-->PONE-D-25-42773-->-->Usefulness of Lung Sound Data Collection Using Skeeper SM-300 ®  Device-->-->PLOS One-->-->

Dear Dr. Lee,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

==============================

Dear Author,

I would like to focus on the comments of Reviewers 1 and 3 during the manuscript revision process. Reviewer 2 thought that the paper should be rejected, and his comments, which require new research, are not relevant to the revision process.

Best regards,

Academic Editor

==============================

Please submit your revised manuscript by Mar 19 2026 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

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We look forward to receiving your revised manuscript.

Kind regards,

Damir Erceg, MD, PhD, Assoc. Prof.

Academic Editor

PLOS One

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When submitting your revision, we need you to address these additional requirements.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

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2.  Thank you for stating the following financial disclosure:

Research funding was raised by SIC from Smartsound Corporation.

Please state what role the funders took in the study. If the funders had no role, please state: "The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript."

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I have read the journal's policy and the authors of this manuscript have the following competing interests: JL, JYK, WYC, HC, and EJL declare a potential conflict of interest due to holding stock/stock options in Smartsound Corporation, which is the funding source for this manuscript. JL, JYK, WYC, and HC are employees of the company. All other authors declare no competing interests.

We note that one or more of the authors are employed by a commercial company: Smartsound Corporation

a. Please provide an amended Funding Statement declaring this commercial affiliation, as well as a statement regarding the Role of Funders in your study. If the funding organization did not play a role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript and only provided financial support in the form of authors' salaries and/or research materials, please review your statements relating to the author contributions, and ensure you have specifically and accurately indicated the role(s) that these authors had in your study. You can update author roles in the Author Contributions section of the online submission form.

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Reviewers' comments:

Reviewer's Responses to Questions

-->Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. -->

Reviewer #1: Partly

Reviewer #2: No

Reviewer #3: Partly

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-->2. Has the statistical analysis been performed appropriately and rigorously? -->

Reviewer #1: No

Reviewer #2: No

Reviewer #3: I Don't Know

**********

-->3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.-->

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

-->4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.-->

Reviewer #1: No

Reviewer #2: Yes

Reviewer #3: No

**********

-->5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)-->

Reviewer #1: Dear Authors, actually it is not understandable to a reader what was the aim of your work. There are too many goals in the research. The sample size is not calculated especially because this is a non-inferiority study as you stated. It is also not known is the non-inferiority associated with all the goals that you mentioned. Your results show some discrepancy between two devices (up to 20%). It is very important how this would possibly influence the outcome of diagnosis and treatment in these subjects. Please correct these important issues.

Reviewer #2: I have significant concerns about this manuscript that prevent me from recommending publication in its current form:

Major Issues:

1. Insufficient sample size and study design: Only 8 participants per condition (n=64 total) is inadequate for a validation study. The authors acknowledge this is a "pilot" study without statistical power calculation, yet draw definitive conclusions about non-inferiority. This sample size is too small to support the broad claims made.

2. Severely limited literature review: Only 8 references is unacceptable for a scientific manuscript. The introduction lacks comprehensive discussion of existing digital stethoscope technology, previous validation studies, and AI applications in respiratory auscultation. The authors fail to adequately position their work within the existing body of knowledge.

3. Limited novelty: This is primarily a device validation study rather than a scientific contribution. Comparing a digital stethoscope to traditional auscultation has been done extensively. What new knowledge does this add to the field?

4. Conflicts of interest concerns: Multiple authors (JL, JYK, WYC, HC, EJL) hold stock in Smartsound Corporation, and several are employees. The study was funded by the device manufacturer. While disclosed, this raises concerns about bias and the independence of the research. The manuscript reads more like a technical validation report for regulatory purposes than independent scientific research.

5. Methodological limitations:

o Single-center study limits generalizability

o No comparison with other digital stethoscopes on the market

o Subjective classification system for lung sounds

o "Tidal breath" analysis showed only fair agreement, yet this limitation is downplayed

6. Overstated conclusions: The abstract and conclusion claim "non-inferiority" and "high credibility" based on limited data. The study shows reasonable agreement for wheezing (>90%) but poor performance for crackles (~80%), yet this is glossed over.

Minor Issues:

• Table 2 formatting could be improved

• Some grammatical inconsistencies throughout

• The mel-spectrogram discussion lacks depth

Recommendations: This manuscript requires major revisions including: expanded sample size with power analysis, comprehensive literature review (minimum 30-40 relevant references), comparison with competing devices, and more balanced discussion of limitations. In its current form, it does not meet the standards for publication in PLOS ONE.

Reviewer #3: The manuscript reports a diagnostic accuracy pilot study with a non-inferiority framework. Auscultatory findings with a traditional stethoscope are compared to reviews of these sounds as they were also recorded using Skeeter-SM-300, a "smart" Bluetooth electronic stethoscope that was introduced to the market in early 2023. The authors found highly accurate results and non-inferiority of Skeeter-SM-300 relative to auscultation with a conventional stethoscope.

Methods:

pg. 6, ln. 95 Participants were checked regarding ongoing acute illness, but it is not clear if or when those with positive findings were excluded.

pg. 6, ln. 113 A coordinator performed conventional auscultation over 6 anterior and 6 posterior sites. He/she marked these sites. Since this coordinator's auscultation served as the "ground truth", it needs to be explained that he/she documented the findings for each location and breath maneuver (deep vs tidal breathing), and that his/her marking of each location (ln. 115) served other coordinators (ln. 99) to immediately record with the Skeeter device at these sites to ideally capture the same sounds that he/she just heard.

pg. 7, ln. 100 The "deep breath" maneuvers of ~10 per minute followed by tidal breaths of ~20 per minute we likely taken at a higher-than-normal inspiratory flow rate. While a critical velocity of airflow is required to elicit airway wall flutter and wheezing, an increased airflow also increases normal lung sounds which then can mask the audibility of crackles. The details of the maneuver may be explained in the Methods section, and/or these influences should be mentioned in the Discussion.

pg. 7, ln, 101 Explain the rationale to record for 1 minute at 12 sites in 64 study subjects? Auscultation in clinical practice would be much shorter, perhaps two or three deeper breaths and over fewer than 12 sites.

pg. 7, ln. 103 One minute of recording at each of 12 sites of the chest should provide 12 minutes per study subject, not 24, unless there were separate "deep breath" and "tidal breath" recordings. Please clarify and consider a flow diagram for easier visualization of these steps of investigation.

pg. 7, ln. 116 Sounds were classified as normal, crackle, wheezing and decreased. In the medical conditions of enrolled patients, it can be expected that, depending on the sites of recording, each of these or even combinations can exist. How was this considered in subsequent analyses of agreement?

pg. 7, ln. 126 The coordinator who had established the "ground truth" (Reference or Gold Standard) by conventional auscultation confirmed the type of breathing sound in cases of disagreement between three raters. He/she additionally referred to Mel-spectrograms. Since he/she knew the "ground truth", there is the potential of bias when using a spectrogram for confirmation. Were there cases in which the spectrogram did not show what he/she had documented? Or did it perhaps show some finding that he/she had not documented but that one or more of the raters had heard? This information is needed to understand sensitivity, specificity and predictive values. Given the different frequency range that is covered by the Skeeter vs. traditional stethoscopes, this needs to be addressed.

pg. 7, ln. 132 The description of decreased lung sound in Fig. 2 claims that energy change over time is small. This is confusing since there are regularly spaced changes that are reflecting heart sounds which is confirmed on listening to the provided examples. On close audiovisual assessment, the logarithmic scale of the Mel-sonogram shows these heart sounds with most energy below 100 Hz but reaching up to ~600 Hz. Is this explained by the clinical status of the participant or perhaps by the acoustic characteristics of the Skeeter? Lung sounds of very low intensity can be distinguished at a rate of around 20 per minute, indicating tidal breathing. The presentation of this spectral plot only makes sense when also showing the recording over the corresponding other side.

pg. 8, ln. 148 Clarify whether the 2 selected raters listened to "the" pre-recorded sounds of 12 tidal and 12 deep breaths in all recordings, i.e. from all 12 sites in all 8 subjects. What does-"pre-"recorded mean in this context?

pg. 8., ln. 153 The secondary outcome of participants comfort is overly complicated. Why five levels of discomfort/comfort? This aspect of the study could be shortened since the participants found the Skeeter either equally or more comfortable than a traditional stethoscope.

pg. 8, ln. 159 Here, the acceptability of digital lung sound also asks for a distinction of "better and considerable acceptable" vs "very acceptable". Without definition of such subtle grading, acceptance by subjects and raters should simply be negative, equal and positive.

pg. 9, ln. 165 When 3 of 64 participants' recordings were arbitrarily (?randomly) chosen to be tested for diagnostic accuracy, was it possible that all 3 came from one of the 8 participants' categories, e.g. all could have had wheezing in acute asthma or crackles in ILD? If not randomly chosen, who was the arbitrator and what were the selection criteria?

Results:

pg. 11, ln. 208 "Crucially, the three Raters’ judgments in classifying electronic lung sounds consistently coincided with the conventional stethoscopic result" should better read "Importantly, the three raters’ classifications of electronic lung sounds were consistent with those obtained using a conventional stethoscope".

Tbl. 3 What explains the significantly higher number of missing values for Rater 1 (68) vs Rater 2 (5)?

Tbl. 4 I suggest describing these findings in the text and omit this table.

Discussion:

pg. 19, ln. 267 Remove “i.e., discontinuous”. Regarding lung sounds, “discontinuous” refers to crackles.

The discussion should present information on the acoustic performance of traditional stethoscopes since the goal of the study was to show non-inferiority. More recent studies are "Acoustical properties of amplified and unamplified stethoscopes when examining typical body sounds" by JA Dunnington in 2017 (doctoral thesis, publicly available at https://digitalcommons.latech.edu/dissertations) and “Acoustic characterization of stethoscopes using auscultation sounds as test signals” by LJ Novak (J Acoust Soc Am 2017; 141(3):1940. doi: 10.1121/1.4978524 ).

The comparison of Skeeter-SM-300 with the Littman Model 3200 stethoscope is not informative. Littman replaced that electronic stethoscope by the CORE model five years ago. The Littman CORE stethoscope has higher amplification, use of Bluetooth, active noise cancellation etc. Comparison with other commercially available stethoscopes might also mention more recently introduced devices, e.g. from TytoCare (https://www.tytocare.com/how-does-tytocare-work/) or Sanolla (https://sanolla.com/product/shop-voqx/) that take different approaches.

As the authors point out, a particular strength of the Skeeter is its usefulness away from the hospital or doctors’ office, i.e. in the homes of patients. This offers a much broader feedback from users who are still needed as the "humans-in-the-loop" to advance the machine learning of chest auscultation (https://doi.org/10.1016/j.chpulm.2024.100079).

**********

-->6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

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Reviewer #1: No

Reviewer #2: No

Reviewer #3: Yes: Hans Pasterkamp

**********

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-->-->-->PONE-D-25-42773R1-->

Usefulness of Lung Sound Data Collection Using Skeeper SM-300 ®  Device

PLOS One

Dear Dr. Lee,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by May 09 2026 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

• A letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'

-->

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

As the corresponding author, your ORCID iD is verified in the submission system and will appear in the published article. PLOS supports the use of ORCID, and we encourage all coauthors to register for an ORCID iD and use it as well. Please encourage your coauthors to verify their ORCID iD within the submission system before final acceptance, as unverified ORCID iDs will not appear in the published article. Only the individual author can complete the verification step; PLOS staff cannot verify ORCID iDs on behalf of authors.

We look forward to receiving your revised manuscript.

Kind regards,

Damir Erceg, MD, PhD, Assoc. Prof.

Academic Editor

PLOS One

Journal Requirements:

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2. Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

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Reviewer's Responses to Questions

-->Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.-->

Reviewer #1: All comments have been addressed

Reviewer #3: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

-->The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.-->

Reviewer #1: Partly

Reviewer #3: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #3: I Don't Know

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

-->The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.-->

Reviewer #1: Yes

Reviewer #3: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

-->PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.-->

Reviewer #1: Yes

Reviewer #3: Yes

**********

6. Review Comments to the Author

-->Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)-->

Reviewer #1: Please as this is the pilot study, you should mention it in the title of the manuscript: Usefulness of Lung Sound Data Collection Using Skeeper SM-300 ® Device: A pilot study

Reviewer #3: I appreciate the changes you made. There are a few remaining issues that you can also see on an uploaded PDF file where I have used strike-out and highlighting for suggested modifications.

Remove detail of your initial 5-level scale of audible acceptability (see page 9, ln 166-174) and references to this elsewhere. The change to just three categories (negative, equal, positive) is logical and will not only appeal to this reviewer but to all readers of your manuscript.

Shorten text on pg. 21, ln 280-291

There were cases where the classification of breath sounds decided by the Coordinator differed from the opinions of the majority of the Raters, so the Coordinator listened to the digitally recorded breath sounds again and checked the Mel-Spectrogram of the breath sounds, and in some cases, the Coordinator's original judgment was revised. This could have occurred because the Coordinator did not listen to the breath sounds with a traditional stethoscope at each site for a whole minute before classifying them as one of the four breath sounds. Considering the limited time for detailed auscultation in doctor’s offices and clinics, Skeeper-recorded breath sounds of patients at home are less constrained by time and thus may provide important clues to clinicians.

Legend for Table 3

Your explanation for the large number of missing values for Rater 1 that you provide to me in your answer has to be added so that all readers who might wonder about possible reasons can understand, e.g., Rater 1 noticed more artifacts from skin friction, low lung sound level during shallower breathing, and/or loud ambient noise. The respective recordings were not counted for him.

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Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.-->

Reviewer #1: No

Reviewer #3: No

**********

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To ensure your figures meet our technical requirements, please review our figure guidelines: https://journals.plos.org/plosone/s/figures

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NAAS will assess whether your figures meet our technical requirements by comparing each figure against our figure specifications.

-->-->-->

Attachments

Attachment

Submitted filename: Review of PONE-D-25-42773_R1.pdf

Usefulness of Lung Sound Data Collection Using Skeeper SM-300 ®  Device: a Pilot Study

PONE-D-25-42773R2

Dear Dr. Lee,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. Please make sure your user information is up-to-date by logging into Editorial Manager at Editorial Manager® and clicking the ‘Update My Information' link at the top of the page. For questions related to billing, please contact billing support.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Damir Erceg, MD, PhD, Assoc. Prof.

Academic Editor

PLOS One

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

-->Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.-->

Reviewer #1: All comments have been addressed

Reviewer #3: All comments have been addressed

**********

-->2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. -->

Reviewer #1: Yes

Reviewer #3: (No Response)

**********

-->3. Has the statistical analysis been performed appropriately and rigorously? -->

Reviewer #1: Yes

Reviewer #3: (No Response)

**********

-->4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.-->

Reviewer #1: Yes

Reviewer #3: (No Response)

**********

-->5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.-->

Reviewer #1: Yes

Reviewer #3: (No Response)

**********

-->6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)-->

Reviewer #1: Dear Authors, you have made all suggested changes that I have made and now your manuscript is acceptable for publication.

Reviewer #3: (No Response)

**********

-->7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

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Reviewer #1: No

Reviewer #3: No

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