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tion in the text. The editors used art spar- material. I found that the book is supportive style of a traditional textbook. The reader ingly and wisely, where needed; for of the current National Institutes of Health can pause and formulate his or her own an- example, flow volume tracings and other recommendations for treating acute respira- swers before proceeding to the text’s an- graphics to illustrate pulmonary functions. tory distress syndrome. I was also encour- swers. In practice it is easy to disseminate The illustrations will greatly enhance the aged to see a discussion on multiple-organ the required information, which adds to this reader’s understanding, and there are excel- dysfunction syndrome, as well as informa- text’s utility as a reference. The design of lent illustrations in many chapters, such as tion on risk factors, morbidity, and mortal- the text stimulates the evaluation of a prob- the chapters “Mediastinoscopy” and “Gen- ity. Another nice facet of this book is its lem and the formulation of creative, effec- eral Approaches to Interstitial Dis- discussions of current controversies in acute tive solutions for patient care. Teaching crit- ease.” The radiographs and computed to- respiratory distress syndrome management. ical thinking in this way creates better mography images, though not abundant, In the section on mechanical ventilation clinicians, which benefits our patients. adequately demonstrate specific and impor- there is an informative discussion on the Overall, Pulmonary/Respiratory Ther- tant clinical findings. Image quality is im- basics of mechanical ventilation, as well as apy Secrets is informative, enlightening, portant to illustrate points effectively, and I an interesting discussion on the mechanisms and interesting. I integrated the book’s in- found the images to be of high quality and of permissive . In the section formation into my daily routines and found easy to view. The references are complete titled “Alternative Invasive Ventilatory it to be a convenient reference. Of particular and current for each chapter. The table of Strategies,” I found some unusual ideas that note is the union of older interesting ideas contents is clearly organized and the index I have not heard much about in recent years, with exciting new ones. The text is not an is comprehensive. including thoracic gas insufflation, inverse instructional work, but rather a resource for The organization of the subject matter ratio ventilation, proportional-assist ventila- clinicians seeking answers to questions departs from the traditional division of man- tion, and partial liquid ventilation. Though about management, pathophysiology, and agement and pathophysiology. Disease pro- these ventilation methods are fraught with the theories behind what we do. I found the cesses are presented categorically and in- pitfalls, they are also thought-provoking al- format refreshing and supportive of our roles clude comprehensive corresponding ternatives for those times when we need to as investigators in the clinical setting. chapters on treatment. This approach works pull a proverbial “rabbit out of our hat.” nicely, as the reader can move quickly from Pulmonary/Respiratory Therapy Se- Fred M Goglia RRT readings on respiratory failure to ventila- crets covers a comprehensive list of topics Respiratory Care Program tory strategies and weaning. An example is in pulmonary medicine. In addition to the Seattle Central Community College the section “Airway Disease,” in which the topics in critical care and mechanical ven- Seattle, Washington chapters flow from and chronic ob- tilation, an entire section is devoted to in- Understanding Lung Sounds, third edi- structive pulmonary disease to oxygen ther- fectious processes, and the list of infectious tion. Steven Lehrer MD. Philadelphia: WB apy and smoking cessation. processes is impressive. This section re- Saunders. 2002. Soft cover, illustrated, 145 The book’s ease of use and convenient mains true to the rest of the text in that each pages plus audio CD (operates with Win- size create a text that is valuable in the clin- chapter is current and contains valuable, up dows or Macintosh operating systems), $49. ical as well as didactic setting. The versa- to date, and interesting information for the tility of the text and the wide variety of clinician. The chapters revolve around the Listening is a magnetic and strange thing, a subject matter make this a good reference current standards of practice but they also creative force. The friends [and caregivers] for frequent use in various patient care set- open up some interesting debates. One nice who listen to us are the ones we move to- tings. An entire chapter devoted to proce- example is the controversy over tracheal as- ward. When we are listened to, it creates us, dures in pulmonary medicine adds a lot of pirate versus bronchoalveolar lavage, dis- makes us unfold and expand. utility to the reference as a whole. The au- cussed in the section on nosocomial pneu- —Karl Menninger MD thors provide instructions for and clarify monia. Though the gamut of pulmonary many points about specific procedures such infections receives a lot of attention in the Understanding Lung Sounds is de- as bronchoscopy, and they address ques- section on infectious disease, it’snicetosee signed to provide background on chest aus- tions such as “What are the indications for an informative chapter on pre- cultation and interpretation skills to medical bronchoalveolar lavage?” and “What are vention. There is also extensive reference to and allied health students and practitioners. palliative bronchoscopic therapies?” Posing lung cancer, vascular disease, interstitial dis- The book is divided into 5 chapters, the first these questions with succinct and current ease, and other topics too numerous to list three of which comprise half of the 124 answers offers respiratory therapists a better here. For each disease category the book pages of the text; these 3 chapters review understanding of the procedures we see ev- provides pertinent information on diagno- (1) fundamentals of pulmonary anatomy and ery day and aids residents when asked for a sis, radiographic and clinical presentation, physiology, (2) the physics of sound, hear- consult. and treatment. ing, and the , and (3) history and A critical care reference must contain The question-and-answer format teaches . The final 2 chapters sound advice, and this text uses current stan- practitioners to ask the right questions about provide detailed discussion on normal and dards of evidence-based practice. With all patient care—one of the primary goals of adventitious breath sounds. The accompa- the current excitement surrounding acute re- thetext.Thisisanicealternativetothe nying audio compact disc contains 22 tracks spiratory distress syndrome in critical care, standard textbook format. The arrangement of lung sounds described in the text, as well naturally this was the first section I read, of questions allows the introduction of new as 6 tracks to test the listener’s skills. At the considering the contemporary nature of the concepts and text without the cumbersome end of each chapter a series of questions

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review the content, and several of the ques- tation by Victor McKusick and David ures that further describe the types and rel- tions are of the critical-thinking type. The Cugell, discussing phonopneumograms ative incidence of in diagnosis. chapters are referenced and there is a bib- from the standpoint of teaching receive similar treatment. How- liography, a section with the answers to skills. That research led to techniques such ever, the author makes no distinction be- chapter questions, a glossary, and an index. as time-expanded waveform analysis, later tween (and there is little discussion about) Chapter 1 begins with a very brief over- promoted by Raymond Murphy, in which high-pitched (sibilant rhonchus) and view of pulmonary anatomy and physiol- adventitious sounds are stored by a com- low-pitched wheeze (sonorous rhonchus). ogy and concludes with a section on pul- puter and replayed slowly. The chapter The section on wheezing does not seem to monary disorders, including paragraphs on briefly discusses subtraction and automated have as much review of potentially associ- atelectasis, emphysema, consolidation, phonopneumography, which has been em- ated pathologies as does the section on crack- , and pleural fluid problems. ployed by Dennis O’Donnell and Steve Kra- les. This chapter includes a paragraph on Although the content in this section is ex- man. These techniques involve multiple re- and hoarseness, with a review of pos- tremely basic, readers without this funda- cordings of lung sounds made from various sible causes of each. The section on adven- mental information would probably not be locations on the chest wall and have re- titious sounds concludes with brief discus- able to connect the pathologies to specific vealed the areas of loudest sound transmis- sions on , mediastinal lung sounds. sion and the relative nonuniformity of sound crunch, bronchial leak squeak, and the in- Chapter 2 provides an introduction to the intensity across the chest. Information on spiratory . There is a brief review of basic physics of sound, describing the char- the latest computer-based technologies can abnormally transmitted voice sounds. The acteristics of frequency, intensity, duration, be found in other articles on these topics.2,3 chapter ends with a short discussion on aus- and timber (or quality). The text reviews the The chapter in Understanding Lung cultation methods to quantitate loudness of capabilities of normal human hearing; the Sounds concludes with a short discussion breath sounds in the context of abnormally various ranges of musical instruments are of dual chest-mounted and low and/or declining forced expiratory vol- used in this discussion, as well as sound stethoscopes inserted into the cir- ume in the first second (FEV1) associated levels of breath sounds. Of interest is that cuit during anesthesia to detect tracheal ver- with emphysema and chronic obstructive most breath sounds fall into the range (be- sus esophageal intubation. pulmonary disease. What I did miss in this low 500 Hz) in which the human ear is least Chapter 5 covers adventitious sounds and book was a summary table of all types of sensitive. The author provides a brief but abnormal voice sounds. The text first deals adventitious sounds, summarizing mecha- fascinating history of lung sounds in an- with the troubling issue of terminology. In nism, sound origin, acoustic pattern, and cient medical practice, including the contri- the days of Lae¨nnec this topic became a clinical relevance. Such tables have been bution of Rene´ The´ophile Lae¨nnec. The problem, and continues to be. Lae¨nnec orig- developed in other publications.2,9 chapter concludes with a “nuts and bolts” inally used the word raˆle (Latin for “rattle”) The audio CD is a combination of nar- discussion of the types and components of generically for all sounds. To add detail for ration and breath sounds. Beginning students stethoscopes, including which sounds are the various lung-sound characteristics, he of chest auscultation will find the narrative best heard with the bell versus the dia- applied adjectives, describing a “sounds- quite helpful to keep the sounds in context. phragm. like” approach. For example, Lae¨nnec cre- The narrator makes connections between Chapter 3 reviews the basics of history atively described types of rhonchus (Greek sounds, their physical causes, and the asso- and physical assessment, including inspec- for “snore”) as sounding like cooing pigeons, ciated pathologies. The script of the narra- tion, , and . Again, al- croaking frogs, or (“raˆle sec sonore tion is printed in the accompanying booklet though this information is rudimentary, ou ronflement”), because of the foreboding in the CD’s case. That booklet includes some without this background the book’s discus- connotation of raˆle for the . Con- material not covered in the book, such as sion on connecting lung-sounds to disease fusion about these terms continues today amphoric (cavernous) breath sounds. It also entities would be incomplete. and has been the source of much research helps with the use of the confusing term The book’s major topics are covered in and editorializing.4–7 In the mid-1970s the rhonchus. The final 6 sounds on the CD are Chapters 4 and 5. Chapter 4 provides in- American College of Chest Physicians and for listener skill-testing, and there is imme- struction in chest auscultation and discusses in 1980 the American Thoracic Society tried diate feedback. normal breath sounds. A table early in Chap- to clarify the muddy waters by categorizing The recordings are of high quality and ter 4 relates alterations in normal breath 3 sounds: crackle, wheeze, and rhonchus.8,9 are repeated enough to provide instruction sounds with the major pulmonary disorders, The British, however, later simplified the without inflicting boredom. Using the CD describing expected alterations in inspec- terminology to crackle (course and fine) and requires that your computer have a sound tion, palpation, and percussion. The chapter wheeze (high-pitched and low-pitched); card and separate speakers. Computers run- concludes with sections that provide inter- wheeze includes rhonchus. In Understand- ning Windows operating systems require esting reading on details such as breath ing Lung Sounds Steven Lehrer uses the Windows 95 or higher, the central process- sounds variations based on location/region British terminology approach. ing unit must operate at at least 166 mega- of the chest wall, heartbeat, and in children. The author carefully describes the sound hertz, and the system must have Ն 8 mega- (Readers with further interest might enjoy characteristics and presumed acoustic causes bytes of random access memory. Robert Loudon and Raymond Murphy’s of crackles (both fine and coarse) and then Overall, Understanding Lung Sounds classic “state of the art” article on lung describes the disorders normally associated is a wonderful aid for learning the basics of sounds.1) The chapter then reviews more with these adventitious sounds. He provides auscultation. The combination of a compact recent technical advances of chest auscul- a table that summarizes findings, and fig- textbook and audio CD makes effective use

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of both media. The level of the material 5. Pasterkamp H Montgomery M, Wiebick W. also devoted to more difficult clinical prob- appears to be targeted to physicians, nurses, Nomenclature used by health care profes- lems, such as wheezing in infants, sleep ap- and respiratory therapists who are in the sionals to describe breath sounds in asthma. nea, severe asthma, and asthma in preg- beginning of their education about physical Chest 1987;92(2):346–352. nancy, as well as chapters on the use of examination or who desire a refresher. The 6. Craige E. Should auscultation be rehabili- medications, such as antihistamines, tated? N Engl J Med 1988;318(24):1611– CD allows easy playback of any specific corticosteroids, leukotriene antagonists, cro- 1613. sound, in contrast to audio tapes, which are 7. Ward JJ. Lung sounds: easy to hear, hard molyn, theophylline, and delivery devices difficult to cue up to the right spot. to describe (editorial). Respir Care 1989; for inhaled medications. One editorial def- On the Internet there are some free lung 34(1):17–19. icit of the book is that the treatment of cer- sounds sites, but few sites provide back- 8. Report of the ATS-ACCP ad hoc subcom- tain subjects is divided and separated; for ground equivalent to Dr Lehrer’s text. There mittee on pulmonary nomenclature. Amer- example, the allergic rhinitis chapter and are Web sites that for a subscription fee ican Thoracic Society News 1977;3:5–6. nonallergic rhinitis chapter are 9 chapters provide color graphic analyses along with 9. Murphy RHL Jr, Holford SK. Basics of apart. The asthma chapter and the severe the sounds, but they cannot compare to the RD: Lung sounds. Respir Care 1980;25(7): asthma chapter are 5 chapters apart. The modest ($49) price of Understanding Lung 763–764,766–770. asthma chapter and the asthma medication Sounds, which I would recommend to any Patterson’s Allergic Diseases, 6th edition. chapter are 11 chapters apart. Still, this is educational program or hospital, medical, Leslie C Grammer MD and Paul A Green- only a slight inconvenience, as the index is or department library. My only concerns re- berger MD, editors. Philadelphia: Lippin- complete. late to the author’s use of British descriptive cott Williams & Wilkins. 2002. Hard cover, The clinical topics were well chosen, and terminology—specifically, the omission of illustrated, 830 pages, $125. I found it extremely difficult to think of a the controversial term rhonchus, as that term question that would arise in an allergy prac- does appear on some American board ex- As a practicing allergist, I am always tice that is not addressed in this text. The ams. However, the CD does include a lovely looking for an up-to-date summary of the chapters are loosely arranged into sections rhonchus sound and it is described as “so- latest developments in the diagnosis and of epidemiology, pathophysiology, clinical norous rhonchus” as well as “low-pitched management of allergic conditions. After manifestations, laboratory diagnosis, and wheeze.” thrashing the binding of the fifth edition of treatment. There is some variability in the A summary table of all adventitious this series from heavy use during fellow- depth and order of these sections, which sounds and their associated pathologies ship training, I was pleased to see this sixth affects chapter length. For example, the ur- would be helpful for both the text and the edition released. The sixth edition is named ticaria and allergic rhinitis chapters have 1–2 pamphlet accompanying the CD. for the late Roy Patterson, who was the pages devoted to pathophysiology, whereas Over the years it seems that the overall Ernest S Bazley Professor of Medicine and the asthma chapter has 6 pages devoted to value of chest auscultation has taken a back the Chief of the Division of Allergy-Immu- pathophysiology. The asthma chapter has seat to chest radiography and other imaging nology at Northwestern University Medical an additional 6 pages on the classification techniques, but auscultation is a time-hon- School. of asthma. As a result of the variability in ored bedside technique that can provide im- The book has an attractive black hard section depth, the asthma chapter and drug mediate, cognitive, and sometimes life-sav- cover, with a solid binding and good-qual- allergy chapter are each roughly 70 pages ing information at low cost. As we listen to ity paper. The typeset is easy to read and the long, which will be helpful for a specialist their bodies it can bring us closer to our text in this edition is arranged in narrower, or interested provider but might be chal- patients. easier-to-read columns, which is a marked lenging for a busy nonspecialist trying to obtain quick guidance during a busy clinic Jeffrey J Ward MEd RRT improvement from the fifth edition. Tables day. A more uniform chapter structure and Program in Respiratory Care are well utilized and the black-and-white a “key points” section (which was present University of Minnesota/Mayo Clinic photographs of pollen and radiographs are in the fifth edition) might be helpful to limit Rochester, Minnesota clear. There are very few typographical er- rors. repetition and shorten chapter length. The goal of the sixth edition is the same: The asthma chapter begins with the ep- to provide a current summary of the diag- idemiology and pathophysiology of asthma. REFERENCES nosis and management of nearly every al- A clinical overview section presents infor- 1. Loudon R, Murphy RL Jr. Lung sounds. lergic condition encountered in a typical al- mation on history, physical examination, Am Rev Respir Dis 1984;130(4):663–673. lergy practice. It addresses the common pulmonary function tests, radiologic find- 2. Pasterkamp H, Kraman SS, Wodicka GR. traditional topics of asthma, allergic rhini- ings, and complications. A 6-page classifi- . Advances beyond the tis, sinus disease, food allergy, anaphylaxis, cation section presents the differences be- stethoscope. Am J Respir Crit Care Med drug allergy, latex allergy, urticaria, angio- tween allergic asthma and other types of 1997;156(3 Pt 1):974–987 , contact dermatitis, and atopic der- asthma. A detailed pharmacology section is 3. Kompis M, Pasterkamp H, Wodicka GR. matitis. In addition it has chapters on less followed by a clinical management section, Acoustic imaging of the human chest. Chest 2001;120(4):1309–1321. common conditions such as immunodefi- which presents an approach to managing 4. Wilkins RL, Dexter JR, Smith MP, Mar- ciency, hypersensitivity pneumonitis, aller- exacerbations, status asthmaticus, and re- shak AB. Lung-sound terminology used by gic bronchopulmonary aspergillosis, occu- spiratory failure. The recommendations are respiratory care practitioners. Respir Care pational lung disease, Stevens-Johnson well supported and well referenced; there 1989;34(1):36–41. syndrome, and eosinophilia. Chapters are are over 300 cited references, though many

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