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Identifying COPD by Crackle Characteristics BMJ Open Resp Res: first published as 10.1136/bmjresp-2020-000852 on 5 March 2021. Downloaded from Respiratory epidemiology Inspiratory crackles—early and late— revisited: identifying COPD by crackle characteristics Hasse Melbye ,1 Juan Carlos Aviles Solis,1 Cristina Jácome,2 Hans Pasterkamp3 To cite: Melbye H, Aviles ABSTRACT Key messages Solis JC, Jácome C, et al. Background The significance of pulmonary crackles, Inspiratory crackles— by their timing during inspiration, was described by Nath early and late—revisited: and Capel in 1974, with early crackles associated with What is the key question? identifying COPD by bronchial obstruction and late crackles with restrictive ► In the diagnosis of chronic obstructive pulmonary crackle characteristics. defects. Crackles are also described as ‘fine’ or disease (COPD), is it more useful to focus on the tim- BMJ Open Resp Res ‘coarse’. We aimed to evaluate the usefulness of crackle ing of crackles than on the crackle type? 2021;8:e000852. doi:10.1136/ bmjresp-2020-000852 characteristics in the diagnosis of chronic obstructive What is the bottom line? pulmonary disease (COPD). ► Pulmonary crackles are divided into two types, ‘fine’ Methods In a population-based study, lung sounds Received 2 December 2020 and ‘coarse’ and coarse inspiratory crackles are re- Revised 2 February 2021 were recorded at six auscultation sites and classified in garded to be typical of COPD. In bronchial obstruc- Accepted 5 February 2021 participants aged 40 years or older. Inspiratory crackles tion crackles tend to appear early in inspiration, and were classified as ‘early’ or ‘late and into the types’ this characteristic of the crackle might be easier for ‘coarse’ and ‘fine’ by two observers. A diagnosis of COPD a listener to recognise than the crackle type. was based on respiratory symptoms and forced expiratory volume in 1 s/forced inspiratory vital capacity below Why read on? lower limit of normal, based on Global Lung Function ► The study shows that crackles identified as ‘early’ copyright. Initiative 2012 reference. Associations between crackle are more strongly associated with COPD than crack- characteristics and COPD were analysed by logistic les identified as ‘coarse’. The timing of crackles is regression. Kappa statistics was applied for evaluating easier to identify than the crackle type. interobserver agreement. Results Of 3684 subjects included in the analysis, 52.9% were female, 50.1% were ≥65 years and 204 (5.5%) opening of airways.2 Since the inflation of had COPD. Basal inspiratory crackles were heard in 306 the lungs happens sequentially, and the basal http://bmjopenrespres.bmj.com/ participants by observer 1 and in 323 by observer 2. When parts inflate later during inspiration than the heard bilaterally COPD could be predicted with ORs of 2.59 central parts,3 crackles may be described by (95% CI 1.36 to 4.91) and 3.20 (95% CI 1.71 to 5.98), time of appearance. Few years after Forgacs annotated by observer 1 and 2, respectively, adjusted © Author(s) (or their for sex and age. If bilateral crackles were coarse the published his findings, Nath and Capel employer(s)) 2021. Re- use corresponding ORs were 2.65 (95% CI 1.28 to 5.49) and observed clear differences in the timing of permitted under CC BY- NC. No 3.67 (95% CI 1.58 to 8.52) and when heard early during crackles between patients with bronchial commercial re- use. See rights and permissions. Published by inspiration the ORs were 6.88 (95% CI 2.59 to 18.29) and obstruction, in whom early crackles usually BMJ. 7.63 (95%CI 3.73 to 15.62). The positive predictive value were heard, and patients with restrictive lung 4 1General Practice Research for COPD was 23% when early crackles were heard over defects, who had late crackles. This differ- Unit, Department of one or both lungs. We observed higher kappa values when ence could be explained by the site of airway Community Medicine, Faculty classifying timing than type. closure, that is, central airways in obstructive on September 29, 2021 by guest. Protected Conclusions ‘Early’ inspiratory crackles predicted of Health Sciences, UIT The and peripheral airways in restrictive defects. Arctic University of Tromsø, COPD more strongly than ‘coarse’ inspiratory crackles. Tromso, Norway Identification of early crackles at the lung bases should Although Nath and Capel proposed that 2Center for Health Technology imply a strong attention to the possibility of COPD. the timing of crackles could be clinically and Services Research helpful, which was also supported by Piirilä et (CINTESIS), University of al,1 recent guidelines for diagnosing COPD5 Porto Faculty of Medicine, and heart failure6 do not mention the distinc- Porto, Portugal 3Department of Pediatrics and INTRODUCTION tion between early and late crackles. Instead, Child Health, University of Crackles are respiratory sounds often heard another subdivision based on crackle char- Manitoba Faculty of Medicine, in chronic obstructive pulmonary disease acteristics is frequently referred to, namely Winnipeg, Manitoba, Canada (COPD) as well as in restrictive conditions, ‘coarse’ versus ‘fine’. These crackle types such as heart failure, lung fibrosis and pneu- are defined by the duration of each single Correspondence to 1 1 Professor Hasse Melbye; monia. Forgacs proposed that crackles heard crackle. Coarse crackles may be caused hasse. melbye@ uit. no during inspiration were related to sudden by sudden opening of obstructed central Melbye H, et al. BMJ Open Resp Res 2021;8:e000852. doi:10.1136/bmjresp-2020-000852 1 BMJ Open Resp Res: first published as 10.1136/bmjresp-2020-000852 on 5 March 2021. Downloaded from Open access bronchii, while fine crackles are related to opening of Data collection distal airways.1 7–9 Coarse and early crackles are related Information on participants’ diseases and smoking habits to each other, since coarse crackles tend to appear early was retrieved from self-administered questionnaires, and during inspiration9 and both coarse and early crackles are daily smoking was categorised as never, former or current. commonly heard in obstructive lung diseases.1 7 The clin- The participants answered the question ‘Do you cough ical usefulness of differentiating coarse from fine crackles about daily for some periods of the year’. At the second has however been questioned due to low agreement visit, the participants answered the modified Medical between clinicians in identifying these crackle charac- Research Council questionnaire (mMRC) on dyspnoea.13 teristics.10 Yet these conclusions have been mainly based Spirometry was performed using SensorMedics Vmax on small datasets, and we hypothesise that the distinction 20c Encore (VIASYS Healthcare Respiratory Technol- between ‘early’ and ‘late’ will generate higher agreement ogies, Yorba Linda, California, USA). Calibration was and possibly also be more useful in clinical practice. done daily. We followed the standards of the American In the seventh Tromsø study (2015–2016), lung sound Thoracic Society/European Respiratory Society (ERS).14 recordings from six chest locations were classified in Tests with FEV1 <0.3 L or with expiration lasting less than more than 4000 participants,11 and the presence of COPD 3 s were regarded invalid. Postbronchodilator measure- could be evaluated in most of these. The possible role of ment was not carried out, the procedure was deemed too crackle characteristics (early/late and coarse/fine) when cumbersome to be included in this comprehensive survey. identifying obstructive lung conditions could now be We used the Global Lung Function Initiative (2012) as a re- evaluated in a non- selected general population. reference with the fifth percentile among healthy never The aim of this study was therefore to assess the diag- smokers as lower limit of normal (LLN).15 Participants nostic value of early vs late, and coarse vs fine inspiratory were advised to take their medications for asthma and crackles heard at the lung bases, for the identification COPD as usual. of COPD. Further, we wanted to evaluate the agree- Lung sounds were recorded at six locations of the ment between clinicians in identifying these crackle chest,11 15 s at each site, with a Sennheiser microphone characteristics. MKE2- EW inserted in the tube of a Littmann Classic II stethoscope and using a Sennheiser wireless system EW112- PG3- G (Sennheiser electronic, Wedemark, METHODS copyright. Germany). The presence of crackles during inspiration Study population and expiration was determined by two observers (physi- The Tromsø study was established in 1974, and seven iter- cians) who, using high-quality head- sets, independently ations of the study have been carried out, with the last classified the recordings, blinded for other informa- health survey performed between May 2015 and October tion.11 When the observers disagreed, they discussed 2016. Main features of the methodology and study design the respective recordings with a third more experi- have been previously described.12 All Tromsø residents enced observer (HM). The recordings judged to contain http://bmjopenrespres.bmj.com/ 40 years and older (n=32 591) received an invitation by crackles (certainly or likely), were evaluated in a second mail to participate in the first visit of Tromsø 7. A random round, again independently by two observers, one of the sample was selected for a second visit including 20% of observers of the first round (JCAS, physician with no those aged 40–59 years and 60% of those aged 60–84 specialty, observer (1) and one experienced lung sound years, and those who attended the first visit were invited. researcher (HP, paediatric pulmonologist, observer Thus, in this cross-sectional study, our sample consists of (2). In the second round the crackles were categorised randomly selected participants attending the second visit as ‘certain’, ‘uncertain’ and ‘not present’. The certain of the seventh survey of the Tromsø study (Tromsø 7). crackles were subclassified as ‘coarse’ or ‘fine’ and as ‘early’, ‘late’ or ‘both early and late’.
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