I've noticed none of my patients are short of breath today, but because they have crackles they for some reason need Albuterol QID. So I've decided there must be something about Albuterol that requires a nebulizer, something we RTs are not privy to. And I found it. I found, somewhere between the pages of 1001 and 1002, in an old dusty version of the Real Doctor's Creed, a listing of the ten different types of crackles. Here they are as best I can read them (some of the letters are worn with age).
1. Positional Crackles: They follow the path of least resistance, like water. When the patient lies on left side, crackles are on left side, and when patient sits up crackles on in bases.
2. Fever Crackles: (synonym: atelectasis). These are your fine bibasilar crackles usually associated with a mild fever. They are very common in post operative patients, sometimes referred to as a post operative respiratory complication. Since they may be the precursor to pneumonia, a nebulizer must be indicated.
3. Lobar crackles: Crackles usually only present in a particular lobe. These are usually used to diagnose lobar pneumonia.
4. Bibasilar crackles: Crackles heard only in bases no matter what position patient is in. Usually associated with COPD. Can either be fine inspiratory type (COPD), or coarse type (heart failure, kidney failure, viral pneumonia)
5. Coarse crackles: See wet crackles, see rhales.
6. Fine inspiratory crackles: Sound of alveoli popping open on inspiration. Usually heard with lobar crackles or bibasilar crackles (COPD type)
7. Wet crackles: loud, and heard on inspiration and expiration. Usually this is fluid. Synonym: Rhales. Often associated with heart failure, kidney failure, pulmonary edema. Can often be heard 1/2 way up the chest, maybe to the nipples. May also be caused by viral pneumonia, and this is usually an "Oh Shit! lung sound if that's the case.
8. Rhales: See coarse crackles, wet crackles