Clearing up the confusion about crackles, percussion, rhonchi in
the bronchi and other lung assessment curiosities
Dr Michal Boyd
Nurse Practitioner/Sr Lecturer
School of Nursing and Freemasons’ Dept. of Geriatric Medicine
The University of Auckland
Waitemata DHB
1
Use a systematic method
Investigate - previous history, medications, labs & imaging
Then
Observe
Palpate (feel)
Percuss (tap)
Auscultate (listen)
Paint the clinical picture and make sure everything fits
together!
2
Skin:

During your assessment you notice that a
patient's skin colour is pallid (pale). What
might this indicate and why?
If hypoxic (low in oxygen) the skin will appear
pale as hypoxia causes vasoconstriction.
Skin:

Cyanosis

Pneumothorax

COPD
Clubbing

Lung cancer is the most common cause
of clubbing. Clubbing often occurs in heart
and lung diseases that reduce the amount
of oxygen in the blood, such as:

Heart defects that are present at birth
(congenital)

Chronic lung infections that occur in people with
bronchiectasis, cystic fibrosis, or lung abscess

Infection of the lining of the heart chambers and
heart valves (infectious endocarditis), which can
be caused by bacteria, fungi, or other infectious
substances

Lung disorders in which the deep lung tissues
become swollen and then scarred (interstitial
lung disease)
Cardiac and
Respiratory
Assessment
Anterior Thorax
Posterior Thorax
Anterior and Posterior Lung Lobes
9
Bronchial
Segments
Anterior View
Lateral View
Percussion & Auscultation
Percussion and Auscultation
Lung Auscultation and Percussion
14
What would percussion sound like?
CHF
What would percussion sound like?
Emphysema
Abnormal Respiratory Sounds

Crackles (Rales)

Rhonchi


Medium

Fine

Late Inspiratory
A coarse rattling sound
somewhat like snoring,
usually caused by
secretion in a bronchial
tube

Wheeze

Stridor

Lung Consolidation
Pneumonia

Pleural Rub
Question?

A person is anxious and clammy with an
obvious increase in work of breathing. Before
reaching for the stethoscope you can hear
this?

What could cause this breath sound?


swelling, a foreign body, or a tumour
What would you do next?
Documentation

What does the person look like?



SOB at rest, with exertion?
Tripod Position?

Has there been a significant change
and if so, how long ago?

Vitals – Respiration rate, Heart rate,
temperature, blood pressure,
Shortness of Breath



Auscultation – what is heard, where
is it heard and does it clear with
cough?

Lung Sounds Clear or abnormal?




Is there a cough and is it productive
– and if so how much and what
does it look like?
Pulse Oxymetry – above 90%

How far can they walk
Are they short of breath at rest?



Crackles?

Recent changes?

Where is it heard on the chest?
Inspiratory, Expiratory or both?
Percussion Dull or hyperresonant?
Auscultation distant, absent or
normal?
Where?
Percussion – dullness? Where?
A patient has fallen and fractured their ribs. A person has a sudden onset of
shortness of breath with associated right-sided chest pain.
The patient is clammy, hypotensive, and tachycardic.
What could be the cause and what would you expect to hear on auscultation
and percussion?

Condition?
 pneumothorax

Auscultation findings?
 Would be decreased/absent breath sounds in the right side of the
chest with increased work of breathing.

Percussion findings?
 Hyper-resonant
Thoracic Expansion
In Conclusion:
Whenever I feel blue,
I start breathing again.
L. Frank Baum (Author of Wizard of Oz)