Bronchial Breathing Research Articles

Detection of bronchial breathing caused by pneumonia.

The classic auscultation with stethoscope is the established clinical method for the detection of lung diseases. The interpretation of the sounds depends on the experience of the investigating physician. Therefore, a new computer-based method has been developed to classify breath sounds from digital lung sound recordings. Lung sounds of 11 patients with one-sided pneumonia and bronchial breathing were recorded on both the pneumonia side and on contralateral healthy side simultaneously using two microphones. The spectral power for the 300-600 Hz frequency band was computed for four respiratory cycles and normalized. For each breath, the ratio R between the time-segments (duration = 0.1 s) with the highest inspiratory and highest expiratory flow was calculated and averaged. We found significant differences in R between the pneumonia side (R = 1.4 +/- 1.3) and the healthy side (R = 0.5 +/- 0.5; p = 0.003 Wilcoxon-test) of lung. In 218 healthy volunteers we found R = 0.3 +/- 0.2 as a reference-value. The differences of ratio R (delta R) between the pneumonia side and the healthy side (delta R = 1.0 +/- 0.9) were significantly higher compared to follow-up studies after recovery (delta R = 0.0 +/- 0.1, p = 0.005 Wilcoxon-test). The computer based detection of bronchial breathing can be considered useful as part of a quantitative monitoring of patients at risk to develop pneumonia.

Clinical features of culture-proven Mycoplasma pneumoniae infections at King Abdulaziz University Hospital, Jeddah, Saudi Arabia.

ObjectiveThis retrospective chart review describes the epidemiology and clinical features of 40 patients with culture-proven Mycoplasma pneumoniae infections at King Abdulaziz University Hospital, Jeddah, Saudi Arabia.MethodsPatients with positive M. pneumoniae cultures from respiratory specimens from January 1997 through December 1998 were identified through the Microbiology records. Charts of patients were reviewed.Results40 patients were identified, 33 (82.5%) of whom required admission. Most infections (92.5%) were community-acquired. The infection affected all age groups but was most common in infants (32.5%) and pre-school children (22.5%). It occurred year-round but was most common in the fall (35%) and spring (30%). More than three-quarters of patients (77.5%) had comorbidities. Twenty-four isolates (60%) were associated with pneumonia, 14 (35%) with upper respiratory tract infections, and 2 (5%) with bronchiolitis. Cough (82.5%), fever (75%), and malaise (58.8%) were the most common symptoms, and crepitations (60%), and wheezes (40%) were the most common signs. Most patients with pneumonia had crepitations (79.2%) but only 25% had bronchial breathing. Immunocompromised patients were more likely than non-immunocompromised patients to present with pneumonia (8/9 versus 16/31, P = 0.05). Of the 24 patients with pneumonia, 14 (58.3%) had uneventful recovery, 4 (16.7%) recovered following some complications, 3 (12.5%) died because of M pneumoniae infection, and 3 (12.5%) died due to underlying comorbidities. The 3 patients who died of M pneumoniae pneumonia had other comorbidities.Conclusionour results were similar to published data except for the finding that infections were more common in infants and preschool children and that the mortality rate of pneumonia in patients with comorbidities was high.

A right upper zone chest mass in a smoker

A 61-year-old man presented with a history of breathlessness and weight loss, as well as rightsided chest and right shoulder pain radiating down the arm. He smoked 20 cigarettes a day. 9 months previously he had undergone total gastrectomy for an undifferentiated adenocarcinoma of the stomach. Staging CT prior to surgery had been normal and had not shown any nodes or distant metastases. Physical examination showed evidence of weight loss, bronchial breathing at the right apex and signs of superior vena cava obstruction. A chest radiograph (Figure 1) and contrast enhanced CT (Figure 2) are shown. What is the likely diagnosis?

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

Teaching Cases from the Royal Marsden and St Mary's Hospitals: Case 18: Severe Anaemia and Thrombocytopenia with Red Cell Fragmentation

A 69 year old male presented with a four week history of exertional dyspnoea and easy fatiguability with two weeks of a flu like illness with productive cough. He was pale with petechial haemorrhages on his ankles and torso. Chest examination revealed crepitations in the right axillary region and bronchial breathing in both the lower and mid zones. There was no hepatosplenomegaly. He was apyrexial and had no neurological abnormalities. Results of biochemical tests were: serum creatinine 77 mol/l, sodium 134 mmols/l, potassium 3.8 mmols/l, LDH 917 U/l (normal range 150-450 U/l), bilirubin 14 mol/l. The results of a full blood count were WBC 7.1 X 109/1, Hb 4.0 g/d1, MCV 91fl, platelets 44 × 109/1 and reticulocyte count 37 X 10/1. The blood film confirmed the thrombocytopaenia and showed red cell fragments, acanthocytes and other poikilocytes (Fig. 1).

Acute lower respiratory tract infections in children in Kuwait.

The features of community-acquired acute lower respiratory tract infections in 390 children are described. Half (50%) presented with bronchiolitis, 37% with pneumonia and 13% with croup. Respiratory syncytial virus was the commonest agent identified (52% of bronchiolitis, 29% of pneumonia, 51% of croup). Positive bacterial blood cultures were obtained in 10% of the patients, all except one with pneumonia. Fever (> 39 degrees C), a toxic ill look, bronchial breathing, WCC > 20 x 10(9)/l, neutrophils > 5 x 10(9)/l, platelet count > 500 x 10(9)/l, ESR > 45 mm/hr, lobar consolidation and pleural effusion were more likely to be associated with bacterial than with viral pneumonia (relative risk > 1.81; p < 0.05). In areas with limited resources, a high fever, a toxic ill look, bronchial breathing and simple laboratory tests may help to identify patients with bacterial pneumonia.

Acoustic properties of the normal chest.

Laënnec invented the stethoscope in 1816 and published a treatise on auscultation in 1819. We then had to wait until the 1950s to observe development of modern devices and methods of recording and signal-processing, which allowed objective studies of lung sounds in time and frequency fields. Tracheobronchial sounds generated by ventilation originate in the upper airways, the frequency content of these sounds has led to extensive research. Consolidated lungs act as more efficient sound conductors to the chest wall (bronchial breathing murmur). Tracheobronchial sounds contain higher frequency components compared to vesicular lung sounds. The origin of vesicular lung sounds has been becoming progressively clear for about 10 yrs. It is at least partly produced locally, deep, and probably intralobular. Clearly, further studies need to be performed in order to elucidate the true mechanisms involved in generating vesicular lung sounds, the redistribution of intrapulmonary gas or vibrations caused by the stretching of lung tissue. The devices developed are already useful for monitoring the state of patients in intensive care. Sooner or later, real time analysis and automated diagnosis will become available.

Respiratory tuberculosis in childhood

During a 16-month period children presenting to a pediatric outpatient facility from an area with a high tuberculosis incidence (> 400/100,000) and suspected of having respiratory tuberculosis (TB) were evaluated for close contact with adult pulmonary tuberculosis, weight loss, symptom duration, respiratory signs, lymphadenopathy and hepatosplenomegaly and by chest radiography and tuberculin testing (Mantoux or tine). Probable tuberculosis was diagnosed in 258 children and was confirmed in 109 (42%) patients with a mean age of 31 months by culture of Mycobacterium tuberculosis from gastric aspirate or another source. Eleven children with confirmed TB had a normal chest radiograph. After review of special investigations, clinical course and follow-up of the remaining 149 children, 86 children (58%) with a mean age of 32.4 months were considered to have probable TB and 63 (42%) with a mean age of 27 months not to have TB. Significantly fewer children in the "not TB" group than in the confirmed and probable TB groups had a close adult pulmonary tuberculosis contact (13 (21%) and 95 (49%), respectively; P < 0.01). There was no difference between the "not TB" group and the confirmed and probable TB groups in the proportion presenting with weight loss, cough or other respiratory symptoms, a symptom duration > 2 weeks, the presence of bronchial breathing, wheeze, hepatomegaly or splenomegaly or peripheral lymphadenopathy. Final diagnoses in the "not TB" group included bacterial or viral pneumonia or bronchopneumonia in 37, asthma often accompanied by segmental collapse in 9 and cavitating pneumonia in 3 children.(ABSTRACT TRUNCATED AT 250 WORDS)

Clinical signs and risk factors associated with pneumonia in children admitted to Goroka Hospital, Papua New Guinea.

This study examined the clinical signs and symptoms in 897 children aged under 5 years presenting with pneumonia to Goroka Hospital in the highlands of Papua New Guinea between June 1982 and July 1985. The usefulness of the signs in predicting severity of disease was determined and risk factors for severe disease were identified. While cyanosis and poor feeding were the strongest predictors of death, bronchial breathing, grunting, and nasal flaring also significantly increased the risk of dying. First-born children, children under 1 year of age, females, malnourished children, and children with symptoms for more than 7 days were at increased risk of severe disease and of dying. Fever alone did not increase the risk of dying unless it was present for more than 7 days. These clinical signs of severity and risk factors may be used to improve the efficiency of health education programmes, for both health workers and mothers, aimed at reducing childhood mortality from pneumonia.

Rene Laennec: his brilliant life and tragic early death.

1. Laennec's lung disease lasted for at least 20 years. Its stigmata included chronic cough, sputum production and intermittent wheeze. 2. Laennec had long term stigmata commonly associated with chronic bronchiectasis, sinusitis, physical frailty, and short stature (5ft 2in). 3. Chronic diarrhoea of at least 20 years duration is not strongly associated with tuberculosis. 4. During Laennec's last illness his physicians equivocated as to whether he had respiratory disease at all. Bronchial breathing at the apex, if indeed present, could have been caused by compensatory emphysema secondary to middle lobe bronchiectasis rather than to active tuberculosis. 5. Laennec did not have haemoptysis in his final illness. 6. Laennec's last illness, a wasting illness characterised by intermittent fevers, cardiac murmur, and persistent tachycardia followed a dental manipulation. The painful "abdominal abscess" noted by Laennec's colleagues may actually have been splenomegaly. These features suggest endocarditis. The cardiac murmurs associated with pulmonary hypertension secondary to bronchiectasis are not usually audible at a remote distance from the patient. Endocarditis was a disease largely unknown to physicians of the early 19th century before Osler clarified its pathology in the 1880s.

Understanding Lung Sounds

How long has it been since you have heard bronchial breath sounds over the chest of a patient with pneumonia? How long since you have heard amphoric breath sounds, late inspiratory crackles, monophonic wheezes, inspiratory and expiratory squawks, and egobronchophony? Well, here is your chance to hear them. Steven Lehrer's cassette tape has these as well as a lot of the other sounds that sick lungs make. And if for some mysterious acoustical reasons, best known to himself, Dr Lehrer recommends listening to the tape through a stethoscope while holding its bell 2 to 3 in from the speaker of the tape player, I shall not gainsay him. Accompanying his cassette tape, Dr Lehrer's paperback gives a bird's eye view of contemporary pulmonology. He discusses, for example, both normal and abnormal breath sounds. Turbulent air flow in lobar and segmental bronchi produces the normal breath sounds. In the alveoli, he

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

Cardiopulmonary function and morphologic changes in beagle dogs after multiple lung lavages.

This study evaluated the long-term biomedical risks risks of multiple, massive saline lung lavage using dogs. Risks were assessed using clinical examinations of cardiopulmonary function, thoracic radiographs, auscultation of the chest, body temperature, and hematologic values. Thirty-six dogs given 10 lavages over a 49-day period had no gross lesions at time of necropsy 7 days after the last lavage. Six dogs, followed with clinical examinations after each of 10 lung lavages, had no detectable effects from the lavage except for elevated body temperature and bronchial breathing at 24 hr after some procedures. No gross lesions were found at sacrifice 28 days after the last lavage. The only histologic lesions found were those also found in unlavaged control dogs. Six dogs that were lavaged 10 or more times had normal pulmonary function values for 4 yr after the last lung lavage. No chronic sequelae were found in healthy beagle dogs given 10 or more lung lavages suggesting a minimal long-term risk associated with these procedures.

Cardiopulmonary Function and Morphologic Changes in Beagle Dogs after Multiple Lung Lavages

Abstract This study evaluated the long-term biomedical risks of multiple, massive saline lung lavage using dogs. Risks were assessed using clinical examinations of cardiopulmonary function, thoracic radiographs, auscultation of the chest, body temperature, and hematologic values. Thirty-six dogs given 10 lavages over a 49-day period had no gross lesions at time of necropsy 7 days after the last lavage. Six dogs, followed with clinical examinations after each of 10 lung lavages, had no detectable effects from the lavage except for elevated body temperature and bronchial breathing at 24 hr after some procedures. No gross lesions were found at sacrifice 28 days after toe last lavage. The only histologic lesions found were those also found in unlavaged control dogs. Six dogs that were lavaged 10 or more times had normal pulmonary function values for 4 yr after the last lung lavage. No chronic sequelae were found in healthy beagle dogs given 10 or more lung lavages suggesting a minimal long-term risk associated with these procedures.

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