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Inspiratory Crackles-Early and Late Thorax: first published as 10.1136/thx.29.2.223 on 1 March 1974. Downloaded from Thorax (1974), 29, 223. Inspiratory crackles-early and late A. R. NATH and L. H. CAPEL The London Chest Hospital, Bonner Road, London E2 Nath, A. R. and Capel, L. H. (1974). Thorax, 29, 223-227. Inspiratory crackles early and late. Inspiratory crackles were recorded simultaneously with the inspiratory flow rate in patients with airways obstruction and in those with a restrictive defect. Early inspiratory crackles were associated with severe airways obstruction and late inspiratory crackles with a restrictive defect. Crackles are non-musical lung sounds of short Electronics Type M6) and the output was displayed duration, in the past referred to variously as rales, on a second channel of the recorder. The flow rate moist sounds, and crepitations. They may occur signal at zero flow was superimposed on the sound at any time or From signal. Thus the start and finish of inspiration was during inspiration expiration. marked off by the flow signal as it crossed the souind a preliminary clinical study it was observed that signal (Fig. 1). crackles occurred early in some patients and late in In all patients spirometric tests and radiological others. Is the timing of inspiratory crackles of examination were carried out. clinical and physiological significance? In an attempt to answer this question a recording of copyright. lung sounds in defined groups of patients was com- PATIENTS pared with the and functional Two groups of patients were studied. In the first group clinical, radiological, (Table I) were 56 patients selected because on clinical findings in each case. examination, confirmed by the phonopneumogram, they were found to have inspiratory crackles. These METHODS crackles were classified as early or late: Early http://thorax.bmj.com/ The lung sounds were recorded using a crystal micro- inspiratory crackles appear shortly after the start of phone in an aluminium cup with a suction chamber inspiration and do not continue beyond the first half fixed on the posterior chest wall 5 cm above the of inspiration (Fig. 1). In contrast, late inspiratory costal margin. The output of the microphone was amplified and displayed on one channel of a UV TABLE I recorder (S.E. Type 30006/DL). The sound amplifier FEV,/VC Y. IN PATIENTS WITH EARLY AND LATE INSPIRATORY CRACKLES incorporated a variable high pass filter which permitted (56 patients selected because of inspiratory crackles) low frequency cut-off up to 600 Hz. The frequency response of the microphone, amplifier, and the re- FEV,/VC on September 23, 2021 by guest. Protected Inspiratory No. of Mean cording system was ±1dB from 200 to 2000 Hz. The Crackles Patients % Range SD inspiratory flow rate was simultaneously recorded at Early 24 31 19-39 5*6 the mouth with a Fleisch pneumotachograph con- Late 32 74 58-90 9 5 nected to a differential pressure manometer (Mercury Insp* Exp. 1 sec FIG. 1. Phonopneumogram of early inspiratory crackles. This is a simul- taneous recording of inspiratory crackles and airflow rate. 223 Thorax: first published as 10.1136/thx.29.2.223 on 1 March 1974. Downloaded from 224 A. R. Nath and L. H. Capel crackles continue into the second half of inspiration RESULTS but may start at any time during inspiration In 24 of the 56 patients selected because they were (Figs. 2-4). In the second group were 44 patients selected for found to have inspiratory crackles the crackles study because they showed spirometric evidence of were heard early in inspiration, and in the re- airways obstruction (FEV1/VC ratio less than 75%) maining 32 patients the crackles were heard late and had a clear chest radiograph. These patients were in inspiration. In the 24 patients with early then examined for the presence and timing of crackles inspiratory crackles there was spirometric evi- (Table II). dence of airways obstruction, with a mean Insp. Exp. 1 sec FIG. 2. Phonopneumogram of late inspiratory crackles: inspiratory crackles are seen late in inspiration. Insp. copyright. Exp. http://thorax.bmj.com/ I sec FIG. 3. Phonopneumogram of late inspiratory crackles: inspiratory crackles are seen mid and late in inspiration. on September 23, 2021 by guest. Protected Ensp. I IT 17 I'f_7 Exp. \ I sec FIG. 4. Phonopneumogram of late inspiratory crackles: inspiratory crackles are seen early, mid, and late in inspiration. Thorax: first published as 10.1136/thx.29.2.223 on 1 March 1974. Downloaded from Inspiratory crackles-early and late 225 TABLE II DISCUSSION SEVERITY OF AIRWAYS OBSTRUCTION AND OCCURRENCE OF EARLY INSPIRATORY CRACKLES In the most important study of lung sounds since (44 patients, selected because of spirometric airways obstruction) Laennec, Forgacs (1967) suggested that inspira- FEVJ/VC Early Inspiratory Crackles tory crackles are produced by abrupt opening of closed airways in deflated regions of the lung. (Range) Present Absent He pointed out that the time of opening will 24-44 19 2 (Mean 34) depend upon the development of tensions in sur- 45-74 1 22 rounding lung tissue. Indeed the moment of (Mean 53) occurrence of a crackle was found to be deter- mined by the transpulmonary pressure during inspiration in experimental observations. The difference in timing between the early FEV,/VC of 31%. Of the 32 patients with late crackles of patients with severe airways obstruc- inspiratory crackles, 25 showed no spirometric tion and the late crackles of those with restrictive evidence of airways obstruction and in the remain- lung disorder can be related to the site of airway ing seven patients airways obstruction was mild closure. (FEV,/VC 58-69%). A source in the proximal and larger airways The diagnosis in those found with early inspi- may be suggested for early inspiratory crackles ratory crackles and in those found with late since they are frequently well transmitted to the inspiratory crackles is shown in Table III. Those mouth and few in number (Figs. 1 and 5). Hence with early inspiratory crackles all showed the the occurrence of early inspiratory crackles may characteristic clinical and spirometric findings of mean that some of the larger airways remain obstructive lung disorder. Those with late inspira- closed at the end of preceding expiration. This tory crackles all showed the characteristic clinical, would happen if bronchial compliance were in- radiological, and (except for the seven mentioned around the creased or if the retractive pressures copyright. above) spirometric findings of restrictive lung bronchi were low (Macklem, Fraser and Brown, disorder. 1965). In the subsequent inspiration a small transpulmonary pressure would then be required to pull these airways open. A common feature of restrictive lung disorder TABLE III http://thorax.bmj.com/ CLINICAL DIAGNOSIS AND TIMING OF INSPIRATORY due to fibrosis, infiltration or oedema is that the CRACKLES lung is partially deflated and this predisposes to the closure of peripheral airways. The distribution Early Late of airway closure is gravity dependent. The basal Chronic bronchitis Fibrosing alveolitis Asthma Asbestosis alveoli of a normal lung deflated to residual Emphysema Pneumonia basal Pulmonary congestion of heart failure volume inflate late in inspiration, and these Pulmonary sarcoidosis airways are first to close towards the end of Scleroderma Rheumatoid lung expiration (Dolfuss, Milic-Emili, and Bates, Pulmonary fibrosis unknown cause 1967). Unlike the early inspiratory crackles of air- on September 23, 2021 by guest. Protected ways obstruction, the late inspiratory crackles are usually more profuse, gravity dependent, and only rarely transmitted to the mouth. We suggest that In 20 of the 44 patients selected because of late inspiratory crackles originate in peripheral spirometric evidence of airways obstruction and airways, each crackle representing abrupt opening a clear chest radiograph, early inspiratory crackles of a single airway. The opening pressure de- were heard and confirmed by phonopneumo- veloped later in inspiration is sufficient to produce gram. In these 20 patients with early inspiratory showers of crackles. crackles the FEV,/VC ratio was less than 45% In addition to timing of crackles in inspiration, in all but one. In contrast, in the 24 patients with- further differentiating features between early and out inspiratory crackles, the FEV,/VC ratio was late inspiratory crackles can be readily elicited at more than 45% in all but two (Table II). the bedside (Table IV). Early inspiratory crackles Thus early inspiratory crackles were associated are typically scanty but may be loud or faint. with a low FEV,/VC ratio in two groups of They are heard at one or both lung bases and are patients, one selected by auscultation and the usually well transmitted to the mouth (Fig. 5). An other by spirometry. important feature of these crackles is that they Thorax: first published as 10.1136/thx.29.2.223 on 1 March 1974. Downloaded from 226 A. R. Nath and L. H. Capel TABLE IV are not silenced by cough or change of posture; CLINICAL DISTINCTION BETWEEN EARLY AND LATE this was true of all the 24 patients examined in INSPIRATORY CRACKLES the present study. Crackles associated with secre- tions in the larger airways, on the other hand, are Early Late modified or silenced by coughing, they are present Scanty Profuse Lower zones Lower zones may extend to mid in inspiration and expiration, and occur in random and upper zones Gravity independent Gravity dependent sequence from breath to breath. Early inspiratory Usually transmitted to mouth Rarely transmitted to mouth crackles are associated with severe expiratory Associated with severe airways Associated with restrictive obstruction lung disorder obstruction, although in some patients with em- physema they may not be heard on the chest wall. lnsp. .1 Chest Uk L..'ialILdl --I,.,.,-1- M..&l U - Wall W---T .
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