Lung Sounds
An Assessment of the
Patient in Respiratory
Distress
Michael Ciccarelli, DO
December 12, 2006
Introduction
• Lungs major function
– Provide continuous gas exchange between
inspired air and blood in the pulmonary
circulation
Anatomy of Respiratory System
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Nasopharynx
Larynx
Trachea
Bronchi
Bronchioles
Alveoli
Anatomy
• Respiratory tract extends from mouth/nose
to alveoli
• Upper airway filters airborne particles,
humidifies and warms inspired gases
• Lower airway serves for gas exchange
Anatomy
Blood Supply
• Lungs have a double blood supply
– Pulmonary circulation for gas exchange with
the alveoli (pulmonary artery with
subdivisions)
– Bronchial arteries arising from descending
aorta supplies lung parenchyma
Contributors of Respiration
• Controlled in the brainstem
• Mediated by muscles of respiration
– Diaphragm primary muscle of inspiration
– Accessory muscles of inspiration
• SCM
• Scalenes
• Intercostals
• Expiration is a passive process from elastic
recoil of lung and chest wall, with passive
diaphragm relaxation
Mechanism for Breathing
• Pressure gradient required to generate air
flow
– Diaphragm contracts, descends and enlarges
thoracic cavity
– Intra-thoracic pressure decreases
– Air flows through tracheobronchial tree into
the alveoli expanding lungs
Technique for Respiratory Exam
• NEED ORDERLY PROCESS
• Before beginning, if possible:
– Quiet environment
– Proper positioning (patient sitting for posterior thorax exam,
supine for anterior thorax exam)
– Bare skin for auscultation
– Patient comfort, warm hands and diaphragm of stethoscope, be
considerate of women (drape sheet to cover chest)
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Inspect
Palpate
Percuss
Auscultate
Initial Respiratory Survey
• Observe the patient’s breathing pattern
– Rate (normal vs. increased/decreased)
– Depth (shallow vs. deep)
– Effort (any sign of accessory muscle use,
inspect neck)
• Assess the patient’s color
– cyanosis
Normal Respiratory Rates
– Infant 30-60
– Toddler 24-40
– Preschooler 22-34
– School-age child 18-30
– Adolescent 12-16
– Adult 10-20
Pertinent History
– Any chronic conditions
• Asthma, COPD, CHF, DM
– Exposure to new medication
• ACE-Inhibitor, Abx
– Recent change in diet
• Peanuts, Strawberries
– Substance abuse/Overdose
• Opioid abuse, ASA toxicity
– Prior DVT, PE
– Recent trauma to chest
Inspection
• Note the shape of the chest and the way it
moves
– Deformities or asymmetry
• Increased AP diameter in COPD
– Abnormal retractions of interspaces during
respiration
• Lower interspaces, supraclavicular in acute
asthma exacerbation
– Impaired respiratory movement
• Flail Chest and paradoxical movement with rib fx’s
Palpation
• Identify tender areas
– Bruising with rib fx
• Observe for appropriate chest wall
expansion
• Feel for tactile fremitus symmetrically
– palpable vibrations transmitted to chest wall
– use ulnar surface of hand, say “ninety-nine”
– decreased with COPD, pleural effusions, PTX
Percussion
• Helps to identify if underlying tissues are
air-filled, fluid-filled, or solid
– Hyperextend middle finger of either hand and
press against chest wall
– Strike with flexed middle finger of opposite
hand
• Always percuss symmetrically on chest
wall
Percussion Notes
• Flatness
– Thigh
• Dullness
– Liver
• Resonance
– Lung
• Hyperresonance
– None
• Tympany
– Stomach, puffed cheek
Percussion
• Dullness replaces resonance when fluid or solid
tissue replaces air containing lung
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PNA
Pleural Effusions
Hemothorax
Tumor
• Unilateral Hyperresonance
– Pneumothorax
• Generalized Hyperresonance
– COPD
Auscultation
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12 anterior locations
14 posterior locations
Auscultate symmetrically
Should listen to at least 6 locations anteriorly
and posteriorly
Breath Sounds
• Normal
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Tracheal
Bronchial
Bronchovesicular
Vesicular
• Abnormal
– Absent/Decreased
– Bronchial
• Adventitious
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Crackles (Rales)
Wheeze
Rhonchi
Stridor
Pleural Rub
Normal Breath Sounds
• Created by turbulent air flow
• Inspiration
– Air moves to smaller airways hitting walls
– More turbulence, Increased sound
• Expiration
– Air moves toward larger airways
– Less turbulence, Decreased sound
• Normal breath sounds
– Loudest during inspiration, softest during expiration
Normal Breath Sounds
• Tracheal
– Very loud, high pitched sound
– Inspiratory = Expiratory sound duration
– Heard over trachea
• Bronchial
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Loud, high pitched sound
Expiratory sounds > Inspiratory sounds
Heard over manubrium of sternum
If heard in any other location suggestive of
consolidation
Normal Breath Sounds
• Bronchovesicular
– Intermediate intensity, intermediate pitch
– Inspiratory = Expiratory sound duration
– Heard best 1st and 2nd ICS anteriorly, and between
scapula posteriorly
– If heard in any other location suggestive of
consolidation
• Vesicular
– Soft, low pitched sound
– Inspiratory > Expiratory sounds
– Major normal BS, heard over most of lungs
Transmitted Voice Sounds
• If abnormally located bronchial or bronchovesicular
breath sounds assess transmitted voice sounds with
stethoscope
– Ask the patient to say “Ninety-nine”, should normally be muffled,
if heard louder and clearer this is bronchophony
– Ask the patient to say “ee”, should normally hear muffled long E
sound, if E to A change this is egophony
– Ask the patient to whisper “Ninety-nine”, should normally hear
faint muffled sound, if louder and clearer sounds are heard this is
whispered pectoriloquy
• Increased transmission of voice sounds suggests that air
filled lung has become airless
Adventitious Breath Sounds
• Crackles (Rales)
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Discontinuous, intermittent, nonmusical, brief sounds
Heard more commonly with inspiration
Classified as fine or coarse
Normal at anterior lung bases
• Maximal expiration
• Prolonged recumbency
– Crackles caused by air moving through secretions
and collapsed alveoli
– Associated conditions
• pulmonary edema, early CHF, PNA
Adventitious Breath Sounds
• Wheeze
– Continuous, high pitched, musical sound,
longer than crackles
– Hissing quality, heard > with expiration,
however, can be heard on inspiration
– Produced when air flows through narrowed
airways
– Associated conditions
• asthma, COPD
Adventitious Breath Sounds
• Rhonchi
– Similar to wheezes
– Low pitched, snoring quality, continuous,
musical sounds
– Implies obstruction of larger airways by
secretions
– Associated condition
• acute bronchitis
Adventitious Breath Sounds
• Stridor
– Inspiratory musical wheeze
– Loudest over trachea
– Suggests obstructed trachea or larynx
– Medical emergency requiring immediate
attention
– Associated condition
• inhaled foreign body
Adventitious Breath Sounds
• Pleural Rub
– Discontinuous or continuous brushing sounds
– Heard during both inspiratory and expiratory
phases
– Occurs when pleural surfaces are inflamed
and rub against each other
– Associated conditions
• pleural effusion, PTX
Causes of decreased or absent
breath sounds
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Asthma
COPD
Pleural Effusion
Pneumothorax
ARDS
Atelectasis
Case #1
• Dispatch Information
– 62 yo female with progressive SOB over past 48 hours
• PMH
– 40 pack year smoking history
– On home O2
– Some type of lung problem
• VS
– O2 sat 78% on 2L O2 NC, RR 26, T 98.1
• Physical Exam
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Barrel shaped chest
Decreased BS B/L
Diffuse expiratory wheezing B/L lung fields
Digital cyanosis and clubbing noted
What is this patient’s condition and
appropriate treatment prior to ED
arrival?
Case #2
• Dispatch Information
– 18 yo male with confusion and multiple episodes of vomiting
• PMH
– No past medical history
– Denies recent drug use or overdose
• VS
– T 98.3, RR 32, HR 116, O2 sat 98% RA
• Physical Exam
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Appears Lethargic
Dry Mucous Membranes
Deep, rapid breathing
Lungs CTA B/L
• Additional Findings
– FS 450
What is this patient’s condition and
appropriate treatment prior to ED
arrival?
Case #3
• Dispatch Information
– 74 yo male with progressive SOB over past week
• PMH
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Poor historian, no family available for information
Difficult time sleeping on 4 pillows
States sees a heart doctor, however, not taking pills
At house full bottles of Coreg, Lisinopril, and Lasix
• VS
– RR 30, O2 sat 82% RA, T 98.4
• Physical Exam
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Rapid, shallow breathing
Accessory muscles of respiration use
Crackles are auscultated at B/L bases
B/L LE pitting edema to knees
What is this patient’s condition and
appropriate treatment prior to ED
arrival?
Case #4
• Dispatch Information
– MVA rollover on Rt. 4 in East Greenbush
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25 yo male
unrestrained driver
significant intrusion into driver door
+ LOC, GCS 13 at present
• PMH
– EtOH abuse
• VS
– RR 28, O2 sat 76% RA
• Physical Exam
– multiple bruises on B/L chest wall
– paradoxical movement of L chest wall
– absent breath sounds on L side
What is this patient’s condition and
appropriate treatment prior to ED
arrival?
Case #5
• Dispatch Information
– 42 yo female with difficulty breathing and facial swelling over
past hour
• PMH
– HTN
– NKDA or food allergies
– Started Lisinopril for BP 1 month ago
• VS
– HR 108, RR 28, O2 sat 86% RA, T 98.4
• Physical Exam
– Perioral facial and lip swelling
– Inspiratory stridor on auscultation
What is this patient’s condition and
appropriate treatment prior to ED
arrival?