Pulmonary Concepts In Critical Care
Breath Sounds
There have been
Visitors to this website.
Return to Nurse Bob's© Page
Planning For a Good Assessment
One of the most important parts for any patient assessment essence
annihilation of the breath sounds. The best way to do that is with ausculation,
that is listening with a stethoscope. Often within an intensive care unit, it is
difficult to create a quiet environment to listen to breath sounds. Even after
turning off televisions and unnecessary equipment there is still quite a bit of
noise within the intensive care unit. The patient should be setting up, or
setting on the side of the bed when the examination is performed. Ideally, he
should have his arms crossed in front of his chest while setting on the side of
the bed. However, at times this is not possible, due to the patient's mental
status, or physical condition. It's always a good idea to ask for assistance when
setting patients up until you determine the patients physical capabilities.when
listening to patients with a stethoscope it is always good practice to listen with
a stethoscope pressed directly on the patients again. Always insure that the
patient is comfortable, he should be drapped and only those areas required
for examination should be expose. it is not a good idea among the attempt to
listen to breast sounds when the patient is uncomfortable, uncooperative, or
in pain. Of course, the stethoscope should be warmed before use.
When listening to thepatient's chest, it is always a good idea to do it in a
symmetrical manner. First listen to the left side, then listen to the right side in
the same location to determine if there's any difference. it's a good idea to
start I still waiting at the apex of the lungs and then glue from side aside to
Perry as you approach the basis. Remember, is best to do it the same way, in
the same sequence, every time. If you get abnormal breath sound title is
around it to time to locate its exact extent and character.
Categories of Breath Sounds
1. Normal Breath Sounds
As mentioned previously, breath sounds categorized according to their
location; pitch, intensity, and inspiratory to expiretory ratio. As an air travels
through the bronchial tree and pulmonary branches breast sounds are
produced. This turbulence is created with each expiration as well as
inspiration. When there are no obstructions to the airways normal air
movement occurs, this is normal breath sounds. However, when there is an
obstruction, by such things as constriction, fluid, or hyperexpansion, abnormal
breath sounds will occur.
Tracheal Breath Sound: These sounds are usually relatively high pitched and
loud. They are equal and a length. They our best heard in the neck over and
the trachea. Unfortunately, for this reason, the sounds are not often
ausculated.
Vesicular Breath Sound:
The vesicular breath sound is the major normal breath sound and is heard over
most of the lungs. They sound soft and low-pitched. The inspiratory sounds
are longer than the expiratory sounds. Vesicular breath sounds may be
harsher and slightly longer if there is rapid deep ventilation (eg post-exercise)
or in children who have thinner chest walls. As well, vesicular breath sounds
may be softer if the patient is frail, elderly, obese, or very muscular.
iii. Bronchial Breath Sound
Bronchial breath sounds are very loud, high-pitched and sound close to the
stethoscope. There is a gap between the inspiratory and expiratory phases of
respiration, and the expiratory sounds are longer than the inspiratory sounds.
If these sounds are heard anywhere other than over the manubrium, it is
usually an indication that an area of consolidation exists (ie space that usually
contains air now contains fluid or solid lung tissue).
iv. Bronchovesicular Breath Sound
These are breath sounds of intermediate intensity and pitch. The inspiratory
and expiratory sounds are equal in length. They are best heard in the 1st and
2nd ICS (anterior chest) and between the scapulae (posterior chest) - ie over
the mainstem bronchi. As with bronchial sounds, when these are heard
anywhere other than over the mainstem bronchi, they usually indicate an area
of consolidation.
2. Abnormal Breath Sounds
i. Absent or Decreased Breath Sounds
There are a number of common causes for abnormal breath sounds, including:
ARDS: decreased breath sounds in late stages
Asthma: decreased breath sounds
Atelectasis: If the bronchial obstruction persists, breath sounds are absent
unless the atelectasis occurs in the RUL in which case adjacent tracheal sounds
may be audible.
Emphysema: decreased breath sounds
Pleural Effusion: decreased or absent breath sounds. If the effusion is large,
bronchial sounds may be heard.
Pneumothorax: decreased or absent breath sounds
ii. Bronchial Breath Sounds in Abnormal Locations
Bronchial breath sounds occur over consolidated areas. Further testing of
egophony and whispered petroliloquy may confirm your suspicions.
3. Adventitious Breath Sounds
i. Crackles (Rales)
Crackles are discontinuous, nonmusical, brief sounds heard more commonly
on inspiration. They can be classified as fine (high pitched, soft, very brief) or
coarse (low pitched, louder, less brief). When listening to crackles, pay special
attention to their loudness, pitch, duration, number, timing in the respiratory
cycle, location, pattern from breath to breath, change after a cough or shift in
position. Crackles may sometimes be normally heard at the anterior lung bases
after a maximal expiration or after prolonged recumbency.
The mechanical basis of crackles: Small airways open during inspiration and
collapse during expiration causing the crackling sounds. Another explanation
for crackles is that air bubbles through secreations or incompletely closed
airways during expiration.
Conditions:
ARDS
asthma
bronchiectasis
chronic bronchitis
consolidation
early CHF
interstitial lung disease
pulmonary edema
ii. Wheeze
Wheezes are continuous, high pitched, hissing sounds heard normally on
expiration but also sometimes on inspiration. They are produced when air
flows through airways narrowed by secretions, foreign bodies, or obstructive
lesions.
Note when the wheezes occur and if there is a change after a deep breath or
cough. Also note if the wheezes are monophonic (suggesting obstruction of
one airway) or polyphonic (suggesting generalized obstruction of airways).
Conditions:
asthma
CHF
chronic bronchitis
COPD
pulmonary edema
iii. Rhonchi
Rhonchi are low pitched, continous, musical sounds that are similar to
wheezes. They usually imply obstruction of a larger airway by secretions.
iv. Stridor
Stridor is an inspiratory musical wheeze heard loudest over the trachea during
inspiration. Stridor suggests an obstructed trachea or larynx and therefore
constitutes a medical emergency that requires immediate attention.
v. Pleural Rub
Pleural rubs are creaking or brushing sounds produced when the pleural
surfaces are inflammed or roughened and rub against each other. They may
be discontinuous or continuous sounds. They can usually be localized a
particular place on the chest wall and are heard during both the inspiratory
and expiratory phases.
Conditions:
pleural effusion
pneumothorax
vi. Mediastinal Crunch (Hamman’s sign)
Mediastinal crunches are crackles that are synchronized with the heart beat
and not respiration. They are heard best with the patient in the left lateral
decubitus postion. As with stridor, mediastinal crunches should be treated as
medical emergencies.
Conditions:
pneumomediastinum
Summary
Type
Characteristic Intensity
Pitch
Description
harsh; not routinely
auscultated
tracheal
loud
high
vesicular
soft
low
bronchial
very loud
high
Normal
bronchovesicular medium
medium
absent/decreased
.
.
bronchial
.
.
Abnormal
Location
over the
trachea
most of the
.
lungs
over the
sound close to
manubrium
stethoscope; gap
(normal) or
between insp & exp
consolidated
sounds
areas
normally in
1st & 2nd
ICS anteriorly
and between
scapulae
.
posteriorly;
other
locations
indicate
consolidation
heard in ARDS,
asthma, ateletasis,
emphysema, pleural
.
effusion,
pneumothorax
indicates areas of
.
consolidation
discontinuous,
may
nonmusical, brief;
sometimes
more commonly
be normally
crackles (rales)
wheeze
Adventitious
rhonchi
stridor
pleural rub
mediastinal
crunch
Return to Nurse Bob's Page
be normally
soft (fine
heard on inspiration;
high (fine
heard at ant.
crackles)
assoc. w/ ARDS,
crackles ) or
lung bases
or loud
asthma,
low (coarse
after max.
(coarse
bronchiectasis,
crackles)
expiration or
crackles)
bronchitis,
after
consolidation, early
prolonged
CHF, interstitial lung
recumbency
disease
continuous sounds
normally heard on
can be
expiration; note if
anywhere
monophonic
over the
(obstruction of 1
lungs;
high
expiratory airway) or polyphonic
produced
(general obstruction);
when there
assoc. w/ asthma,
is
CHF, chronic
obstruction
bronchitis, COPD,
pulm. edema
continuous musical
sounds similar to
low
expiratory
wheezes; imply
.
obstruction of larger
airways by secretions
musical wheeze that
heard
suggests obstructed loudest over
.
inspiratory
trachea or larynx;
trachea in
medical emergency inspiration
creaking or brushing
usually can
sounds; continuous
be localized
or discontinuous;
.
insp. & exp.
to particular
assoc. w/ pleural
place on
effusion or
chest wall
pneumothorax
crackles
best heard
not
synchronized w/
w/ patient in
synchronized
.
heart beat; medical
left lateral
w/
emerg.; assoc. w/
decubitus
respiration
pneumomediatstinum position