Rhonchi in the Chest: Causes and Treatment
Rhonchi are low-pitched continuous lung sounds (≤200 Hz) that indicate airway secretions or obstruction, most commonly caused by bronchiectasis, COPD, bronchitis, or pneumonia, and treatment focuses on addressing the underlying condition rather than the rhonchi themselves. 1, 2
What Are Rhonchi?
Rhonchi are continuous adventitious lung sounds with these key characteristics:
- Low-pitched rumbling noises with dominant frequency of approximately 200 Hz or less 1, 3
- Most prominent during forced expiration 1, 2
- May clear or change after coughing as secretions move, which distinguishes them from other adventitious sounds 1, 2
- Not specific to any single disease and require correlation with other clinical findings 1
Primary Causes
Most Common Conditions
Bronchiectasis is a major cause where rhonchi commonly occur alongside crackles and clubbing, though physical examination findings may be entirely normal in some cases 4, 2. High-resolution CT scanning is the diagnostic procedure of choice when bronchiectasis is suspected, as the presence or absence of rhonchi does not reliably correlate with HRCT findings 2.
Chronic Obstructive Pulmonary Disease (COPD) produces rhonchi that reflect underlying chronic obstructive lung disease pathology, though physical findings are nonspecific and often coexist with other pulmonary conditions 2.
Bronchitis and Pneumonia commonly present with rhonchi due to airway secretions or obstruction in both acute and chronic forms 1, 2. However, in pediatric pneumonia evaluation, rhonchi alone without other findings like tachypnea, rales, or decreased breath sounds do not significantly increase the likelihood of pneumonia on chest radiograph 2.
Less Common Causes
- Asthma exacerbations can present with bilateral polyphonic rhonchi 5
- Cardiac conditions such as left atrial myxoma may rarely present as refractory wheeze with rhonchi 6
- Kartagener's syndrome with bronchiectasis and situs inversus 7
Diagnostic Approach
Critical Limitation
Rhonchi are not sufficiently diagnostic to determine the specific underlying condition and do not reliably predict the severity of airway obstruction 1, 2. Their detection should prompt further evaluation rather than serve as a standalone diagnosis.
Recommended Workup
Initial imaging: Obtain chest radiograph initially; proceed to high-resolution CT if bronchiectasis is suspected 2.
Assess for associated findings:
- Sputum production volume and character 2
- Presence of clubbing 2
- Other adventitious sounds (crackles, wheezes) 2
- Pattern of symptoms (acute vs. chronic) 1
Pulmonary function testing should be considered to assess the degree of obstruction 2.
Sputum cultures are indicated if chronic productive cough is present 2.
Treatment Approach
General Principle
Treatment targets the underlying respiratory condition causing the rhonchi, not the rhonchi themselves. The specific intervention depends entirely on the diagnosed etiology.
Condition-Specific Management
For bronchiectasis: Management should be multidisciplinary with involvement of respiratory physicians, and may include intravenous antibiotic therapy based on known microbiology during exacerbations 4. Major hemoptysis requires involvement of interventional radiology and thoracic surgeons, with bronchial artery embolization as first-line treatment if significant hemoptysis persists 4.
For COPD/bronchitis: Treatment includes bronchodilators, corticosteroids, and oxygen therapy as indicated by severity 4, 5.
For pneumonia: Appropriate antimicrobial therapy based on suspected or confirmed pathogen 4.
For acute severe presentations: Nebulized bronchodilators, systemic steroids, oxygen, and chest physiotherapy may be required 5.
Important Caveat
The presence of rhonchi during physical examination may guide diagnostic testing such as imaging studies or pulmonary function tests, but should never delay treatment of obvious acute respiratory distress 1. In patients presenting with severe dyspnea and rhonchi, immediate supportive care and oxygen therapy take precedence over diagnostic workup 4, 5.