-----tie special NPOris
International Symposium on Lung Sounds·
Synopsis of Proceedings
Riichiro Mikami, M.D., RC.C.P., Yokohama, Japan,
General Chairman
Makoto Murao, M.D., RC.C.P., Tokyo, Japan,
Moderator
David W Cugell, M.D., RC.C.P.,
Moderator and Recorder
Jacques Chretien, M.D., Paris, France, Presenter
Peter Cole, M.D., London, England, Presentor
J. Meier-Sydow, Frankfurt, Gennany, Presenter
Raymond L. H. Murphy, M.D., RC.C.P.,
Wellesley Hills, MA, Presentor
Robert G. Loudon, M.D., RC.C.P., Cincinnati,
Summarizer
The International Lung Sounds Association consists
of a small, but dedicated group of physicians,
engineers, and physiologists. Despite professional
obscurity and meager financial support, they doggedly
pursue their common interest in thoracic acoustics.
The first of their annual scientific meetings was held in
1976. In keeping with the "International" in its name,
meetings were held in London in 1980 and in Tokyo in
1985. Presentations at these meetings have covered a
wide range of topics-primarily the physical charac-
terization of respiratory sounds, physiologic mecha-
nisms of sound production, clinical significance of
different respiratory sounds, and a terminology or
nomenclature for general use. Despite dramatic prog-
ress in technology and research, there has been only
limited progress in the development of a satisfactory
terminology for both normal and adventitious breath
sounds. Reference to recent textbooks of physical
diagnosis will readily confirm that written descriptions
of what we hear with a stethoscope continue to be an
acoustic "Tower of Babel." In recognition of this prob-
lem, and the additional difficulties that arise when
terms of uncertain meaning are translated from one
language to another; an International Symposium on
Lung Sound Nomenclature was convened in Tokyo by
the Tenth International Lung Sound Conference gen-
eral chairman, Professor Riichiro Mikami.
*Presented by the J~ Lung Sounds Association and The Interna-
tional Lung Sounds Association.
Sponsored by the Japan Medical Association, Tokyo, September 21,
1985.
Reprint requests: Dr. CugeU, Pulmonary, Rm454, 250East Superior
Street, Chicago 60611
342
Oral or written descriptions of what one hears with a
stethoscope require an ability to describe one sensory
experience by analogy to others. Thus, respiratory
sounds are variously described as "wet, coarse,
sonorous," etc. Although similar descriptive terms
have been in general use almost since the invention of
the stethoscope, they convey quite different meanings
to different people. If selected respiratory sounds that
are faithfully recorded are played to an audience of
trained pulmonary physicians, there will be consider-
able disagreement over the use of such basic descrip-
tors as coarse, low pitched, etc. I These semantic
uncertainties increase and become major obstacles to
effective communication when more than one lan-
guage is involved. The current terminology of adven-
titious respiratory sounds originated in the French
language and was incorrectly translated into English. A
German version of the original terminology was trans-
lated into Chinese, and the Chinese characters appro-
priated for use in Japan! It is apparent that an Interna-
tional Conference on Lung Sound Nomenclature was
long overdue.
The electronic revolution in which we are now
immersed together with modern techniques of signal
processing and analysis provide us with the tools for
identifying respiratory sounds on the basis of their
physical characteristics. It is traditional to describe
both respiratory and adventitious breath sounds in
terms of pitch. Since we have the means of determin-
ing the frequency of respiratory sound, should we not
agree upon the frequency bands that constitute what
we call high, low or some other pitch? Crackles, much
preferred to the traditional "rales," as the comments to
follow will amply confirm, can be separated into "fine"
and "coarsen categories from appropriate measure-
ments of their graphic representations. A crackle can
be characterized from such measurements with a pre-
cision that is comparable to defining the width ofa QRS
complex on an electrocardiogram.
The complex, conflicting, and confusing body of
terms that are used to describe respiratory sounds may
be responsible in part for the widespread reluctance to
embrace yet another terminology. Furthermore, there
is no handy "dictionary" to facilitate a translation of
these multiple terms. This obstacle was partly over-
come by a classification of adventitious sounds first
International Symposium on Lung Sounds (Mlkami at 81)
recommended by Robertson and Coope in 1957.I All
adventitious sounds were divided into two major cate-
gories: continuous sounds or wheezes, and discon-
tinuous sounds or crackling noises. This classification
sidestepped the confusion and substituted words that
can be defined in acoustic terms. These two categories
of adventitious sound, and the physical characteristics
of normal and abnormal breath sounds, are the major
focus of this conference.
Dr: Chretien: Rene Laennec not only conceived,
designed, and constructed the first stethoscope, but
also used it to make extensive, systematic clinical
observations. His most comprehensive description of
respiratory sounds is in chapter 6 of his text, "Iraite de
l'Auscultation Mediate", published in Paris in 1826.
Numerous types ofacoustic phenomena are described,
including breath sounds, heart sounds, and extra-
thoracic sounds such as those produced by a liver
abscess, bladder calculus, etc. Laennec separated the
rattling sounds heard over the lungs into five catego-
ries, and they are listed along with an English transla-
tion in Table 1. He used instructive similes to describe
these different sounds. Crepitations were likened to
the sound created by agitating a container of moder-
ately heated salt. Mucous rales were compared to the
sound of soap bubbles produced by a blowpipe, snor-
ing rales to the cooing of a woodpigeon, and sibilant or
wheezing sounds to the sound produced when two
marble plates coated with oil are suddenly separated.
Laennec's original definitions were soon altered. In
other countries, changes could be expected because of
translation problems, but even in France, meanings
gradually changed as attempts were made to subdivide
and add qualifying terms. Furthermore, even in its
country of origin, use of the stethoscope went into
decline in the 19th century as direct auscultation-
putting the ear directly on the chest-became the
norm for a medical examination. There were two major
sources of semantic confusion, and they continue to
the present as follow: (1) use of the terms wet, dry, and
crepitations; and (2) the changing meaning of rhon-
chus. Crepitations are generally considered equivalent
to dry rales, whereas when originally used, crepita-
Table l-Claaijication ofChest "Battles"
Laennecs Original
Description English Thmslation
1. Rile humide ou crepitation Wet rale, crepitation,
or crackle
2. Rile muqueux ou Mucous or gurgling rale
gargouillment
3. Rile sec sonore ou Dry or snoring rale
ronflement
4. Rile sibilant sec ou Dry whistling or
sifllement wheezing rale
5. RAle crepitant sec a grosses Dry crackling rale with
bulles ou craquement large bubbles
tions were equated with wet rales. In Laennec's time,
the word rile or rattle was used to describe the well
known "death rattle" -the stertorous breathing of the
terminally ill who cannot clear upper airway secre-
tions. To avoid frightening his patients, Laennec sub-
stituted the word rhonchus which soon took on another
meaning-low pitched, sonorous sounds only.
Dr: Cole: Confusion about lung sound terminology
originates in part with us in England, I'm ashamed to
say, because in 1831 Forbes, (as reported by Robertson
and Coppe"), incorrectly translated Laennecs terms-
rale and rhonchus-as having different meanings
rather than the same meaning as was orginally in-
tended. In the United Kingdom, we are trying hard to
unify our nomenclature of lung sounds primarily to
simplify student teaching. Many teachers, along with
our students, use rather muddling terms that delay or
interfere with the educational process. Despite our
high national prevalence of chronic bronchitis, there is
poor recognition of the disease. Lung sounds are of
great importance in the detection of airway narrowing,
and therefore, a matter of concern for the health and
welfare of our populace. We use rale, crepitation, and
crackle interchangeably. We believe that crackle is the
most descriptive term to use for these discontinuous
sounds, and we subdivide crackles into fine and coarse.
We use rhonchus and wheeze interchangeably for con-
tinuous adventitious sounds, but tend to call high
pitched continuous noise a wheeze, and a low pitched
continuous one a rhonchus (Table2). There are various
other adventitious sounds-rubs, stridor, squeaks
etc-most of which have not yet been adequately
defined in terms of their acoustic characteristics. Thus,
it seems proper to place these less common sounds in
an "other" category for the time being. Finally, there
are the normal breath sounds. They have been well
characterized, but what they should be called is less
clean Although use of the term, vesicular, is wide-
spread, it is misleading inasmuch as the source of the
sound cannot be within the vesicles because bulk air-
How within the alveoli is much too low to generate any
audible sound.
Dr: Meier-Sydow: The teaching of pulmonary ausculta-
tion in West Germany is, in the German tradition,
quite extensive. Contrary to what has happened in
many established fields, the time devoted to this disci-
pline is increasing, having expanded from 56 hours
prior to the 1970s, to 84 hours at present. This time
does not include bedside experiences during the
"practical" year, equivalent to the "clinical clerkships"
of the United States, and outpatient experience. In
Frankfurt, we use an auditorium equipped with elec-
tronic stethoscopes. Students can hear the same
sounds at the same time while the instructor com-
ments on the patient and the acoustic phenomena. Our
students use physical diagnosis textbooks because few
CHEST I 92 I 2 I AUGUST. 1987 343
 Table I-Lung Sound Nomenclature ira the World

TIme
Japan U.K. Germany U.S. France Expanded Waveform

Discontinuous
Fine
(high pitched,
low amplitude,
ltaft Fine crackles
(= Fine rales/
Feines
Rasseln
Fine
crackles
RAles
crepitants
~~ j
short duration) crepitations)
Coarse
(low pitched, iki£l# Coarse crackles Crobes Coarse lWes bulleux
I~i ~I 'V"~\NJ~i {i\~\rJ\"v,~\I~J
high amplitude, (=Coarse rales/ Rasseln crackles ou
long duration) crepitations) Sous-erepitants J ~~ I

Continuous ~ A. (II)
High pitched
U
II
Wheezes
(= High pitched
wheezes/rhonchi)
Peenen Wheezes lWes sibilants
il~W~i~I\~ \~ /~ ~ WI~ ~J
Low pitched Jl (ttl) Rhonchi Brummen Rhonchus RAles ronflants
1d.~j1Il \; I\~I\!W~\i !\~ IHJW
(=Low pitched Ii' ~ ~ • I I I V •

i Il \~ wheezes/rhonchi)

English Portuguese* Spanisht *Kindly provided by Dr.

Fine crackles Crepitaeoes 6nas Estertores 6nos Abraham B. Bohadana,
Coarse crackles Crepltaeoes grossas Estertores gruesos Faculdade Regional de
Wheezes Sibilos Sibilancias Medicina, Sao Jose do Rio
Rhonchi Roneos Roncus Preto , Sao Paulo, Brazil
and tDr. Rolando Berger
of the University of Ken-
tucky.

internal medicine texts mention pulmonary ausculta-
tion. In addition, we make a conscious effort to present
auscultatory, as well as all physical findings, in a
coordinated, clinically relevant fashion. Emphasis on
simple things such as breath and vocal sounds indicate
parenchymal disease, whereas adventitious sounds
suggest disease in the airways, gives students some
perspective on what they otherwise may perceive as
isolated acoustic phenomena with little clinical signifi-
cance. In Germany, as elsewhere, nomenclature is a
problem. Numerous qualifying and special descriptive
terms are employed to identify adventitious breath
sounds, but they should be abandoned. Common
German expressions are well suited to the nomen-
clature system that I believe we all support (Table 2).
For example, "grossblasige Rasselngerausche," which
roughly translates to big, bubbling rales, is easily
modified by using "grob," an exact translation of
coarse, and abbreviating the entire expression to
"grebes Rasseln" which is identical with coarse
crackles. Substituting "fein" for "klein" plus a similar
abbreviation results in a comparable expression for fine
crackles, "femes Rasseln," Continuous sounds should
be called "Pfeifen" (wheezes) or "Brummen" (rhonchi).
"Schnurren" (snoring or rattling) is no longer used in
our country.
Dr: Mikami: Although we started considerably later
than the French, lung sound research has been under-
way in this country for quite a while. In 1955, Professor
Ebina of the University ofTohoku developed a method
for displaying the acoustic spectrum of breath sounds
on a cathode ray tube. He recorded the spectra on film
and then identified the frequency components
throughout the respiratory cycle. In 1962, Professor
Ueda, with Drs. Hatano and Yanai, published Aus-
cultation of the Lung, a book that was sold with a
phonograph record. The text included illustrations of
frequency spectra and time expanded records, analyti-
cal methods that are still considered quite novel. The
importance of visual representation of pulmonary
sounds was fully appreciated by these authors a gener-
ation ago. In Japan, the nomenclature of breath sounds
and adventitious sounds is based upon German terms,
but with considerable modifications. We use the Japa-
nese word, "raon" which is derived from the German
"Rassel," and it is equivalent to rale or crackle. We also
adopted the usual qualifying terms regarding pitch,
whether moist or dry, coarse, medium or fine, etc.
Some of the descriptive Japanese words consist of
Chinese characters. Because they are difficult to use,
we have an additional reason, other than a lack of
precision, for abandoning them. The current recom-
mendation to limit lung sound terminology to the four
basic terms shown in Table 2 is well suited to transla-
tion into Japanese. The general adoption of this system
of nomenclature will be of great benefit to education
and research in my country.
Dt: Murphy: Normal and abnormal breath sounds,
plus adventitious respiratory sounds can be charac-
terized by a method we have called TIme Expanded
Waveform Analysis. Stored or recorded breath sounds
are "played back" at one eighth to one tenth the speed

International Symposium on LungSounds(Mikemi et aJ)

at which they were originally recorded. This time
expansion procedure spreads out the original wave
form so that individual crackles can be visualized.
Inspection of a time expanded recording of adven-
titious sounds enables one to make visual distinctions
between a wheeze and a rhonchus, or between a fine
and coarse crackle, differences that may be readily
audible but impossible to discern from a real time rec-
ord. The sounds can also be located quite precisely at
different points in the respiratory cycle. A time ex-
panded record of a breath sound recorded over a large
airway readily demonstrates the difference in pitch
between inspiration and expiration as well as the silent
phase between them. At a distance from the larger
airways, where normal vesicular sounds are present,
the acoustic pause between inspiration and expiration
noted over the larger airways is absent. We have
characterized crackles on the basis of a variety of
graphic features, but the two most useful appear to be
the initial deflection width and the two cycle duration
(Fig 1). The initial deflection width is the distance or
time between the first departure of the graph of the
crackle from and subsequent return to the baseline,
whereas the two cycle duration is the time required for
the crackle wave to complete two S-shaped deviations
or four zero crossings. Both the initial deflection width
and two cycle duration can be used to separate crackles
into coarse or fine categories. We have demonstrated
good agreement between these two physical measure-
ments of adventitious sounds. In general, if crackles
with an initial deflection width of 0.8 ms or less and a
two cycle duration of 1.2 ms or less are designated as
"fine," then qualified physicians will nearly always
correctly classify similar sounds from patient record-
ings or teaching tapes. Crackles of intermediate char-
lOW
2CD
FIGURE 1. The initial deflection width (lOW) is the time in millisec-
onds from the first deviation, above or below the baseline, to the
return to the baseline. The two cycle duration (2 CO) is the time in
milliseconds for two S-shaped waves, or cycles, to occur. (Repro-
duced with permission from Seminars in Respiratory Medicine.
1985;6:210-19)
acteristics, medium crackles, are infrequent, but are
usually present as would be expected if adventitious
sounds comprise a continuum from high to low pitch.
Pleural friction rubs and other sounds can be similarly
analyzed. With personal computers becoming so prev-
alent, TIme Expanded Waveform analysis may soon be
widely available.
Dr: Loudon: I can only comment on a very few of the
numerous interesting presentations and questions that
I have heard here today. Dr. Haruto Haneda (Presi-
dent, Japan Medical Association) emphasized that
auscultation requires touching the patient, an observa-
tion that deserves considerable emphasis. This phys-
ical contact creates a bond or an interaction for which
no form of automated measurement can substitute. It
leads the physician into the patients private world and
involves us with him in a manner that no amount of
complex machinery, irrespective of its importance, can
achieve. DJ: Chretien's illustration of the title page of
Laennec's second edition contained a Greek quotation
followed by a French translation that DI: Chretien tells
me means, 'The possibility of exploration is an impor-
tant part of the art of medicine." I take "exploration" to
mean "investigation," and that is exactly how Laennec
used the instrument that he created. It was used for
medical investigation, for physiologic and clinical
study, and was thus, the forerunner of the massive
diagnostic hardware that is an integral part of medical
investigation, diagnosis, and treatment today. Drs.
Cole and Meier-Sydow emphasized the importance of
a standard, readily comprehensible nomenclature for
both students and teachers. Both the description and
our understanding of mechanisms of disease are
greatly facilitated when unambiguous terminology is
used. DI: Mikami has told us of past Japanese studies of
respiratory acoustics, but failed to mention the exten-
sive research now in progress and the technical
achievements of his countrymen in this field. Dr;
Murphy has shown us what I believe is the wave of the
future-a method for both graphic display and auto-
matic analysis of adventitious sounds. Much work re-
mains to be done, but the basic principles have been
firmly established. The most important outcome of
this Lung Sounds Symposium is the unanimous ac-
ceptance of a nomenclature system for adventitious
lung sounds. I hope that everyone here will dedicate
himself to the task of encouraging its widespread
implementation. All of us, and especially those who
follow, will surely benefit if our mission succeeds.
REFERENCES
1 Cugell OW Lung sounds: classification and controversy. Sem
Respir Med 1985; 6:180-82
2 Robertson Al Coope R. Rales, rhonchi and Laennec. Lancet
1957; 2:417-23
CHEST I 92 I 2 I AUGUST, 1987 345