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PubMed1979

Prevalence and significance of the fourth heart sound (S4) in presumably healthy middle-aged men, with particular relation to latent coronary heart disease.

As part of a cardiovascular survey phonocardiography and auscultation concentrating on the presence/absence of S4 were studied prospectively in 1714 presumably healthy men aged 40--59 yr. The following conclusions were reached: (1) routine phonocardiograms revealed an S4 in greater than 50%; (2) auscultation suggested the presence of S4 in greater than 30%; (3) interobserver variation was approximately 1/6 in the blind interprelation of the phonocardiograms by 2 observers; (4) approximately 3/4 of reported audible S4s were correctly identified; (5) a direct association between S4 and the length of the PQ (PR) interval was found, and (6) a positive association between higher blood pressure and S4, but (7) no association to age, latent coronary heart disease (CHD) nor various CHD risk factors. Thus an S4 is of little diagnostic value in screening of apparently healthy middle-aged subjects, but probably is not a completely innocent finding as suggested recently by some investigators.

Adult↗
PubMed1995

[Respiratory sounds].

After having invented the stethoscope, Laennec published his treatise on auscultation in 1819, describing the acoustic events generated by ventilation and linking them with anatomopathological findings. The weak points of his semiology lay in its subjective and interpretative character, expressed by an imprecise and picturesque nomenclature. Technical studies of breath sounds began in the middle of the twentieth century, and this enabled the American Thoracic Society to elaborate a new classification of adventitious noises based on a few physical characteristics. This terminology replaced that of Laennec or his translators (except in France). The waveforms of the different normal and adventitious noises have been well described. However, only the study of the time evolution of their tone (frequency-amplitude-time relationship) will enable a complete analysis of these phenomena. This approach has been undertaken by a few teams but much remains to be done, in particular in relation to discontinuous noises (crackles). Technology development raises hope for the design, in near future, of automatic processes for respiratory noise detection and classification. Systematic research into the production mechanisms and sites of these noises has progressed equally. It should, in time, reinforce their semiological value and give to auscultation, either instrumental or using the stethoscope or instrumentally, an increased diagnostic power and the status of respiratory function test.

Auscultation↗
PubMed1994

[Continuing importance of the clinical approach. Observations on a regional collaboration between general practitioners, internists and cardiologists].

The advent of high-tech diagnostic methods raises concerns nowadays about the value of the clinical approach and bedside diagnosis. This at least is the impression given by modern scientific literature, which rarely even mentions this part of examination of the patient. In order to define the actual role played by auscultation in the management of cardiological patients by the primary care physician, the records of 250 patients consecutively referred to a cardiologist are analyzed. The practitioner's initial clinical diagnosis is compared to the final cardiological diagnosis. Per referred patient, 1.76 specialized consultations were needed. In 64% of the cases only one such consultation took place. Initial diagnosis was correct in 80% of all cases, partly correct in 11% and incorrect in 9% of the cases. Out of the 64 cases of valvular diseases, 33 were initially correctly recognized by the physician. The cardiological investigation was also invasive in 6.5% of all cases, 4.5% of the patients eventually undergoing invasive or surgical treatment. Thus the great majority of the patients (93.5%) were managed by the primary physician with "first-line" cardiologist's support, which was often only occasional (only one specialized consultation in about two thirds of all cases). This highly independent and presumably cost-effective patient management by the primary care physician implies a high level of clinical skill. It stresses the outstanding importance of continuing teaching of the clinical approach and particularly of cardiac auscultation, which is still the best screening method for valvular heart disease.

Adult↗
PubMed1994

[Femoral arteriovenous fistulas after vascular puncture for hemodialysis].

From 1978 to 1991 we observed 10 patients who developed femoral arteriovenous fistula after venous puncture for hemodialysis. The fistula most often appeared after several punctures, but 3 developed after a single puncture. Diagnosis was made on the basis of local observation and auscultation of the vessel (bruit + thrill n = 10, hematoma n = 4, pulsatile mass n = 1). Two patients had arteriography and 2 had echo-doppler. Arteriography was not required for diagnosis (since clinical signs were sufficient), or for treatment, since echo-doppler and surgery indicated the location of the fistula. Five patients underwent surgery. In all cases, continuity of the main vessels of the lower member was maintained or reestablished during surgery. Surgery is mandatory for high flow rate. Such fistulas cannot be used and can cause cardiac failure in patient with another fistula for hemodialysis. Surgery should not be undertaken too early because of the possibility of spontaneous clotting (particularity if echo-doppler shows low flow rate), and to allow organization of the lesions and easier dissection. Auscultation of the vessel should be a routine procedure after any femoral vein puncture in order that this complication not be overlooked.

Adult↗
PubMed1996

Electronic fetal monitoring.

Currently, recommendations regarding the marginal value of electronic fetal monitoring (EFM) to the standard practice management of the patient in labor must be couched in qualifications regarding both patient tolerance for risk and health team uncertainty about practice guidelines for intermittent auscultation during pregnancy. If stresses on a maternity unit's manpower prevent strict registered nurse or nurse mid-wife compliance with an auscultatory monitoring program, then EFM may make both quality and health outcomes sense. If, on the other hand, the unit employs stringent patient care quality monitoring guidelines, then a course of intermittent auscultation may make both safety and cost-effectiveness sense.

Auscultation↗
PubMed1997

[Mitral insufficiency simulating aortic stenosis].

We report a patient with a mitral insufficiency due to myxomatous valve change, with a regurgitation murmur heard principally at aortic area and radiating to the neck base. Even though the topography of the murmur seemed to suggest aortic stenosis, the other auscultation findings and the initial clinical tests clearly supported its source in a mitral insufficiency. The echocardiography allowed us not only to confirm our suspicion, but also to explain this auscultation finding mechanism, to show a severe mitral insufficiency with a anterior and medial jet, which struck the aorta and atrial septum. The surgery found a clear aortic vibration, which disappeared after implanting the mitral protheses. Our case illustrates the value of new diagnostic image techniques to complement the semiologic findings.

Aortic Valve Stenosis↗
PubMed1997

[Post exertion bronchospasm--usefulness of different methods for evaluating bronchial constriction after exertional provocation].

55 children with bronchial asthma were tested using three exercise provocation tests: a treadmill, stairways running and cycloergometer. The results were evaluated on the base of the lung function tests, auscultation and airways resistance measurement with occlusion method. Of these three tests the treadmill test seemed to be the most useful to prove bronchial hyperreactivity towards exercise. Stairways running occurred to be very congenial. The study also proved usefulness of auscultation in evaluating of bronchial constriction after exercise.

Airway Resistance↗
PubMed1997

[Importance of differential diagnosis of ringing and splashing sounds in the abdomen of adult cattle].

In cattle liquid and gas in the abdominal cavity can be detected from the outside by use of simultaneous auscultation and percussion or by auscultation with simultaneous shaking of the abdominal wall. Size, area and the quality of the "ping" and splashing sounds are helpful to determine which organs are involved in the disease. Nine possible reasons for intraabdominal gas- and liquid accumulation are discussed. In 12 schematic figures the areas of externally detectable "ping" and splashing sounds are compared with the topographic anatomical situation inside the abdomen.

Abdomen↗
PubMed1998

The rational clinical examination. Does this infant have pneumonia?

Acute lower respiratory tract illness is common among children seen in primary care. We reviewed the accuracy and precision of the clinical examination in detecting pneumonia in children. Although most cases are viral, it is important to identify bacterial pneumonia to provide appropriate therapy. Studies were identified by searching MEDLINE from 1982 to 1995, reviewing reference lists, reviewing a published compendium of studies of the clinical examination, and consulting experts. Observer agreement is good for most signs on the clinical examination. Each study was reviewed by 2 observers and graded for methodologic quality. There is better agreement about signs that can be observed (eg, use of accessory muscles, color, attentiveness; kappa, 0.48-0.66) than signs that require auscultation of the chest (eg, adventitious sounds; kappa, 0.3). Measurements of the respiratory rate are enhanced by counting for 60 seconds. The best individual finding for ruling out pneumonia is the absence of tachypnea. Chest indrawing, and other signs of increased work of breathing, increases the likelihood of pneumonia. If all clinical signs (respiratory rate, auscultation, and work of breathing) are negative, the chest x-ray findings are unlikely to be positive. Studies are needed to assess the value of clinical findings when they are used together.

Cough↗
PubMed2006

Clinical manifestations of noncoronary atherosclerotic vascular disease after moderate dose irradiation.

BACKGROUND: Accelerated atherosclerosis and carotid stenosis are well-established risks occurring after high radiation doses that are used to treat cancers of the head and neck. Noncoronary vascular disease has been observed and may relate to more moderate dose irradiation. METHODS: A search of patients treated for Hodgkin disease, non-Hodgkin lymphoma, or seminoma was performed to identify cases with noncoronary vascular complications after irradiation. These three groups were chosen because of the use of intermediate dose radiation and prevalence of long-term survivors. Individual patient records were reviewed to document the type and presentation of the stenosis and the clinical factors that may have contributed to this risk. RESULTS: Twenty-one patients were identified who developed disease in noncoronary arteries after treatment. The median time from irradiation to diagnosis of vascular stenosis was 15 years. Antecedent risk factors for vascular disease were prevalent. Five patients had disease identified by auscultation of bruits before an adverse clinical event occurred. Five patients died from complications related to their vascular disease, which included three deaths after stroke and two after small bowel infarction. CONCLUSION: Twelve cases arose at an atypically young age for atherosclerotic vascular disease and featured unusual clinical presentations. Nine cases identified occurred at an advanced aged and at a shorter median interval, making a causal relation to irradiation uncertain. Incorporating careful auscultation for bruits in followup evaluation of irradiated patients may identify individuals who are at risk for adverse vascular events. The potential for early vasculopathy in individuals exposed to intermediate dose irradiation suggests a need to manage dyslipidemia and reduce vascular risk factors throughout the posttreatment period.

Adolescent↗
PubMed2004

Use of a respiratory clinical score among different providers.

Respiratory assessment of children with asthma or bronchiolitis is problematic because both the components of the assessment and their relative importance vary among care providers. Use of a systematic standard assessment process and clinical score may reduce interobserver variation. Our objective was to determine observer agreement among physicians (MD), nurses (RN), and respiratory therapists (RT), using a standard respiratory clinical score. A clinical score was developed incorporating four physiologic parameters: respiratory rate, retractions, dyspnea, and auscultation. One hundred and sixty-five provider pairs (e.g., MD-MD, RN-RT) independently assessed a total of 55 patients admitted for asthma, bronchiolitis, or wheezing at an urban tertiary-care hospital. A weighted kappa statistic measured agreement beyond chance. Rater pairs had high observed agreement on total score of 82-88% and weighted kappas ranging from 0.52 (MD-RN; 95% CI, 0.19, 0.79) to 0.65 (RN-RN; 95% CI, 0.46, 0.87). Observed agreement on individual components of the score ranged from 58% (auscultation) to 74% (dyspnea), with unweighted kappas of 0.36 (respiratory rate; 95% CI, 0.26, 0.46) to 0.53 (dyspnea; 95% CI, 0.41, 0.65). In conclusion, this respiratory clinical score demonstrates good interobserver agreement between MDs, RNs, and RTs. Future research is needed to examine validity and responsiveness in clinical settings. By standardizing respiratory assessments, use of a clinical score may facilitate care coordination by physicians, nurses, and respiratory therapists and thereby improve care of children hospitalized with asthma and bronchiolitis.

Adolescent↗
PubMed2004

Is clinical wheezing reliable as the endpoint for bronchial challenges in preschool children?

The present study was designed to compare the clinical finding of wheeze by auscultation with an objective evaluation by acoustic means at the endpoint of a bronchial challenge in preschool children. Challenges were undertaken using a tidal breathing method in 51 preschool children as part of the investigation of possible asthma. An electronic stethoscope was used for auscultation of each lung and for the simultaneous recording of the acoustic sonogram for analysis. In 24 children, the pediatrician determined that the challenge was positive, and in 22 of these, he heard wheezing at the endpoint of the challenge. In 2 children the challenge was considered positive, based on a modest fall in saturation. The acoustic record was scanned manually for presence of wheeze defined in terms of duration, and power spectrum without reference to auscultatory findings. In positive challenges, the mean wheeze rate was 28.1% (95% CI, 19.5-36.8%), while no wheeze was detected acoustically in negative challenges. Using a cutoff wheeze rate (duration of wheeze/duration of breath phase x100) of 10% for the whole group, clinical wheezing detected by the pediatrician had a sensitivity of 100% (no false negatives) and a specificity of 91%. In conclusion, the clinical observation of wheeze agrees very well with its detection by acoustic measurement at the endpoint of a bronchial challenge in preschool children.

Asthma↗
PubMed2005

Timing and nature of wheezing at the endpoint of a bronchial challenge in preschool children.

Bronchial reactivity to inhaled agents in preschool children can be undertaken by auscultating the lungs to detect wheezing, but there is a lack of information on when wheeze first appears at the endpoint of the challenge and on the acoustic characteristics of the wheeze. We recorded breath sounds continuously during tidal breathing inhalation challenges with adenosine 5'-monophosphate, using sensors attached over each upper lobe in 80 preschool children. In 35 children, the challenge was considered positive by a pediatrician who determined the endpoint by detecting wheeze on auscultation after an inhalation. Using acoustic analysis, we determined that the first wheeze appeared during the 2-min period of nebulization in 31% of positive challenges; it was unilateral in 37%, and only inspiratory in 46%. A running window of 6 sec was used to detect at least two wheezes without reference to phase of breathing, and this index had a sensitivity of 97.6% and specificity of 99.7% for determining the endpoint of a challenge. Detecting wheeze acoustically adds safety to the technique by enabling the challenge to be stopped earlier, while the lack of a need to document the phase of breathing simplifies the technique.

Acoustics↗
PubMed1995

Noninvasive blood pressure monitoring from the supraorbital artery using an artificial neural network oscillometric algorithm.

OBJECTIVE: Our objective was to overcome the limitations of linear models of oscillometric blood pressure determination by using a nonlinear technique to model the relationship between the oscillometric envelope and systolic and diastolic blood pressures, and then to use that technique for near-continuous arterial pressure monitoring at the supraorbital artery. METHODS: An adhesive pressure pad and transducer were used to collect oscillometric data from the supraorbital artery of 85 subjects. These data were then used to train an artificial neural network (ANN) to report diastolic or systolic pressure. Arterial pressure measurements defined by brachial artery auscultation were used as a reference. ANN results were compared with those obtained using a standard oscillometric algorithm that determined pressures based on fixed percentages of the maximum oscillometric amplitude. RESULTS: The ANN produced better estimates of reference blood pressures than the standard oscillometric algorithm. Mean difference between target and actual output for the ANN was 0.50 +/- 5.73 mm Hg for systolic pressures, compared to the mean difference of the standard algorithm of 2.78 +/- 19.38 mm Hg. For diastolic pressures, the ANN had a mean difference of 0.04 +/- 4.70 mm Hg, while the mean difference of the standard algorithm was -0.34 +/- 9.75 mm Hg. CONCLUSIONS: The ANN produced a better model of the relationship between the oscillometric envelope and reference systolic and diastolic pressures than did the standard oscillometric algorithm. Noninvasive blood pressure measured from the supraorbital artery agreed with pressure measured by auscultation in the brachial artery, and may sometimes be more clinically useful than an arm cuff device.

Adult↗
PubMed2004

Detection of the third heart sound using a tailored wavelet approach.

The third heart sound is normally heard during auscultation of younger individuals but disappears with increasing age. However, this sound can appear in patients with heart failure and is thus of potential diagnostic use in these patients. Auscultation of the heart involves a high degree of subjectivity. Furthermore, the third heart sound has low amplitude and a low-frequency content compared with the first and second heart sounds, which makes it difficult for the human ear to detect this sound. It is our belief that it would be of great help to the physician to receive computer-based support through an intelligent stethoscope, to determine whether a third heart sound is present or not. A precise, accurate and low-cost instrument of this kind would potentially provide objective means for the detection of early heart failure, and could even be used in primary health care. In the first step, phonocardiograms from ten children, all known to have a third heart sound, were analysed, to provide knowledge about the sound features without interference from pathological sounds. Using this knowledge, a tailored wavelet analysis procedure was developed to identify the third heart sound automatically, a technique that was shown to be superior to Fourier transform techniques. In the second step, the method was applied to phonocardiograms from heart patients known to have heart failure. The features of the third heart sound in children and of that in patients were shown to be similar. This resulted in a method for the automatic detection of third heart sounds. The method was able to detect third heart sounds effectively (90%), with a low false detection rate (3.7%), which supports its clinical use. The detection rate was almost equal in both the children and patient groups. The method is therefore capable of detecting, not only distinct and clearly visible/audible third heart sounds found in children, but also third heart sounds in phonocardiograms from patients suffering from heart failure.

Adolescent↗
PubMed2003

[First clinical experiences with the new LTS. A laryngeal tube with an oesophageal drain].

OBJECTIVE: The feasibility of prototypes of the LTS, a laryngeal tube with an additional oesophageal drain tube for pressure relief, was tested for ventilation during surgery. METHODS: After approval of the ethics committee, a LTS was placed in 30 orthopaedic patients, ASA I and II, induction of general anaesthesia with fentanyl and propofol. Position of the LTS was verified by auscultation and end tidal CO(2)-measurement. Oxygen saturation, number of placement attempts, cuff pressure, time until first tidal volume, tidal volume and airway pressures were registered intraoperatively. Patients were questioned about hoarseness and soar throat 1 h, 6 h and 24 hours after surgery, graded on a visual analogue scale (VAS). RESULTS: 16 women and 14 men were investigated. In 29 patients (96.7%), the LTS was placed successfully (second attempt in three patients). In one patient, sufficient ventilation was not possible. In this case and in another patient with sufficient ventilation but estimated duration of surgery >3 h, endotracheal intubation was performed. Average time until first tidal volume was 17.3 seconds, ventilation was performed for 74 minutes. Pulse oximetric oxygen saturation was > or =97% at all times. Auscultation over the stomach was negative in all patients with an average cuff pressure of 73.7 cm H(2)O. During controlled ventilation aiming at an end tidal CO(2) of 35 mmHg (average 36.3 mmHg), an average tidal volume of 579 ml was reached, resulting in an inspiratory peak pressure of 20.2 cm H(2)O. Minimal traces of blood on the LTS were found in 5 patients, hoarseness was present in one patient after 6 hours, soar throat was stated after 1 hour by one patient (VAS 3), after 6 hours by 6 (average VAS 2.7) and after 24 hours by 3 patients (VAS 1.3). CONCLUSIONS: The LTS can be used for ventilation during elective surgery and can be placed with a high success rate. Postoperative complaints are infrequent and mild.

Adult↗
PubMed2003

Foreign body aspiration in children: diagnosis and treatment.

A total of 235 children, aged between 7 months and 15 years had bronchoscopy on suspicion of foreign body aspiration. The histories of these patients were studied to examine the diagnostic value of symptoms, signs, and chest x-rays, and rate of negative bronchoscopy. The sensitivity of choking and coughing was high (82% and 80%), but the specificity was poor (37% and 34%). The sensitivity of a chest radiograph was 66%, the specificity was 51%. The sensitivity of asymmetric auscultation was 80% and specificity was 72%. The sensitivity and specificity of combination of symptoms, signs and abnormal chest radiograph was 61% and 83%, respectively. In 206 (87.7%) children a foreign body was identified and extracted. The remaining 29 patients (12.3%) had negative bronchoscopy. A wide variety of objects was recovered, the most common being seeds and peanuts. Foreign bodies were in the right and left main bronchus in 72 (35%), 50 (24.3%) cases, respectively, while in the remaining 84 cases, the foreign bodies were in other parts of the respiratory tree. In 204 (99%) patients with foreign body aspiration, the foreign bodies were removed successfully using a rigid bronchoscopy. Minor complications like subglottic edema and bronchospasm occurred in 4 children. In conclusion, rigid bronchoscopy is a safe procedure and the only tool that will give certainty about the correct diagnosis of foreign body aspiration in children. Asymmetric auscultation is more specific than history and chest radiograph. The combination of history, clinical signs and radiological signs are more specific than each one separately.

Adolescent↗
PubMed2006

Phonocardiographic signal analysis method using a modified hidden Markov model.

Auscultation is an important diagnostic indicator for cardiovascular analysis. Heart sound classification and analysis play an important role in the auscultative diagnosis. This study uses a combination of Mel-frequency cepstral coefficient (MFCC) and hidden Markov model (HMM) to efficiently extract the features for pre-processed heart sound cycles for the purpose of classification. A system was developed for the interpretation of heart sounds acquired by phonocardiography using pattern recognition. The task of feature extraction was performed using three methods: time-domain feature, short-time Fourier transforms (STFT) and MFCC. The performances of these feature extraction methods were then compared. The results demonstrated that the proposed method using MFCC yielded improved interpretative information. Following the feature extraction, an automatic classification process was performed using HMM. Satisfactory classification results (sensitivity > or =0.952; specificity > or =0.953) were achieved for normal subjects and those with various murmur characteristics. These results were based on 1398 datasets obtained from 41 recruited subjects and downloaded from a public domain. Constituents characteristics of heart sounds were also evaluated using the proposed system. The findings herein suggest that the described system may have the potential to be used to assist doctors for a more objective diagnosis.

Data Interpretation, Statistical↗