Article by Dr Manasa S, B.A.M.S
Understanding the sounds of breathing is like deciphering a coded language spoken by our lungs. Every inhale and exhale narrates a story of our respiratory health. From the gentle whisper of normal breathing to the ominous murmurs of abnormalities, each sound holds valuable clues for medical professionals.
Breath sounds serve as the frontline messengers, signaling any underlying conditions within the intricate pathways of our respiratory system. Through auscultation, the ancient art of listening to the lungs with a stethoscope, healthcare providers unravel these auditory mysteries, offering insight into potential issues.
In this realm where sound becomes diagnosis, the distinction between normal and abnormal breath sounds is important. Normal sounds reassure the rhythmic dance of oxygen exchange, ensuring the sustenance of life. Conversely, abnormal sounds, like discordant notes in a melody, hint at disruptions within the respiratory orchestra, prompting further investigation and intervention.
In this journey through the symphony of breath, let us delve into the nuances of these auditory cues, understanding their significance in safeguarding the health and vitality of our lungs.
In this article we will delve into the details of Rhonchi and rales
Rhonchi
Rhonchi is a low-pitched sound typically originating in the larger airways of the lungs.
It is audible during both inhalation and exhalation, often likened to the sound of snoring.
It may occur intermittently during breathing or persist continuously.
Causes of Rhonchi
Produced when an obstruction, such as fluid, impedes the airway.
The sound results from air flowing around the blockage.
Rales
Rales, also known as crackles or bibasilar crackles, are higher-pitched sounds.
The terms “rales” and “crackles” are often used interchangeably and are mostly a matter of preference, not indicative of a difference in the condition.
These sounds occur when air moves into closed spaces, typically in the smaller parts of the lungs like the alveoli.
Alveoli are tiny sacs of air that inflate and deflate with each breath. When damaged or laden with fluid or mucus, they produce a crackling sound as they attempt to fill with air.
Unlike rhonchi, rales do not get relieved by coughing.
Rales are further categorized into specific types based on their sound:
– Fine
– Coarse
– Dry
– Moist
Causes for Rhonchi and rales
In general, it is difficult to differentiate abnormal lung sounds from one another and more difficult is to find out what is the cause behind these abnormal sounds. Infections and fluid build up in the lungs are the common reasons behind these two abnormal sounds.
The following are the causative factors common for both rhonchi and rales –
– Bronchitis
– Chronic lung diseases like COPD
– Pneumonia
– Respiratory infections that are reasons behind building up of mucus in the lungs
– Conditions common to Rhonchi
– Chronic obstructive pulmonary disease
– Cystic fibrosis
– Asthma
– Bronchiectasis
– Pneumonia
Conditions common to rales
– Pulmonary edema
– Interstial lung disease
– Asbestosis
– Pneumonia
– Sarcoidosis
– Idiopathic pulmonary fibrosis
– Atelectasis
– Autoimmune diseases like Lupus and rheumatoid arthritis can attack the lungs leading to progressive scarring of lung tissues.
Chief difference between rhonchi and rales
| Sl No | Rhonchi | Rales |
| 1 | Heard during expiration | Heard during inspiration |
| 2 | Might disappear after coughing | Coughing does not have any effect |
| 3 | Associated with obstructive lung disease | Associated with restrictive lung disease |
| 4 | Mainly affects larger airways | Largely affects functional lung tissues and alveoli |
Utility of investigation in rhonchi and rales
If someone is experiencing rhonchi and rales for the first time and cause is not known clearly then the following tests are beneficial to detect the underlying cause
– Chest x-ray
– Pulmonary function tests
– Sputum culture
– Bronchoscopy function tests
– Evaluation of heart condition if heart failure is suspected
Treatment
In cases where abnormal lungs are detected, healthcare professionals prioritize identifying the exact cause.
Treatments are tailored to alleviate underlying chronic issues or address short-term infections.
For instance, if heart failure leads to fluid buildup in the lungs, the treatment approach differs from that for fluid buildup due to COPD.
Medications may include –
– Inhaled steroids for inflammation reduction.
– Bronchodilators to relax and widen airways.
– Mucolytics or other drugs to diminish mucus production and ease congestion.
– Antibiotics to combat infections causing the buildup.
– Antiviral medications for respiratory viruses such as influenza.
Specific treatment for rhonchi
Rhonchi develops as a symptom of underlying obstructive lung disease. Treatment aims at clearing the obstruction. Treatment measures include:
Oxygen support – when regular breathing fails to provide sufficient oxygen, supplemental oxygen is administered.
– Lung inflammation is reduced by inhaled steroids like fluticasone.
– Rapid and sustained control of severe exacerbations is achieved through oral steroids such as prednisone.
– Relaxing the lungs and widening the airways, bronchodilators like Proventil (albuterol) are inhaled.
– Antibiotics are prescribed for treating bacterial pneumonia or preventing secondary bacterial lung infections.
– Employing a combination of huffing, coughing, and chest percussion, postural clearance clears mucus from the lungs.
– Singulair (montelukast) is an oral drug utilized for preventing asthma attacks.
Specific treatment for rales
Rales are associated with restrictive lung diseases and may require different interventions to improve breathing due to damage to the functional tissue of the lungs.
Treatment for rales may involve
– Bronchodilators
– Inhaled steroids
– Oral steroids
– Supplemental oxygen
– Antifibrotics like Ofev (nintedanib) and Pirespa (pirfenidone) to slow lung scarring and damage caused by ILD.
– Immunosuppressants such as methotrexate or Imuran (azathioprine) to temper the immune response in autoimmune lung disease or severe sarcoidosis.
– Pulmonary rehabilitation, which is a supervised program including exercise training, health education, and breathing techniques.
– Lung transplant, considered a last-resort option for severe ILD or asbestosis.
Prevention of Rhonchi and Rales
Stop Smoking – Cigarette smoke significantly increases the risk of various lung diseases and exacerbates symptoms. It also heightens susceptibility to pneumonia.
Get Vaccinated – Vaccines can prevent many infections that lead to pneumonia, including pneumococcal, influenza, and COVID-19. Adherence to recommended vaccination schedules is crucial, with catch-up vaccinations if necessary.
Avoid Triggers – For individuals with asthma, identifying triggers such as colds, allergies, smoke, fumes, aspirin, and stress is essential. Keeping a diary to track occurrences of attacks and their precursors can aid in identifying triggers.
Utilize Medications for chronic conditions – Consistent use of prescribed medications for chronic conditions like COPD, severe asthma, or cystic fibrosis is vital. Proper medication adherence can prevent flare-ups and slow disease progression. This includes adherence to inhaled medications commonly used for these conditions.
In conclusion, understanding the distinctions between rhonchi and rales is crucial in diagnosing and managing various respiratory conditions. Rhonchi, characterized by a low-pitched snoring or gurgling sound upon exhaling, typically signals obstructive lung diseases such as COPD or asthma. Conversely, rales, manifesting as crackling noises during inhalation, often indicate restrictive lung diseases like interstitial lung disease. Recognizing these distinctive sounds aids healthcare professionals in providing targeted treatment and improving patient outcomes.
Rhonchi and Rales: Ayurveda Understanding
The references of abnormal breath / respiratory sounds have not been explained in detail in Ayurveda texts. But whatever minimum references we get directly or by inference with special reference to ‘rhonchi or rales’ can be found in the contexts of –
1. Shwasa Roga – diseases presenting with difficulty in breathing as predominant symptom
Example – In case of Maha Shwasa, the person breathes with difficulty and the sounds produced are similar to those produced by an intoxicated bull. The sounds here have a ‘rhonchi’ or ‘wheeze’ like pattern. Similarly, in Urdhwa Shwasa, the sounds are a mixture of rales and rhonchi. Tamaka Shwasa presents with ‘ghurghuraka shabda’ i.e. ‘wheezing’ or ‘rhonchi’ sounds.
2. Kasa Roga – diseases presenting with cough as predominant symptom
Example – Vataja Kasa – may present with rales and Kaphaja Kasa – with rhonchi.
3. Pranavaha Sroto Dushti – symptoms of contamination or damage of channels responsible for transportation of vital life force (oxygen / air) i.e. prana energy in the body
Symptoms explained in this context covers a wide array of abnormal breath sounds including rhonchi and rales.
Related Reading – ‘Abnormal Breathing Sounds as explained in Ayurveda Treatises – Clinical significance’
