"a powerful learning tool..."

J.J, Ward, MEd, RRT in Respiratory Care


Respiratory Care, September 2002
Vol 47 No 9 pg 1024

R.A.L.E Lung Sounds 3.0 CD-ROM. Winnipeg, Manitoba, Canada: PixSoft and Medi-Wave; 2001. Professional edition $59. Institutional edition $195. Student edition $19.95. Requires: operating system Windows 95, 98, ME, NT, or 2000, and Windows-compatible 16-bit sound card. Best sound reproduction with headphones or high-fidelity audio speakers.

A variety of teaching aides have appeared on the market over the past 30 years to assist students and practitioners in learning to recognize and describe lung sounds. Initial teaching aides consisted of audiocassettes that contained a medley of normal and abnormal lung sound samples. Such products are a bit monotonous and lack the ability to stimulate the learner with simultaneous visual and auditory stimuli and often leave the listener wondering whether the sound was inspiratory or expiratory, because of the lack of visual cues. Those problems are now solved with the R.A.L.E. Lung Sounds 3.0 CD-ROM.

This product is a tutorial program designed for "physicians, nurses, and allied health professionals or anyone listening to lung sounds." I found the program appropriate for students as well as practitioners. The language of the program is self-contained and does not require a medical background, but an understanding of pulmonary anatomy and physiology is helpful, and a World Wide Web link to a review of pulmonary anatomy and physiology is provided early in the program.

The program’s design is unique and well thought out. The text is on the right side of the screen; the left side shows color figures and sonograms of sound samples that relate to the corresponding discussion. The reader scrolls through the text and clicks on visual cues in the text to trigger the appearance of figures and sound samples that coincide with the text. As a result, the reader can work at his or her own pace and repeat sections and sound samples as often as needed. The lung sound examples are beautifully presented with sonograms that illustrate the intensity and frequency of the example with color. In addition the sonograms have parallel flow graphs that allow the listener to note the corresponding inspiratory and expiratory breathing cycle. The listener does not have to guess as to which sounds are inspiratory and which are expiratory, as when listening to an audio cassette. The sound samples present a thin vertical line that displays across the screen as the sound is played, which allows the listener to match the color sonogram display with the parallel flow graph.

The program begins with an introduction to acoustics. This section is a little technical but very helpful to learn how sound is created and perceived. The reader gains a better understanding of sound amplitude, frequency, and intensity, and this section also helps to understand the sonograms later in the program. This section also includes brief overviews of how the human ear functions and use of the stethoscope, and a link is provided to a World Wide Web site that describes the history of the stethoscope, shows pictures of early monaural stethoscopes from the 1800s, and describes how Laennec came to produce the first modern-day stethoscope.

The next section describes the basics of lung sounds: normal breath sounds, adventitious lung sounds, and other sounds. Excellent discussions and sound samples of tracheal, bronchovesicular, and vesicular breath sounds are presented. The program describes how normal and abnormal breath sounds are created. Adventitious lung sounds presented include examples of fine and coarse crackles, wheezes, rhonchi, and stridor. The discussion covers current understanding of how adventitious lung sounds are produced in the lung when disease is present. The other sounds in this section include grunting, friction rubs, squeaks, and squawks. This section concludes with a list of current references.

The next section includes 6 case studies of such disorders as asthma, pneumonia, and interstitial pulmonary fibrosis. The cases are relatively brief but illustrate how lung auscultation can be very useful in the diagnosis of pulmonary disorders. Cases of adult, pediatric, and infant chest diseases are included here.

The final section of the program presents 24 quiz lung sounds with which to test your ability to recognize normal and abnormal lung sounds, each of which is presented with a color sonogram. The user is also asked to indicate the timing of the sound during the respiratory cycle (eg, early, mid, or late inspiratory). Once the user has settled on an answer, he or she clicks on an indicator to see the correct answer, which is presented by shading the correct response in blue. I did not disagree with any of the 24 answers provided by the authors.

The authors of this program wisely chose to use the nomenclature encouraged by the International Lung Sounds Association: crackles for discontinuous adventitious lung sounds, wheeze for high-pitched, continuous adventitious lung sounds, and rhonchi for low-pitched, continuous adventitious lung sounds.1 I commend the authors for using the recommended nomenclature, as it may help standardize the terms used by clinicians to describe adventitious lung sounds.

The only problem I found with this program was the labeling of Figure 18b. The "inspiratory" sound of this sample is, in my opinion, an expiratory sound and vice versa. This error is also repeated in quiz sound sample number 8. This error does not detract from the primary purpose of the sample, which is to teach how rhonchi present, but could mislead the novice.

The program was very easy to load; it only took about 3 minutes. I used a computer with the Windows 98 operating system, a Pentium 1 MMX processor (233 MHz), 32 megabytes of random-access memory, and a Yamaha sound card. I recommend the use of head phones for good sound quality.

In summary, the R.A.L.E. Lung Sounds 3.0 program is a complete package designed to teach students and practitioners how to recognize normal and abnormal lung sounds. The authors present each sound sample with exciting color sonograms and flow tracings to illustrate the samples and allow the listener to see which sounds are inspiratory and which are expiratory. The price of the package is very reasonable, especially considering the level of expertise and technology that went into producing it. The user of this program will gain excellent sound recognition skills and learn the proper use of appropriate terminology to describe lung sounds. I highly recommend this product to educators who desire a better understanding of lung sounds for their students, to managers of respiratory care departments who are looking for ways to educate their staff on bedside patient assessment skills, and to clinicians who care for patients with chest diseases.

Robert L Wilkins RRT PhD FAARC
Department of Cardiopulmonary Sciences
School of Allied Health Professions
Loma Linda University
Loma Linda, California


  1. Mikami R, Murao M, Cugell DW, Chretien J, Cole P, Meier-Sydow J, et al. International Symposium on Lung Sounds. Synopsis of proceedings. Chest 1987;92(2):342-345