Sympoms in respiratory
organs diseases based
on the results of
auscultation of lungs.
Pulmonary auscultation has been a
principal feature of standard physical
examinations for many years and is a very
useful initial noninvasive test for lung
diseases.
direct auscultation
Before you begin, there are certain things
that you should keep in mind:
• a) It is important that you try to create a quiet
environment as much as possible.
• b) The patient should be in the proper position for
auscultation.
• c) Your stethoscope should be touching the patient’s
bare skin whenever possible or you may
hear rubbing of the patient’s clothes
against the stethoscope and
misinterpret them as abnormal sounds.
d) Always ensure patient comfort. Be
considerate and warm the diaphragm of
your stethoscope with your hand before
auscultation.
Remember - Don't examine thru clothing or "snake"
stethoscope down shirts/gowns
Good exam options
As you are auscultating your patient,
please keep in mind these 2
questions:
1) Are the breath sounds increased,
normal or decreased?
2) Are there any abnormal
or adventitious
breath sounds?
Points and lobes of auscultation.
Anterior view
Posterior view
categories of breath sounds
•
•
•
•
•
Normal
Tracheal
Vesicular
Bronchial
bronchovesicular
– Abnormal
• absent/decreased
• bronchial
•
•
•
•
•
•
•
Adventitious
crackles (rales)
wheeze
Rhonchi
Stridor
pleural rub
mediastinal crunch
(Hamman's sign)
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.
The vesicular breath sound is the major normal breath sound and is heard over
most of the lungs.
The inspiratory sounds are longer than the expiratory sounds.
Expiration
Inspiration
heard only during the first third of the expiration phase
Vesicular breathing may be louder
or softer for both physiological
and pathological reasons.
1.Vesicular breath sounds
may be harsher and slightly
longer if there is rapid deep
ventilation or in children
(“ puerile respiration” ).
2.Vesicular breath sounds may be softer if the patient is
frail, elderly, obese, or very muscular.
!Physiological changes in vesicular
respiration always involve both parts of the
chest, and respiratory sounds are equally
intensified at the symmetrical points
of the chest.
•
Alterations
in vesicular respiration
in pathology depend on:
― the amount of intact alveoli;
― the properties of their walls;
― the amount of air contained in
them; ― the length and strength
of the expiration and inspiration
phases;
― the conditions of sound
conduction from the vibrating
elastic elements of the pulmonary
tissue to the surface of the
chest.
Pathologically decreased vesicular
respiration
can be:
~ due to a significantly diminished
number of the alveoli;
~ due to inflammation and swelling
of the alveoli walls in a part of the
lung;
~ decreased also in insufficient
delivery of air to the alveoli through
the air ways;
~ due to obstructed conduction of
sound waves from the source of
vibration (alveolar walls) to the
chest surface.
1. Abnormally increased
vesicular breathing
depends on obstruction to the air
passage through small bronchi or
their contracted lumen (increased
expiration).
2. Harsh vesicular breathing
occurs in marked and nonuniform
narrowing of the lumen in small
bronchi and bronchioles due to
inflammatory oedema of their
mucosa (the inspiration and
expiration phases are intensified).
3. Interrupted or cogwheel vesicular respiration is characterized by
short jerky inspiration efforts interrupted by short pauses between them;
the expiration is usually normal
(occurs in non-uniform contraction of the respiratory muscles, when a
patient is auscultated in a cold room, or when he has nervous trembling,
or diseases of the respiratory muscles, Interrupted breathing over a
limited part of the lung indicates pathology in fine bronchi
(their tuberculous infiltration)
Bronchial Breath Sound Respiratory sounds known as bronchial or tubular
breathing arise in the larynx and the trachea as air passes through the vocal
slit. As air is inhaled, it passes through the vocal slit to enter wider trachea
where it is set in vortex-type motion. Sound waves thus generated propagate
along the air column throughout the entire bronchial tree. Sounds generated
by the vibration of these waves are harsh. During expiration, air also passes
through the vocal slit to enter a wider spase of the larynx where it is set in a
vortex motion. But since the vocal slit is narrower during expiration, the
respiratory sound becomes longer, harsher and longer. This type of
breathing is called laryngotracheal
Respiratory sounds known as bronchial or tubular
breathing arise in the larynx and the trachea as air
passes through the vocal slit.
•
Inspiration
Еxpiration
Bronchial breathing can be heard
instead of vesicular
(or in addition to the vesicular
breathing) over the chest in
pulmonary pathology. This breathing
is called pathological bronchial
respiration.
Bronchial breath sounds.
If these sounds are heard anywhere other
than over the manubrium, it is usually an
indication that an area of consolidation
exists (i.e. space that usually contains air
now contains fluid or solid lung tissue).
Amphoric respiration arises in the presence of a
smooth-wall cavity( non less than 5-6 cm in diameter)
communicated with a large bronchus
Metallic respiration differs from both bronchial and amphoric. It
is loud and high, and resembles the sound produced when a
piece of metal is struck. Metallic respiration is heard in open
pneumothorax when the air of if pleural cavity communicates with
the external air.
Stenotic respiration is heard in cases with narrowed trachea or
a large bronchus (due to a tumor);
Bronchovesicular or mixed respiration is heard in lobular
pneumonia or infiltrative tuberculosis, and also in
pneumosclerosis, with foci of consolidated tissue being seated
deeply in the pulmonary tissue and far from one another.
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.
Tracheal Breath Sound
• Tracheal breath sounds are very loud and
relatively high-pitched. The inspiratory and
expiratory sounds are more or less equal
in length. They can be heard over the
trachea which is not routinely auscultated.
Normal Breath Sounds
Feature
Tracheal
Bronchial
Broncho
vesicular
Location
Trachea
Manubri
um
Mainstem
bronchi
Quality
Loud,
harsh,
hollow
Loud, less
harsh,
hollow
Soft
Softer
Pitch
Highest
Higher
High
Low
^\
/"
Duration
/"\
-""\
Vesicular
Peripheral lung
Adventitious
sounds
are rales, crepitation,
and pleural friction.
Rales arise in pathology of the
trachea, bronchi, or if a cavern
is formed in the affected lung.
Rales are classified as
dry (rhonchi) and moist rales.
Dry rales can be due to
(1) spasms of smooth muscles of the bronchi during fits of
bronchial asthma;
(2) swelling of the bronchial mucosa during its inflammation;
(3) accumulation of viscous sputum in the bronchi which
adheres to the wall of the bronchus and narrows its lumen;
(4) formation of fibrous tissue in the walls of separate
bronchi and in the pulmonary tissue with subsequent
alteration of their architectonics (bronchiectasis,
pneumosclerosis);
(5) vibration of viscous sputum in the lumen of large and
medium size bronchi during inspiration and expiration: being
viscous, the sputum can be drawn (by the air stream) into
threads which adhere to the opposite walls of the bronchi
and vibrate like strings.
Dry rales are heard during inspiration
and expiration and vary greatly in their
loudness, tone and pitch. According to
the quality and pitch of the sounds
produced, dry rales are divided into:
sibilant (high-pitched and whistling
sounds are produced when the lumen
of the small bronchi is narrowed)
sonorous rales (low-pitched and
sonoring rales are generated in
stenosis of medium calibre and large
calibre bronchi or when viscous sputum
is accumulated in their lumen).
Moist rales are generated because of
accumulation of liquid secretion (sputum,
oedematous fluid, blood) in the bronchi
through which air passes. Air bubbles
pass through the liquid secretion of the
bronchial lumen and collapse to produce
the specific cracking sound.
Moist rales are heard during both the
inspiration and expiration, but since the
air velocity is higher during inspiration,
moist rales will be better heard at this
respiratory phase.
Depending on the calibre of bronchi where
rales are generated, moist rales are
classified as fine, medium and coarse
bubbling rales.
Fine bubbling rales are generated in fine
bronchi and are percepted by the ear as
short multiple sounds;
Medium bubbling rales are produced in
bronchi of a medium size;
Coarse bubbling rales in large calibre
bronchi, in large bronchiectases, and in
pulmonary cavities (abscess, cavern)
containing liquid secretions and
communicating with the large bronchus.
Depending on the character of the pathology in the lungs, moist
rales are subdivided into:
~ consonating or crackling,
~ non-consonating or bubbling rales.
Consonating moist rales are heard in the presence of liquid
secretions in the bronchi surrounded by airless (consolidated)
pulmonary tissue or in lung cavities with smooth walls surrounded
by consolidated pulmonary tissue. The cavity itself acts as a
resonator to intensify moist rales.
Non-consonating rales are heard in inflammation of
bronchial mucosa (bronchitis) or acute oedema of the
lung due to the failure of the left chambers of the
heart. The sounds produced by collapsing air bubbles
in the bronchi are dampened by the "air cushion" of
the lungs as they are conducted to the chest surface.
Crepitation originates in the alveoli. Crepitation
is a slight crackling sound that can be imitated by
rubbing a lock of hair. The main condition for
generation of crepitation is accumulation of a
small amount of liquid secretion in the alveoli.
During expiration, the alveoli stick together, while
during inspiration the alveolar walls are
separated with difficulty and only at the end of the
inspiratoryn movement. Crepitation is
therefore only heard during the heighi
of inspiration. In other words, crepitation
is the sound produced by many alveoli
during their simultaneous reinflation.
Pleural friction sound.
Pleural friction sound are heard
during both inspiration and
expiration.
The sounds are differentiated by
intensity, or loudness, length,
and site over which they are
heard.
Pleural friction sounds can be differentiated from fine
bubbling rales and crepitation by the following signs:
(1) the character of rales is altered or rales can disappear
for a short time after coughing, while pleural frictionsounds
does not change in these conditions;
(2) when a stethoscope is pressed tighter against the
chest, the pleural friction sound is intensified, while rales do
not change;
(3) crepitation is only heard at the height of inspiration,
while pleural friction sound is heard during both inspiration
and expiration;
(4) if a patient moves his diaphragm in and out while his
mouth and nose are closed, the sound produced by the
friction of the pleura due to the movement of the diaphragm
can be heard, while rales and crepitation cannot because
there is no air movement in the bronchi.

Common errors of
auscultation:
_Auscultating one entire lung, and
then moving to the other lung
__Auscultating over a patient’s
gown or article of clothing
__Beginning auscultation inferiorly
at the lower lung fields
__Moving your stethoscope before
each exhalation is complete
__Examiner does not make the
room quiet enough to hear breath
sounds.
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