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BOOKS, FILMS, TAPES, & SOFTWARE
is true throughout the book, applications one can spend hours hopping around cyber- I think will help avoid some potential frus-
are discussed and illustrated by using sim- space. trations of developing a database. Because
ilar examples from the 2 principal hand- The first medical application presented is of its clarity and medical specificity, the
held computer operating systems: Palm patient tracking. The biggest selling point of description is actually more useful than the
and Pocket PC. The generous use of im- these applications is probably the accurate program manual.
ages of handheld computer screens helps recording of charges. The data entry for the The ability of a handheld computer to
to illustrate concepts and the stepwise use patient tracking programs presented is mostly transmit, store, and display rich media such
of applications. Also included in this chap- menu-driven. This technique requires enter- as photographs, video, and audio can add a
ter is an explanation of the 2 methods of ing certain information before moving on to new dimension to the clinician’s practice.
information sharing with these devices: the next step, which prevents omitting in- While the size of the screen limits the use-
synchronizing and beaming. These pro- formation and guarantees that all appropri- fulness of visual media, it adds a valuable
cesses can be especially challenging for ate patient information is entered, including tool to the clinician’s repertoire. For exam-
the novice, and the authors provide a suc- charges. Of course, having all the necessary ple, the video recording of a bronchoscopy
cinct, clear explanation. The issue of con- information required for diagnosis and treat- could be shared with colleagues at a dis-
fidentiality of patient information is also ment is critical, and this would also be guar- tance, allowing collaboration from virtually
mentioned and emphasized here, because anteed with a menu-driven system. anywhere. The authors discuss several ex-
of the ease with which information can be Another invaluable feature of handhelds amples of the value of this multi-media ca-
shared between handhelds, from handheld is that information can be transmitted im- pability.
to desktop computer, and from desktop to mediately, as the clinician enters the data, to Overall, Handhelds in Medicine is an
handheld. The issue of information secu- a central database, where it could be avail- excellent introductory text for nonusers and
rity/confidentiality is still being debated, able to other users. The clinician can also novices. It is also useful for more experi-
weighing the benefit of availability of in- receive updated information, such as labo- enced clinicians, providing introductions
formation with the potential for breaches ratory results, patient updates, and new con- and “how-tos” on more advanced topics.
in confidentiality of patient information. sults. This application can be a very useful, The wealth of information on available re-
The authors then review the process of time-saving tool. sources alone may be worth the book’s pur-
acquiring and installing new software. The Clinical calculations can be made easy chase price. In addition, many of the pro-
chapter is devoted to the technical proce- with appropriate handheld applications, grams described in the book are available
dures for downloading and installing soft- which is reviewed in the next chapter. Cal- on the included CD-ROM. I would recom-
ware. Finding specific software is discussed culations such as anion gap, predicted spi- mend this book to all clinicians as an intro-
in later chapters. Included in the chapter is rometry values, and Glasgow coma scale duction to the coming widespread use of
a discussion of the use of the main memory are preprogrammed. The user has only to handheld computers in medicine.
of the device versus use of expansion mem- enter the relevant data and the calculator
Randy De Kler MSc RRT
ory, which can be tricky. This issue is dis- produces the results. Several of these pro-
School of Allied Health Technologies
cussed honestly, including the caveat that grams are free and download information is
Miami Dade College
some software is limited in the ways it can included in the book.
Miami, Florida
be installed and used, and that technical dif- Another effective exploitation of the size
ficulties are not uncommon. and capacity of handheld computers is hand-
The remainder of the book introduces the held-based references. Entire reference texts R.A.L.E Lung Sounds 3.1 Professional
reader to the many potential uses of hand- can be stored and viewed on a handheld Edition. Winnipeg, Manitoba, Canada: Pix-
held computers in medicine, highlighting se- computer. The reader programs used to ac- Soft and Medi-Wave. 2004. Professional
lected software. This part begins with an cess these texts allow for searching the text, edition download $49; CD-ROM $59; in-
effective review of Internet sites related to which expedites information retrieval. Ref- stitutional edition CD ROM $195; student
handheld computing. The chapter includes erencing peer-reviewed journals is also pos- edition download $19.95.
over 80 Web sites devoted to handheld com- sible. The authors describe services that pro-
The difference between listening to a
puting in medicine, many of which the au- vide access to journal citations and, in some
radio sermon and going to church . . .
thors rate regarding organization, usefulness cases, abstracts. Although the full text of
is almost like the difference between
and timeliness of information, and various articles is not widely available for hand-
calling your girl on the telephone and
intangible features unique to some sites. The helds, many full-text articles will be soon.
spending an evening with her.
rating system resembles movie rating sys- Articles in some of the popular electronic
—Dwight L Moody
tems that use a number of stars to indicate formats can be read by handhelds, so it is
the movie’s quality. Here stethoscopes are possible to maintain a library of current lit- R.A.L.E. Lung Sounds 3.1 is a multi-
used instead of stars, with 5 stethoscopes erature on a handheld. media computerized textbook and educa-
being the highest rating. In their enthusiasm Another valuable ability of handhelds is tional program. It encompasses over 50 re-
for the subject, the authors do not mention developing custom databases. While this is cordings of lung sounds, each with color
the potential for excessive time consump- probably not something a novice would be graphics that relate the sounds to pitch, tim-
tion in searching for information or soft- comfortable with, the process is not very ing within the breathing cycle, and inten-
ware. Anyone who searches the Internet on difficult with some of the database programs. sity. The program includes 12 teaching case
a regular basis knows that the search must The authors describe the process in a clear, studies and 24 cases in a quiz/self-assess-
be focused and as narrow as possible. If not, easily understood, and encouraging way that ment format. Version 3.0 of this product
RESPIRATORY CARE • OCTOBER 2005 VOL 50 NO 10 1385
BOOKS, FILMS, TAPES, & SOFTWARE
Fig. 1. Sample of the teaching window in the R.A.L.E. Lung Sounds tutorial. This frame describes stridor. In the text box (right) the user
can read content and click on hypertext-linked words. The white vertical line moves left to right in synchrony with the lung sound as it plays.
In this graphic the line is nearing the end of inspiration of the last breath of a flow-versus-time curve. The sonogram (below the flow-
versus-time curve) shows both the frequency and the loudness (in decibels [dB], with a color spectrum). Note that the stridor in this
recording is predominately during inspiration. The solid bar on the upper right corner of the sonogram elevates and descends with
inspiration and expiration. The navigation buttons (at the bottom of the graphics area) are “Help”, “Find”, “Back”, “Stop”, and the
volume-control button (speaker symbol). (Courtesy of PixSoft.)
was reviewed in RESPIRATORY CARE in 2002.1 and later pick up where they left off, or Yellow or red lines are used for volume-
The present analysis will again provide a classroom instructors who want to go to a versus-time curves. A blue vertical “respi-
general description of the software and com- specific area of the text as part of their pre- ration bar” (on the right side of the graphics
ment on the changes in version 3.1. sentation or quiz. The pink hypertext links area) dynamically displays the inspiratory
The computer-based tutorial functions point to Web sites, and these links have versus expiratory movements of the breath.
much like a “hybrid” Internet-based format been updated for this version 3.1. The linked This helps the learner easily reference the
that combines written text, digital images, Web pages provide both background and inspiratory versus expiratory timing of the
and hypertext links to Web sites. Figure 1 greater details on the topics discussed in the breath sounds. This bar is an updated fea-
shows the basic screen layout, with the text. The interactivity of the tutorial allows ture from the previous version of R.A.L.E.
graphics and navigation buttons on the left breaks in the reading and makes wonderful Lung Sounds. A white vertical line scans
and a text box on the right. The initial in- use of Web resources. left-to-right over the flow or volume curve
structions clearly explain the system. The The advantage of R.A.L.E. Lung as the sound is played, correlating the sound
reader proceeds through the text and clicks Sounds over other lung-sounds teaching to the position on the curve. The lower part
on the blue hypertext links to bring up the systems is the integration of the text, graph- of the graphics area shows the sonogram
graphics and sounds. ics (sonograms), and sound recordings. The and the breath’s “sound characteristics.” As
The table of contents includes blue hy- upper part of the screen’s graphics area (see it moves across the screen (ie, through time),
pertext links that allow immediate naviga- Fig. 1) shows flow-versus-time curves, for the white vertical line’s dynamic position
tion to all parts of the tutorial. This is handy several breaths, with a blue line, similar to on the left vertical axis represents frequency
for independent learners who want to stop the graphics on contemporary ventilators. (in hertz) or pitch as the sound evolves. The
1386 RESPIRATORY CARE • OCTOBER 2005 VOL 50 NO 10
BOOKS, FILMS, TAPES, & SOFTWARE
intensity of the sound (in decibels) is shown which accompany rib fractures or gas-col- section, though this link is provided later, in
with a color spectrum (black low, yel- lection in tissue space. And there was no the separate “references” section.3 Many of
low medium, hot pink high). The com- discussion of bilateral or unilateral abnor- the journal articles listed at the end of the
bination of the visual sonogram and simul- malities in either the absence of or reduced lung-sound tutorial section are classics from
taneous sound playback is a key learning volume of breath sounds, which accompany older publications that could not be hyper-
feature of this tutorial. It allows learners to pleural effusion, pneumothorax, and endo- text linked. Since version 3.1 became avail-
connect the sounds with visual cues and with bronchial intubation. able in 2004, a few articles have appeared
the timing of the inspiratory-expiratory cy- Links to Internet sites are given to sup- that are full-text online.9 –15
cle. A similar physiologic display is a pho- port the discussion on chest assessment I think the case studies will be the most
nocardiogram, which links electrocardio- via percussion, spirometry, spirometry in- helpful sections to those either initially learn-
gram graphics with echocardiogram sounds. terpretation, and an overview of respira- ing auscultation or refreshing their patient-
In the table of contents there is a hyper- tory physiology. Adventitious sounds in- assessment skills. Version 3.0 had only 6
text link to PixSoft’s Web site, which Pix- clude wheezes, rhonchi, crackles, squeaks, case studies; Version 3.1 has 12. The cases
Soft calls the R.A.L.E. Repository.2 There, squawks, and pleural friction rubs. Upper demonstrate connections between the nor-
anyone can find a sampling of breath sounds, respiratory or voice sounds include grunt- mal and abnormal lung sounds with patho-
which are in the recording-plus-sonogram ing and stridor. I was pleased at the brief physiologic manifestations. The case stud-
format described above. The Web site also but helpful discussion and example of ies are the most interactive part of the tutorial.
provides audio links, citations, and links to rhonchus/rhonchi. The term “rhonchus” The user is asked to identify normal lung
full-text access to classic articles on respi- has been part of the general confusion on sounds, upper-airway sounds, adventitious
ratory sounds.3 The site is also a “clearing- terminology that appears to have been on- lung sounds, and when in the breathing cy-
house” for the links in the R.A.L.E. Lung ¨
going since Laennec’s time. “Rhonchus” cle the sounds are heard. Feedback from the
Sounds tutorial. has even been deleted in some teaching program is immediate.
Following the instruction text section, the materials and early terminology standards. The R.A.L.E. Lung Sounds tutorial can
initial tutorial covers the scientific aspects R.A.L.E. Lung Sounds does an excellent be purchased as a CD-ROM or as a down-
of acoustics. The basic physics of sound are job of using current accepted terminolo- load from the company’s Web site. Those
reviewed, with short discussions and sono- gy.7,8 However, it is curious that this soft- who have purchased either the 3.0 or 3.01
graphic examples of frequency (pitch), in- ¨
ware is named after Laennec’s rale which versions can download the updated version
tensity, harmonics, and audible perception is currently not recommended; “crackles” at http://www.rale.ca/updates.htm, for free.
by the human ear. Although adequate for is the favored term. R.A.L.E. Lung Version 3.1 is very similar, but provides
most beginning respiratory care or nursing Sounds does provide 2 very nice exam- updated Internet links, adds the dynamic res-
students, a link is provided to a Web site for ples (sound/sonographic) of rhonchi com- piration bar, and maximizes to a full-size
those who need details on acoustic phys- bined both with tracheal breath sounds Windows screen.
ics.4 Next in this section is a discussion of and its higher pitched variant, wheezing. The software is quite easy to load into a
the stethoscope, complete with a link to the Text in this section briefly describes cur- computer and very easy to navigate while
history of its development and a biography rent understanding of the acoustic events using the tutorial. The hardware require-
´ ¨
of Rene Laennec. The final section is a very responsible for adventitious sounds. This al- ments are: Windows 95 or later operating
brief review of positioning a stethoscope on lows the learner to connect auscultation find- system, a Windows-compatible 16-bit sound
the chest, with graphic examples. A link is ings with various pathologies. I found it un- card, and 11–15 megabytes of available disk
provided to the University of Iowa’s Virtual fortunate that the tutorial grouped such a space. Sound reproduction is enhanced by
Hospital Web site for details on lung anat- heterogeneous group in a section called using either headphones or high-quality ac-
omy, relating radiographic and computed “other sounds,” which combined sounds cessory computer speakers.
tomography images to external anatomic lo- from the upper airway (stridor and grunt- There are several pricing levels. The stu-
cations of lung lobes and pulmonary seg- ing) and the pleura (pleural friction rubs) dent edition (requires proof of student sta-
ments.5 Of interest was the absence of a with those from within the lungs (squeaks tus) download version, for an individual stu-
link to information on lung auscultation at and squawks). Although the text does men- dent for one year, costs $19.95. The student
that same site.6 tion the locations, it might have been easier upgrade to the professional edition costs $29.
The 2 main sections of the tutorial re- for the beginner if the sounds were grouped The professional edition download costs
view normal and adventitious breath sounds. according to anatomic site. $49. The professional edition on CD-ROM
The sonograms help the learner visually to The tutorial does a very nice job of graph- costs $59. The CD-ROM institutional edi-
differentiate tracheal, bronchial, and vesic- ically illustrating the issue of paradoxical tion for a single computer costs $195. A site
ular sounds. The text discussion of bron- breathing, by contrasting movement be- license for use on any number of comput-
chial sounds, which are inappropriately lo- tween the chest and abdomen in upper-air- ers, provided they are permanently located
cated where vesicular sounds should be, is way obstruction. At the end of this key sec- at the offices, grounds, and/or campus of
deferred to the case studies (eg, pneumo- tion there are links to 12 related books and the licensing company or educational insti-
nia). Both adult and infant sounds are pro- journal articles, but unfortunately none of tution, costs $995.
vided. That approach is also used with “voice these links are to the full-text item. Also R.A.L.E. Lung Sounds is a powerful
sounds,” including bronchophony, whis- unfortunately, the link to the most informa- learning tool. There is some documentation
pered pectoriloquy, and egophony. There is tive article on lung sounds that is available that multimedia of this type do provide an
no discussion on crepitations or crepitus, full-text on-line was not included in this advantage to beginning students, compared
RESPIRATORY CARE • OCTOBER 2005 VOL 50 NO 10 1387
BOOKS, FILMS, TAPES, & SOFTWARE
to conventional teaching methods.15,16 This to an already fine learning system. I would 8. Cugell DW. Lung sound nomenclature. Am
tutorial is unique among lung-sounds teach- recommend this teaching system for both Rev Respir Dis 1987;136(4):1016–1017.
ing materials. The first lung-sounds teach- individuals who are beginning their study 9. Mikami R, Murao M, Cugell DW, Chretien
ing systems used audio tapes with books. of chest auscultation and educational pro- J, Cole P, Meier-Sydow J, et al. Intern-
grams for nurses, respiratory therapists, and tional symposium on lung sounds. Synop-
Audio CDs then replaced tapes. Some sys-
sis of proceedings. Chest 1987;92(2):342–
tems have offered CD-ROMs with narrated physicians. It is a great starting point. How-
346.
script and the user clicked on (static) spec- ever, since there is considerable variation in 10. Verghese ST, Hannallah RS, Slack MC,
tral images of breath sounds while the sounds lung sounds among patients, the next step is Cross RR, Patel KM. Auscultation of bi-
were played. R.A.L.E. Lung Sounds is the to listen to many lung sounds with an ex- lateral breath sounds does not rule out en-
first to combine dynamic graphics with perienced mentor. dobronchial intubation in children. Anesth
acoustics. I commend PixSoft for their com- Analg 2004;99(1):56–58.
panion R.A.L.E. Repository Web site, at Jeffrey J Ward MEd RRT 11. Paciej R, Vyshedskiy A, Bana D, Murphy
University of Minnesota/Mayo Program in R. Squawks in pneumonia. Thorax 2004;
which they make many sounds available.2
Respiratory Care 59(2):177–178.
Chest auscultation requires blending an 12. Welsby PD, Parry G, Smith D. The stetho-
understanding of the physics of acoustics Rochester, Minnesota
scope: some preliminary investigations.
with the skills of interpretation and human Postgrad Med J 2003;79(938):695–698.
interaction. It is neither exact science nor 13. Sprikkelman AB, Grol MH, Lourens MS,
voodoo. In addition to auscultation, assess- REFERENCES Gerritsen J, Heymans HS, van Aalderen
ment of breathing also requires inspecting WM. Use of tracheal auscultation for the
chest motion, muscle movement, skin color, 1. Wilkins RL. R.A.L.E. Lung Sounds 3.0 assessment of bronchial responsiveness in
(media review). Respir Care 2002;47(9): asthmatic children. Thorax 1996;51(3):
and palpation of the body. The challenge of
1024–1025. 317–319.
bringing new acoustic and imaging technol- 2. PixSoft. The R.A.L.E. Repository. http:// 14. Kompis M, Pasterkamp H, Wodicka GR.
ogy along with computers to this cognitive www.rale.ca. Accessed July 26, 2005. Acoustic imaging of the human chest. Chest
and time-honored standard has provided 3. Pasterkamp H, Kraman SS, Wodicka GR. 2001;120(4):1309–1321.
plenty of grist for editorials.17–19 Portable Respiratory sounds: advances beyond the 15. Mangione S, Duffy F. The teaching of chest
ultrasound devices may evolve to parallel stethoscope. Am J Respir Crit Care Med auscultation during primary care training:
the usefulness of the imaginary “tricorder” 1997;156(3 Pt 1):974–987. has anything changed in the 1990s? Chest
bioscanner device in Gene Roddenberry’s 4. http://www.campanellaacoustics.com/ 2003;124(4):1430–1436.
faq.htm. Accessed July 26, 2005. 16. Sestini P, Renzoni E, Rossi M, Beltrami V,
“Star Trek” science fiction series. Most com-
5. Thompson BH, Lee WJ, Galvin JR, Wilson Vagliasindi M. Multimedia presentation of
mentaries recount the stethoscope’s power
JS. University of Iowa’s virtual hospital: lung sounds as a learning aid for medical
as a bonding tool for the clinician and the lung anatomy. 1993. http://www.vh.org/ students. Eur Respir J 1995;8(5):783–788.
patient, especially since many patients are adult/provider/radiology/lunganatomy/ 17. Ward JJ. Lung sounds: easy to hear, hard
unable to speak because they are intubated. introduction.html. Accessed July 26, 2005. to describe (editorial). Respir Care 1989;
I found a recent letter-to-the-editor in RE- 6. Gudmundsson G, Asmundsson T. Lung 34(1):17–19.
SPIRATORY CARE quite interesting; Murphy sounds: chest auscultation. University of Io- 18. Wilkins R. Is the stethoscope of the verge
recounted that the original impetus for the wa’s Virtual Hospital: Lung Anatomy. 2000 of becoming obsolete? (editorial) Respir
development of the stethoscope was in fact http: //www.vh.org/adult/provider/internal Care 2004;49(12):1488–1489.
medicine/lungsounds/lungsounds.html. 19. Hubmayr RD. The times are a-changin’:
to distance the listener from the patient’s
Accessed July 26, 2005. should we hang up the stethoscope? (edi-
body odors and lice.20 7. Updated nomenclature for membership re- torial) Anesthesiology 2004;100(1):1–2.
R.A.L.E. Lung Sounds is a wonderful action. Reports of the ATS-ACCP Ad Hoc 20. Murphy RL. The stethoscope—obsoles-
software tutorial. This 2004 update, Ver- subcommittee on pulmonary nomenclature. cence or marriage (letter). Respir Care
sion 3.1, provides some minor enhancements ATS News 1977; 3:5–6. 2005;50(5):660–661.
1388 RESPIRATORY CARE • OCTOBER 2005 VOL 50 NO 10
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