Dr Athulya C Soman
Breath sounds are generated by turbulent flow of air in the upper respiratory tract, the trachea, and the central bronchi. The decrease of bronchial caliber increases flow velocity and intensifies turbulence. Discrepancies between sound, airway resistance, and forced expiratory measurements may indicate the site and mechanism of airway obstruction in individual patients.  Deep knowledge and understanding of the breath sounds helps the physician to arrive in a diagnosis as well as a remedy without any invasive and expensive investigations.
As homoeopathy is based on symptom relief, breath sounds are major symptom that speaks about the pulmonary conditions that cannot be neglected.
Keywords: Breath sounds, Auscultation, Adventitious sounds, Homoeopathic approach, rubrics, medicines, Murphy’s repertory, Kent’s repertory, BBCR.
Abbreviation: BBCR:Boger Boenninghausen’s Characteristics and Repertory
From nineteenth century auscultation of the lungs has been a central element in clinical examination .However, newer diagnostic equipments have more and more been challenged the role of the stethoscope in our diagnostic work-up. 
Normal breath sounds generated by turbulent airflow in upper airways, and larger airways of the lungs ( 200 to 2000 Hz) As the sound is transmitted to the lungs, it gets dampened, higher frequencies are lost and a softer, lower pitched sound is heard (200 to 400 Hz). In the smaller airways, air flow is laminar and slower, turbulence and sound cannot develop. Smaller airways and alveoli are therefore a filter and not a source of sound.
In inspiration, air moves into progressively smaller airways with the alveoli as its final location. As air hits the walls of these airways, turbulence is created and produces sound and in expiration, air is moving in the opposite direction towards progressively larger airways. Less turbulence is created, thus normal expiratory breath sounds are quieter than inspiratory breath sounds.
ABNORMAL BREATH SOUNDS
Breath sounds may be heard abnormal due to two main reasons:
- ABNORMAL GENERATION: Narrowed airways intensify the linear velocity of breath sounds and thus increasing their turbulence making the breath sounds louder.
- ABNORMAL CONDUCTION: Abnormal lung will conduct the centrally generating breath sounds abnormally for e.g. consolidated lung and the overinflated lung of emphysema. 
Abnormal types of bronchial breathing and adventitious (added) sounds may help the physician to diagnose the disease condition and predict the stage of the condition.
ABNORMAL TYPES OF VESICULAR BREATHING
- EXAGGERATED OR LOUD BREATH SOUNDS: physiologically seen in children ,thin chest individuals and women, pathologically in bilaterally in states of dyspnoea or bronchitis unilaterally in pulmonary TB or compensatory emphysema.
- Rubric : Kent’s repertory: RESPIRATION – LOUD, RESPIRATION – ACCELERATED Murphy’s repertory: Breathing – LOUD, breathing
- Medicines: Spongia tosta: Respiration short, panting, difficult
Antimonium tartaricum: Rapid, short, difficult breathing; seems as if he would suffocate
- DIMINISHED OR FEEBLE: Normally seen in habitual shallow breathers, during quiet breathing, thick chest wall, and obesity. Abnormally seen in Obstruction of bronchial tree (by secretions, mucous plug, foreign body), emphysema.
- Rubric: Kents repertory :RESPIRATION – FEEBLE
Murphy’s Repertory: Breathing – DIFFICULT, breathing – weakness
BBCR : RESPIRATION – Feeble
Belladonna: Respiration oppressed, quick, unequal. Cheyne-Stokes respiration
Aconitum napellus: oppressed breathing on least motion, Shortness of breath
- ABSENT BREATH SOUNDS : pathologically seen in Massive pleural effusion , pneumothorax , area of lung collapse , secondary occlusion of a bronchus.
Murphy’s Repertory :Breathing – CEASED, breathing
Camphora: Suspended respiration, Suffocative dyspnœa. Asthma
Veratrum viride: Congestion of lungs. Difficult breathing.
ABNORMAL TYPS OF BRONCHIAL BREATHING
- Cavernous: Low pitched with hollow character ,suggestive of underlying cavity in the lung, open pneumothorax , pulled trachea syndrome .
- Tubular: High pitched with tubular or aspirate quality character, suspected Pneumonia Pulmonary infarction, Atelectasis or collapse of lung .
- Amphoric : High pitched with metallic or echo like quality ,heard in large cavity in the lungs with smooth walls Pneumothorax communicating with the bronchus 
ADVENTITIOUS (ADDED) SOUNDS
Adventitious sounds are the sounds not normally heard in the lungs, caused by moving air colliding with secretions in trachea or bronchi, or from popping open of previously deflated airways .
Diseases can give rise to 5 types of added sounds namely :-
- Pleural rub
High pitched musical squeaking sound predominantly during expiration. Formed by air squeezed or compressed through narrowed airways (collapsing, swelling, secretions, tumors)
- Fixed monophonic wheeze :
- Is a single note of constant pitch, timing and site.
- Bronchial carcinoma is the commonest cause, Foreign body, bronchial stenosis
- Random monophonic wheeze:
- These are random single notes which may be scattered and overlapping throughout inspiration and expiration and are of varying duration, timing and pitch Eg asthma or bronchitis.
- Expiratory polyphonic wheeze
- Results from the oscillation of several large bronchi simultaneously brought to the point of closure by congestion of the mucus lining, contraction of smooth muscle and thickening of layer of mucus. E.g. in asthma and COPD.
- Sequential inspiratory wheezes (SQUAWKS)
- A series of sequential but not overlapping inspiratory sounds or occasionally a single sound , resulting from opening of airways which had become abnormally apposed during previous expiration .
- They tend to occur in deflated areas of lung and hence are heard in lung fibrosis , especially fibrosing alveolitis.
Murphy’s repertory: Breathing – DEEP, breathing – slow, wheezing
Lungs – ASTHMA, general – wheezing
Lungs – WHISTLING, in lungs – wheezing
Kents repertory: RESPIRATION – WHEEZING
Spongia tosta: Bronchial catarrh, with wheezing, asthmaticRespiration short, panting.
Kalium carbonicum: Bronchitis, whole chest is very sensitive, Wheezing
Arsenicum album; Wheezing respiration
Crackles are non musical, interrupted added sounds of short duration. They are explosive in nature. The mechanism of crackles is inhaled air collides with secretions in trachea, large bronchi sudden opening of successive bronchioles and alveoli with rapid equalization of pressure causing sequence of explosive sounds
COARSE CRACKLES :-
- loud, low-pitched, bubbling and gurgling sounds early in inspiration. Sound like Velcro
- Heard in consolidation, lung cavitation, abscess, pulmonary congestion or edema and bronchiectasis.
FINE CRACKLES :-
- Sign of parenchymal infiltration
- Localised, constant and accentuated by coughing
- Characteristic of first stage of pneumonia, collapse/atelactasis of lung, bronchitis or pulmonary edema
Murphy’s Repertory : Generals – CRACKLINGS
BBCR:LARYNX AND TRACHEA – Crackling, creaking in
Veratrum album:Rattling in chest, Coarse rales.
Balsamum peruvianum: Bronchitis, and phthisis,Loud rales in chest
Calcarea carbonica: Chest very sensitive to touch, percussion, or pressure, Coarse rales. Extreme dyspnśa. 
Rhonchi are low-pitched, musical snoring, continuous sound heard in inspiration and expiration
Mechanism of rhonchi is sound comes from copious secretion from large airways or bronchi
Heard in Bronchitis, obstruction of bronchus from obstruction or tumor.
Murphy’s repertory:Coughing – SONOROUS, cough
Spongia: Cough, dry, barking, croupy Respiration short, panting, difficult
Stramonium: spasmodic cough, in fine, shrieking tone, from constriction of larynx and chest. Difficult (hurried or) sighing respiration.-Suffocating obstruction of respiration. 
Stridors are high pitched, inspiratory, crowing sound, louder in neck than over chest wall. Loudest over trachea. Originate in larynx or trachea. Upper airway obstruction from inflamed tissue or obstruction such as croup and acute epiglottitis , obstructed airway by inhaled foreign body.
Kent’s repertory :RESPIRATION – STRIDULOUS
Murphy’s repertory :Larynx – LARYNGISMUS, stridor , Breathing – STRIDULUS
Gelsemium: Slowness of breathing, with great prostration. Spasm of the glottis
Moschus: Sudden constriction of larynx and trachea. Difficult respiration
Coarse and low pitched superficial sound heard both in inspiration and expiration. Heard when pleurae become inflamed and lose normal lubricating fluid. Pleural surfaces rub together during respiration. Heard best in anterolateral wall. Eg Pleuritis.
PULMONARY DISEASES AND BREATH SOUNDS
Excessive trachea bronchial mucous production, leads to cough with expectoration.
- Normal vesicular
- Chronic – prolonged expiration
- Crackles over deflated areas.
- May have wheeze
Atelectasis is the collapse or closure of a lung resulting in reduced or absent gas exchange.
- Breath sounds: Decreased vesicular or absent over area
- Voice sounds: usually decreased or absent over affected area
- None if bronchus is obstructed
- Occasional fine crackles if bronchus is patent
Emphysema caused by destruction of pulmonary connective tissue
- Decreased breath sounds
- May have prolonged expiration
- Muffled heart sounds secondary to over distention of lungs
- Usually none ,occasionally wheeze
Hypersensitivity to certain inhaled allergens that produce a complex response
- Diminished air movement.
- Breath sounds : decreased,with prolonged expiration
- Bilateral wheeze on expiration
- Sometimes inspiratory & expiratory wheeze
An infectious disease usually caused by Mycobacterium tuberculosis.
- Normal or decreased vesicular breath sounds
- Crackles over upper lobes common,persist following full expiration and cough
An abnormal collection of air in the pleural space between the lung and the chest wall. Air in pleural space neutralizes the usual negative pressure present thus lung collapse.
- Breath sounds decreased or absent.
- Voice sounds decreased or absent.
Adventitious : none
Infection in lung parenchyma leaves alveolar membrane edematous and porus. Alveloli progressively become consolidated which resluts in hypoxemia
- Breath sounds louder with patent bronchus , as if coming directly from larynx
- Children –diminished breath sounds may occur early in pneumonia
- Crackles fine to medium
Lungs auscultation findings should be interpreted with caution and should be related to the case history and other clinical findings which solely depend upon the physician. Even with the emergence of new technologies to diagnose lung disorders, auscultation is the base of medical practice. We are blessed with rubrics and their corresponding remedies for the abnormal breath sounds in our repertories.
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- Boericke W. Pocket manual of homoeopathic materia medica. Motilal Banarsidass Publ.; 1993.
- Jameson JL. Harrison’s principles of internal medicine. McGraw-Hill Education,; 2018.
Dr Athulya C Soman
Department of Practice of Medicine
Father Muller Homeopathic medical college and hospital
Deralakatte, Mangaluru 575018