Animesh Ray
Department of Pulmonary Critical Care and Sleep Medicine, Fortis Flt. Lt. Rajan Dhall Hospital, New Delhi, India

Correspondence Address:
Animesh Ray
Department of Pulmonary Critical Care and Sleep Medicine, Fortis Flt. Lt. Rajan Dhall Hospital, New Delhi
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/1817-1737.165311

1. Along with posttussive crepitations, which the authors have discussed at length, posttussive suction also deserves special mention. Posttussive suction refers to the hissing sound caused due to air entering the cavity (during inspiration) which has collapsed due to forceful expiration during coughing. ^[2]
2. Lung auscultatory findings are often represented in graphical terms as symbols and signs by different physicians. However, the lack of universally accepted guidelines and consequent inconsistency in representation and interpretation make the use of symbols and signs obfuscating. As such written descriptions or proper coding/labeling of diagrams/symbols are an essential part of every clinical note to avoid unnecessary confusion. ^[3]
3. Besides the signs mentioned by the authors some other auscultatory signs which are not that commonly used but have been described in literature are:



• Bacelli's sign: It refers to the relative preservation of the whispered sounds over nonpurulent effusions as compared to purulent effusions. ^[4]
• Falling drop sound: It refers to the highly resonant and reverberating metallic sound or tinkle resembling the tolling of a distant church-bell or the sound of drops of water falling into a partially filled metallic cistern. These sounds are brought about by changing of posture from supine to sitting up or by coughing, laughing or forced breathing, and can be seen in cases of hydropneumothorax or large cavity. ^[5]
• Water whistle sign: If there is a pleuropulmonary fistula with the opening of fistula below the fluid level in the pleural sac then with every inspiration there may be a whistling sound produced which is called the water whistle sign. ^[5]
• Bagpipe sign: Normally no sound is audible after a sudden expiration since the pressure in the lungs rapidly approaches atmospheric pressure in the absence of airways obstruction. However, if there is partial obstruction due to any cause the pressure in the lung during expiration persists for some time during which the expiratory sound may be heard. This is called bagpipe sign. ^[6]
4. Besides vesicular and bronchial breath sounds bronchovesicular breath sounds have been described. They have intermediate characteristics between bronchial and vesicular breath sound. They can be normally heard over the upper part of the sternum and the interscapular region posteriorly because of bifurcation of the trachea. The presence of these sounds in any other regions is indicative of disease and is commonly seen in incomplete or patchy consolidation.
5. Regarding vocal resonance, two special types of resonance deserve special mention:



• Amphoric vocal resonance refers to the echoing voice sounds heard typically over cavities or open pneumothorax.
• Artificial vocal resonance refers to repeated percussion or tapping of the patient's thyroid cartilage in cases of deaf-mutism, aphonia, and coma in order to produce sounds which are auscultated over the chest.

References

1.	Sarkar M, Madabhavi I, Niranjan N, Dogra M. Auscultation of the respiratory system. Ann Thorac Med 2015;10:158-68.   [PUBMED]
2.	Post-tussive Suction. Available from : http://www.medilexicon.com/medicaldictionary.php?t=86191 .
3.	Scott G, Presswood EJ, Makubate B, Cross F. Lung sounds: How doctors draw crackles and wheeze. Postgrad Med J 2013;89:693-7.
4.	Bacelli′s Sign. Available from: http://www.medilexicon.com/medicaldictionary.php?t=81812 .
5.	Bauer J. Differential Diagnosis of Internal Diseases. 3 rd edition. William Heineman Medical Books Limited. 2013.
6.	Murray and Nadel′s Textbook of Respiratory Medicine. 6 th edition.Elsevier Inc. 2015.