Bronchial Breath Sounds Research Articles

Valor predictivo de la historia clínica y examen físico en el diagnóstico de neumonía del adulto adquirida en la comunidad

Community-acquired pneumonia in adults is a serious health problem in the ambulatory care setting. To define clinical variables associated with the presence of pneumonia in adult patients presenting with fever or respiratory symptoms to the emergency department. Prospective study carried out in the emergency department from the Catholic University Hospital in Santiago, Chile. Three hundred twenty-five patients (53+/-22 years) presenting fever or acute respiratory symptoms were included. After obtaining a clinical history and physical examination, the physician established a tentative diagnosis. Subsequently, a definitive diagnosis was made with the chest X rays. Thirty-four percent of the patients had pneumonia. The clinical diagnosis of pneumonia before X-ray examination was variable among emergency physicians (positive likelihood ratio: 1.5-4.8) and showed only moderate sensitivity (79%) and specificity (66%). The clinical variables significantly associated with the presence of pneumonia were: advanced age (over 75 years), cardiovascular disease, fever, chills, sputum production, orthopnea, altered mental status, cyanosis, dullness on percussion, bronchial breath sounds, crackles, any abnormal vital sign (heart rate>or=100 beats/min, respiratory rate>or=20 breaths/min or temperature>or=38 degrees C) and oxygen saturation below 90% breathing air. Clinical judgment prior to observation of chest X rays had moderate sensitivity and specificity for the diagnosis of pneumonia. There were no individual clinical findings, or combination of findings, that could confirm or exclude the diagnosis of pneumonia for a patient suspected of having this illness.

Unusual occurrence of destroyed lung syndrome in childhood: a case report

A 10-year-old male child presented with three weeks history of neck swelling, fever and cough of insidious onset. On examination he was wasted and had dull percussion notes, bronchial breath sounds and crepitations on the left side. The ESR was high. Sputum AFB was positive. The chest radiograph showed features of Destroyed Lung Syndrome (DLS), one of the most severe complications of secondary PTB. The patient is doing well on antituberculous drugs. This case of DLS is presented here because it occurred in a child, a rather unusual presentation. Keywords: destroyed lung, tuberculosis, childhood Nigerian Journal of Surgical Research Vol. 7(3&4) 2006: 46-47

Propylthiouracil-induced anti-neutrophil cytoplasmic antibody-associated vasculitis

CASE PRESENTATION A 20-year-old woman was referred to Peking University First Hospital, Beijing, China, owing to massive pulmonary hemorrhage and gross hematuria. She had been well until 2 years before admission when she was diagnosed with Graves' disease and was treated with propylthiouracil (PTU) 300 mg/day first and then maintained with PTU 100 mg/day. Five months before admission, she complained of palpitations and was found to have an elevated serum T3 and T4 and decreased thyroid stimulating hormones. In response, the dose of PTU was changed to 300 mg/day by her local doctors. Shortly thereafter, she started to complain of arthralgia, myalgia, and skin rash. Three months before admission, she developed a cough, hemoptysis, and gross hematuria, and subsequently a gradual decline in her hearing, 'red eye', and weight loss. One week before admission, her PTU dose was further increased to 450 mg/day and then the patient became severely ill with massive pulmonary hemorrhage. At physical examination on admission, her paleness, exophthalmos, and goiter were revealed. The blood pressure was 120/80 mm Hg, the pulse 96 beats/min, the respiratory rate 24 breaths/min, and the temperature 37.2°C. The body weight was 45 kg. Auscultation of the lungs revealed scattered expiratory wheezes and coarse bronchial breath sounds. A cardiac examination revealed tachycardia with normal heart sounds and no murmurs, rubs, or gallops. The abdomen was soft, nontender. There was no edema on lower extremities. Laboratory data are shown in Tables 1 and 2. Chest radiography indicated massive pulmonary hemorrhage (Figure 1a). Her serum perinuclear cytoplasmic stained pattern on ethanol-fixed neutrophil was positive with specificity to myeloperoxidase, lactoferrin, and azurocidin. Anti-nuclear antibody and anti-glomerular basement membrane antibody were negative.

Multiple Lytic Bone Lesions in an 85-Year-Old Man

An 85-year-old, Russian-speaking man of Eastern European origin with a past medical history of Parkinson disease, hypothyroidism, and chronic anemia was evaluated for gradual increase in shortness of breath that worsened 2 days before admission. The patient did not complain of any chest pain, fever, cough, nausea, or vomiting. Physical examination showed an elderly man with shortness of breath during talking and at rest. His temperature was 36.18C; pulse, 100 beats per minute; respiratory rate, 30 to 40 breaths per minute; and blood pressure, 140/70 mm Hg. Examination of the cardiovascular system was unremarkable. Auscultation of the lungs revealed decreased breath sounds at the right base and bronchial breath sounds on the right side. No crackles, rhonchi, or wheezing were found. Physical examination of the patient’s abdomen showed splenomegaly, but no significant hepatomegaly. No lymphadenopathy was found. Examination of the nervous system showed no evidence of focal neurologic signs or evidence of any neuropathy. Examination of the neck showed deformities of the cervical spine, reportedly caused by fractures. The patient also complained of chronic bone pain for many years. Abnormal laboratory tests included serum sodium, 124 mEq/L; hemoglobin, 10.7 g/dL; hematocrit, 31.4%; and thyroid stimulating hormone, 3.2 mIU/mL. Both the white blood cell count and the platelet count were within normal limits. Total gamma globulins were slightly elevated (4.3

Multiple lytic bone lesions in an 85-year-old man: type 1 Gaucher disease, adult onset (nonneuronopathic form).

An 85-year-old, Russian-speaking man of Eastern European origin with a past medical history of Parkinson disease, hypothyroidism, and chronic anemia was evaluated for gradual increase in shortness of breath that worsened 2 days before admission. The patient did not complain of any chest pain, fever, cough, nausea, or vomiting. Physical examination showed an elderly man with shortness of breath during talking and at rest. His temperature was 36.18C; pulse, 100 beats per minute; respiratory rate, 30 to 40 breaths per minute; and blood pressure, 140/70 mm Hg. Examination of the cardiovascular system was unremarkable. Auscultation of the lungs revealed decreased breath sounds at the right base and bronchial breath sounds on the right side. No crackles, rhonchi, or wheezing were found. Physical examination of the patient’s abdomen showed splenomegaly, but no significant hepatomegaly. No lymphadenopathy was found. Examination of the nervous system showed no evidence of focal neurologic signs or evidence of any neuropathy. Examination of the neck showed deformities of the cervical spine, reportedly caused by fractures. The patient also complained of chronic bone pain for many years. Abnormal laboratory tests included serum sodium, 124 mEq/L; hemoglobin, 10.7 g/dL; hematocrit, 31.4%; and thyroid stimulating hormone, 3.2 mIU/mL. Both the white blood cell count and the platelet count were within normal limits. Total gamma globulins were slightly elevated (4.3

Hemoptysis in a 38-Year-Old Woman Receiving an Oral Contraceptive

A 38-year-old woman presented with intermittent chest pain and hemoptysis of 1 week in duration, producing less than a cup of blood throughout the week. She denied constitutional symptoms, dyspnea, or orthopnea. Her medical history was unremarkable. She was receiving oral contraceptives and smoked cigarettes. On physical examination, she was afebrile. Bronchial breath sounds and crackles were audible at the left base. The rest of her examination was negative.

Comparison of neural network predictors in the classification of tracheal–bronchial breath sounds by respiratory auscultation

Despite extensive research in the area of identification and discrimination of tracheal–bronchial breath sounds by computer analysis, the process of identifying auscultated sounds is still subject to high estimation uncertainties. Here we assess the performance of the relatively new constructive probabilistic neural network (CPNN) against the more common classifiers, namely the multilayer perceptron (MLP) and radial basis function network (RBFN), in classifying a broad range of tracheal–bronchial breath sounds. We present our data as signal estimation models of the tracheal–bronchial frequency spectra. We have examined the trained structure of the CPNN with respect to the other architectures and conclude that this architecture offers an attractive means with which to analyse this type of data. This is based partly on the classification accuracies attained by the CPNN, MLP and RBFN which were 97.8, 77.8 and 96.2%, respectively. We concluded that CPNN and RBFN networks are capable of working successfully with this data, with these architectures being acceptable in terms of topological size and computational overhead requirements. We further believe that the CPNN is an attractive classification mechanism for auscultated data analysis due to its optimal data model generation properties and computationally lightweight architecture.

35-Year-Old Woman With Cough, Fever, and Anorexia

35-Year-Old Woman With Cough, Fever, and Anorexia

A 48-Year-Old Smoker With Cough and Weight Loss

A 48-year-old male smoker was referred for the evaluation of symptoms of cough, weight-loss, and chest radiograph abnormality. The patient had a medical history significant for chronic bronchitis and had been seen by his primary care physician 2 months previously for worsening nonproductive cough without fever or shortness of breath. He was treated with erythromycin after chest radiography demonstrated a right middle-lobe infiltrate, while the results of a sputum culture revealed ”normal flora.” The patient's cough continued over the following month, complicated by gradually worsening dyspnea on exertion and weight loss, and he returned to the clinic. On examination, the patient was afebrile and had normal room air oximetry findings, but had persistent bronchial breath sounds in the right mid-chest. The results of serum chemistry tests and CBC were in the normal range. A repeat chest radiograph and a chest CT scan were performed (Fig 1). Fiberoptic bronchoscopy revealed an erythematous, narrowed right middle-lobe orifice with extruding tan purulence. The results of an endobronchial biopsy demonstrated only inflammatory changes, while the results of an acid-fast bacillus stain of endobronchial washings were negative. A Papanicolaou stain of the washings is shown in Figure 2. Figure 2Papanicolaou stain of endobronchial washings. View Large Image Figure Viewer

Defining the burden of pneumonia in children preventable by vaccination against Haemophilus influenzae type b.

To determine the burden of pneumonia requiring hospitalization in infants and young children preventable by vaccination against Haemophilus influenzae type b (Hib). Vaccination centers in Santiago, Chile, were randomly selected to administer PRP-T, an Hib conjugate vaccine, combined with diphtheria-tetanus toxoids-pertussis (DTP) vaccine or DTP alone. Infants who received > or =2 doses of DTP or DTP and Hib conjugate vaccine combined. Pneumonia episodes leading to hospitalization accompanied by indicators of likely bacterial infection including radiologic evidence of alveolar consolidation or pleural effusion, an elevated erythrocyte sedimentation rate (> or =40 mm/h) or bronchial breath sounds on auscultation. In participants age 4 to 23 months, PRP-T reduced the incidence of pneumonia associated with alveolar consolidation or pleural effusion by 22% (95% confidence interval, -7 to 43) from 5.0 to 3.9 episodes per 1000 children per year. When the pneumonia case definition included any of the following, alveolar consolidation, pleural effusion, erythrocyte sedimentation rate > or =40 mm/h or bronchial breath sounds, PRP-T provided 26% protection (95% confidence interval, 7 to 44) and prevented 2.5 episodes per 1000 children per year. Hib vaccine provides substantial protection against nonbacteremic pneumonia, particularly those cases with alveolar consolidation, pleural effusion or other signs of likely bacterial infection. Hib vaccination prevented approximately 5 times as many nonbacteremic pneumonia cases in infants as meningitis cases, thus indicating that the largest part of the effect of Hib vaccination might be undetectable by routine culture methods.

Diagnosing pneumonia by physical examination: relevant or relic?

The reliability of chest physical examination and the degree of agreement among examiners in diagnosing pneumonia based on these findings are largely unknown. To determine the accuracy of various physical examination maneuvers in diagnosing pneumonia and to compare the interobserver reliability of the maneuvers among 3 examiners. Fifty-two male patients presenting to the emergency department of a university-affiliated Veterans Affairs medical center with symptoms of lower respiratory tract infection (cough and change in sputum) were prospectively examined. A comprehensive lung physical examination was performed sequentially by 3 physicians who were blind to clinical history, laboratory findings, and x-ray results. Examination findings by lung site and whether the examiner diagnosed pneumonia were recorded on a standard form. Chest x-ray films were read by a radiologist. Twenty-four patients had pneumonia confirmed by chest x-ray films. Twenty-eight patients did not have pneumonia. Abnormal lung sounds were common in both groups; the most frequently detected were rales in the upright seated position and bronchial breath sounds. Relatively high agreement among examiners (kappa approximately 0.5) occurred for rales in the lateral decubitus position and for wheezes. The 3 examiners' clinical diagnosis of pneumonia had a sensitivity of 47% to 69% and specificity of 58% to 75%. The degree of interobserver agreement was highly variable for different physical examination findings. The most valuable examination maneuvers in detecting pneumonia were unilateral rales and rales in the lateral decubitus position. The traditional chest physical examination is not sufficiently accurate on its own to confirm or exclude the diagnosis of pneumonia.

Pulmonary edema in malaria

A 33-year-old Australian woman, who had been stationed in Liberia for 4 months, flew to New York City for vacation. Several days later, she developed fever, rigors, lower back pain, and headache. On the third day of symptoms, she was acutely ill and was admitted to The New York Hospital where a peripheral blood smear showed characteristic ring forms of Pfalciparum (Figure 1). She had discontinued chloroquine and proguanil prophylaxis due to gastrointestinal intolerance 10 weeks before admission. Initial laboratory studies included white blood cell (WBC) count of 4800/mm3; hemoglobin, 11.9 g/dL; hematocrit, 34%; platelet count, 43,000/mm3; lactic dehydrogenase (LDH), 399 IU; prothrombin time (PT), 14.7 seconds (control 12.0 s); and partial thromboplastin time m, 35.1 seconds (control 38 s). Admission chest examination and roentgenogram were normal (Figure 2, A). After 18 hours of treatment with oral quinine and doxycycline, parasitemia was reduced from 2. IL to 1.2%. However, 12 hours later, the patient developed acute respiratory distress with severe hypoxemia (arterial PO, 38 mmHg breathing room air). Bronchial breath sounds and rales were heard over both lower lung fields. Fever to 39°C persisted, although parasitemia was less than 0.1%. The patient developed evidence suggesting coagulopathy or disseminated intravascular coagulation (DIG) with a further increase in PT to15.4 seconds and a positive D-dimer test. Repeat chest x-ray was consistent with

1161 CHLAMYDIA-ASSOCIATED LOWER RESPIRATORY TRACT INFECTIONS (LRI) IN CHILDREN OVER 1 YEAR OF AGE

Chlamydia trachomatis (Ct) is believed to be a cause of LRIs mainly in young infants. Close surveillance for LRIs was maintained since birth on a group of 1182 children. Over a period of 17 months, we obtained nasopharyngeal and throat swabs for acute LRI from 340 children. All specimens were cultured for viruses, Ct and Mycoplasma pneumoniae. One or more of these agents were isolated from 67% of LRIs. Ct was isolated from 3/52 (5.8%) of infants ≤6 months of age, 0/61 (0%) infants 7-12 months and 9/227 (4.0%) children 1-3 years with LRI. Infection with Ct in these 9 older children (ages 17-34 mos, med=21 mos) occured from December to April and was associated with a variety of syndromes and with concurrent isolation of other pathogens.Symptoms and signs included cough (9), rhinitis (8), fever (3), abnormal bronchial breath sounds (3), hoarseness (2), shortness of breath (2), stridor (2) and wheezing (1).These results suggest that Ct is associated with a diversity of LRIs in children >1 year of age, and may often be present with other pathogens.(Supported by NHLBI-SCOR Grant HL-14136)

Acute Dyspnea in a Young Woman Taking Birth Control Pills

History A 26-year-old black woman was initially seen with an acute onset of shortness of breath, right-sided pleuritic pain in the chest, and a history of one week of pain without swelling of the right leg. She denied any unusual medical history. A routine employment roentgenogram of the chest obtained two years earlier was normal. Her only medication was a mestranol-norethindrone combination product. Physical examination revealed a well-developed, well-nourished woman in moderate respiratory distress. Her BP was 110/70 mm Hg; heart rate, 108 beats per minute; respirations, 28/min; and temperature, 37.8 °C. Pertinent physical findings included a left conjunctival nodule, right supraclavicular adenopathy, and bronchial breath sounds heard over the right upper-lung region. Her extremities were normal. Findings from routine laboratory studies were unremarkable except for an ESR of 56 mm/hr. Arterial blood gas levels on room air were Po2, 77 mm Hg; Pco2, 30 mm Hg; and

High-Altitude Pulmonary Infarction

To the Editor. —High-altitude exposure has not been noted to produce pulmonary infarction in patients with S-C hemoglobinopathy. We describe a patient with S-C hemoglobin who had bilateral pulmonary infarctions develop during travel in an unpressurized aircraft. Report of a Case. —A 35-year-old black woman was transferred to the University of Colorado Health Sciences Center, Denver (elevation, 5,280 ft [1,609 m]) with dyspnea and diffuse muscle pain. She had been well three days earlier, when she noted the sudden onset of the previously mentioned symptoms while flying in an unpressurized aircraft at 16,000 ft (4,877 m). After several days of progressive symptoms at an elevation of 8,000 ft (2,438 m), she was transferred for evaluation of her condition. The patient's respirations were 35/min, and her temperature was 38.5 °C. The lower half of the chest was dull to percussion, with bronchial breath sounds. The abdomen was tender with a palpable

Life-Threatening Mycoplasma pneumoniae Pneumonia

PNEUMONIA caused by Mycoplasma pneumoniae is usually a mild and self-limited infection. However, several overwhelming or fatal instances have been reported, usually in individuals with underlying systemic disease. 1 We shall describe a previously healthy young man who became critically ill with pneumonitis caused by this organism. His clinical course and response to therapy are presented to further characterize the nature of severe pneumonitis due to M pneumoniae . Report of a Case A 25-year-old man was hospitalized after two days of fever, chest pain, and cough productive of scant, yellow sputum. His temperature was 38.8 C (102 F); blood pressure, 120/90 mm Hg; pulse, 100 beats per minute, and respirations, 20/min. Dullness and bronchial breath sounds were noted at the lung bases. The remainder of the physical examination showed no abnormalities. The peripheral white blood cell count was 8,600/cu mm, with a normal differential. Serum cold agglutinins were absent. A

Case 14-1962

Presentation of Case First admission. A fifty-nine-year-old man was referred to the hospital because of a mediastinal mass.Two years previously an x-ray film of the chest taken at another hospital after an upper respiratory infection showed a mediastinal mass; no additional studies were performed at that time. The patient was asymptomatic until three weeks before admission, when a mild upper respiratory infection again developed. An x-ray film of the chest taken shortly before entry demonstrated slight enlargement of the mass.Physical examination revealed bronchial breath sounds and slight dullness to percussion over the left scapula. X-ray films of . . .

Pneumocystis carinii pneumonia.

Pneumocystis carinii pneumonia is apparently still rare in the United States, since only seven deaths from this cause have been unequivocally proved. The seventh of these cases, from the John Sealy Hospital, Galveston, Texas, brought to our attention this interesting and serious interstitial plasma-cell pneumonia which we had not heretofore recognized. Pneumocystis carinii pneumonia has been known in Europe only in recent years, reaching epidemic proportions in the last decade. It was first described by Ammich (2) in 1938. An increasing number of cases were subsequently reported in Germany and Switzerland, with rapid spread peripherally from these countries into other European areas. In 1955, 1 case was reported from England. Three cases were reported from Canada in 1956 and from 1957 to 1959 there have been reported 1 case from Connecticut (3), 2 from Oklahoma (11), 1 from Georgia (8), 1 from Arizona (5), and 1 from Louisiana (10). The first recognized case in the United States was reported in 1955 (9) and Pneumocystis carinii may yet present an important problem in this area. The disease occurs endemically or epidemically within hospital nurseries and seems to have a predilection for premature or debilitated infants, although it has been recorded several times in adult subjects. The organism is described as a parasite of controversial taxonomy, and the mode of transmission is unknown. Antemortem diagnosis is difficult. Treatment is unsatisfactory, and mortality ranges from 15 to 100 per cent. Clinical Features The onset of interstitial plasma-cell pneumonia is so insidious that it is difficult to determine. The first signs are usually restlessness, languor, and lack of appetite. Tachypnea and a peculiar cyanosis around the mouth and under the eyes suggest respiratory tract involvement. Generalized grayish cyanosis and dyspnea with sternal retraction and prominent flank movements are seen. Deamer and Zollinger (4) quote Willi as considering the rapid respiratory movement of the lateral abdominal wall the most important clinical finding. Cyanosis may persist even during the administration of oxygen. While cough is not a characteristic feature, it may occur in sudden exhausting attacks. There is usually an inconstant, low-grade fever, or none at all. Rhinitis, diarrhea, and inertia may precede pulmonary involvement by as much as a month. The discrepancy between the severity of dyspnea and the paucity of physical findings is typical, although fine crepitant rales and bronchial breath sounds may be heard over some lung areas. Clinical studies in various European hospitals have shown that many infants have mild attacks which are detected only by routine counts of the respiratory rate along with frequent chest roentgenograms following exposure to the disease. A respiratory rate exceeding 40 to 50 per minute in the sleeping premature infant is regarded with suspicion. Interstitial emphysema develops progressively.

Calcification of Pleura and Lung

Calcification of the pleura or of the lung is not uncommon, but the massive involvement of an entire lung is so rare that the following case may be of interest. A few such lesions have been reported in the American and foreign literature, but none of these has been studied by body-section (planigraphic) roentgenography. Case Report A white female of 74 years gave a history of diphtheria and scarlet fever in youth, pneumonia at 40 years, influenza at 42 years, and pulmonary tuberculosis with pleuritis (hospitalization for one year) also at 42 years. The diagnosis of tuberculosis was confirmed by two sputum samples of separate date positive for acid-fast bacilli. Symptoms at that time (1912) included cough, fever, and left thoracic pain. No thoracentesis or roentgen study was done. There were two admissions to the Hospital of the University of Pennsylvania, in 1915 and 1924, because of pain in the left shoulder, thorax, and lumbar area, loss of weight, hoarseness, dyspnea, palpitation, and vertigo. At these times expansion was almost entirely right thoracic; tactile fremitus and vocal resonance were increased on the left above the 7th rib posteriorly. There were bronchial breath sounds, whispered pectoriloquy, depression of the supraclavicular fossa, and dullness to percussion on the left. The heart and trachea were constantly retracted to the left. On the second admission, the sputum was negative for acid-fast bacilli and roentgen study of the chest revealed no expansion on the left, the heart retracted to the left lateral chest wall, and left deviation of the trachea. Other findings were probable thickening of the pleura and pulmonary fibrosis, and a suggestion of encroachment by emphysematous right lung upon the left hemithorax. (The plates were not available for review.) No mention was made of calcification. From 1934 to 1945 the patient has been seen by Dr. O. H. Perry Pepper (to whom we are indebted for this report), as an outpatient. She has been in rather good health, suffering occasionally and moderately from cough, weakness, dyspnea, vertigo, sore chest or shoulder, and “heart attacks.” However, these do not prevent her doing all her housework and driving a car. Discussion High-speed Potter-Bucky roentgenograms in the postero-anterior and lateral projections reveal an extensive calcification in the left thorax and obscuration of the heart (Fig. 2, A and B). The contour of the upper and lower lobes can be seen well, and apparently both have undergone contraction with upward displacement. The right lung has expanded across the mid-line. The distance between the left rib cage and the calcium might be due to an uncalcified parietal pleura, but may be attributable simply to the fact that the shrunken lung lies posteriorly in the thorax and does not reach the lateral wall at its greatest diameter. This is analogous to a plan view of a spherical jar partly occupied by an opaque material (as in the accompanying sketch, Fig. 3).

The Point of Origin of the Bronchial Breath Sounds

A tracheotomy was performed on a patient who had a carcinoma of the larynx, and a pneumonia developed in the left lower lobe. With the patient's nose closed firmly by the fingers of the doctor and the mouth closed firmly by the patient, bronchial breath sounds which sounded typical were heard over the left lower lobe. The breath sounds over the other lower lobe were normal. This would seem to show that the vocal cords play no very large rôle in the formation of the bronchial breath sounds, but that the bronchial breath sounds are formed by the passage of air through the bronchial tubes much after the manner of the formation of sound in lip pipes. A patient who had loud bronchial breath sounds over the right lower lobe came to autopsy. A rubber tube was passed through the vocal cords and air was periodically allowed to enter the lungs from an oxygen tank. There was a side tube for allowing the egress of air and by alternately closing the outflow and inflow tubes, artificial inspiration and expiration could be produced. Auscultation over the right lower lobe produced bronchial breath sounds resembling fairly closely those heard over the same area by the intern and resident physician before the death of the patient. The trachea was now cut off below the larynx and the same rubber tube was inserted down just beyond the bifurcation. On auscultation the breath sounds were still bronchial and apparently were a little higher pitched than when the tube was passed just beyond the vocal cords. This experiment shows that the components of the bronchial breath sounds are formed largely in the bronchial tubes below the vocal cords and that some of the bronchial breath sound is formed apparently beyond the primary bronchus.