it sneaks up on you.  They may forgive you for using the more civilized `rales` in the French tradition when your take the extra steps and correctly diagnosis a case of early pneumonia.