LUNG SOUNDS :
ASCULTATION
• The lungs produce three categories of sounds that clinicians appreciate during
auscultation:
• breath sounds
• adventitious sounds, and
• vocal resonance.
• Breath Sounds
• Normal breath sounds are classified as bronchial, vesicular, or
bronchovesicular, which have different acoustic properties based on the
anatomical characteristics of the location where you are auscultating.
Bronchial sounds (also called tubular sounds) normally arise from the
tracheobronchial tree, and vesicular sounds normally arise from the finer lung
parenchyma. Loud, harsh, and high-pitched bronchial sounds are typically
heard over the trachea or at the right apex. They are predominantly heard
during expiration. If heard in other areas of the lung, bronchial sounds are
abnormal. In contrast, vesicular breath sounds are soft, low-pitched,
predominantly inspiratory, and appreciated especially well at the posterior
lung bases. Bronchovesicular sounds can be heard during inspiration and
expiration and have a mid-range pitch and intensity. They are commonly heard
over the upper third of the anterior chest.
• Adventitious Sounds
• The most commonly heard adventitious sounds include
crackles, rhonchi, and wheezes. Stridor and rubs
• The first trait that assists in the classification of
adventitious sounds is whether the sounds are
continuous or intermittent.
• The next thing to note is the pitch
• Crackles are generated by small airways snapping open on
inspiration.[2] Therefore, they are predominantly
inspiratory. The difference between the coarse and fine
crackles is believed to come from the size of the airway
snapping open (larger airways, deeper pitched, coarser
crackles
• Wheezes are musical sounds caused by air movement
through constricted small airways, such as bronchioles.
Rhonchi are coarse, loud sounds caused by constricted
larger airways, including the tracheobronchial passages.
These sounds occur during expiration, or both inspiration
and expiration, but they do not occur in inspiration alone.
• Stridor is a high-pitched sound originating from the
upper airway and occurring on inspiration. It is
distinguished from other sounds by its intensity in the
neck more so than the chest, timing (inspiratory), and
pitch (high)
• A rub is a grating sound coming from an inflamed
pleura rubbing against one another. It is usually louder
than other lung sounds due to its generation closer to
the chest wall. Rubs usually occur during both
inspiration and expiration at a mirrored point in the
respiratory cycle.
• Vocal Resonance Normal lung tissue acts as a low-pass filter in that it allows low-
frequency sounds to move through easily while filtering high-frequency sounds.
Pathological lung tissue can transmit higher frequency sounds more efficiently; this
occurs when a normally air-filled lung becomes occupied by another material, such as
fluid. Physicians can exploit this phenomenon through the physical exam.[2] Tests used
to detect this phenomenon, known as vocal resonance, include bronchophony,
egophony, and whispered pectoriloquy. To test for these, the clinician places their
stethoscope over symmetric areas of the patient's chest and asks the patient to speak.
The clinician usually would hear an unintelligible, distant, and muffled vocal sound. In
bronchophony, the voice appears closer and louder. Egophony occurs when pathological
lung tissue distorts vowel sounds and makes them more nasal in quality, and therefore
makes the sound of a hard E heard as an A, referred to as "E to A changes." [6]
Pectoriloquy describes the finding of a clear and intelligible sound when the patient
whispers; it usually is unclear and unintelligible.
• Methods of performing auscultation1. Auscultation should be done in a
quiet room, preferably in asitting position. If the patient cannot assume
sitting posture,roll the patient from one side to the other to examine
theback.2. Always warm up the cold stethoscope by rubbing thechest
piece in your hands before placing it on naked body.Auscultation
should never be done through the clothing.3. Ask the patient to take
deep breaths through the openmouth.4. Using the diaphragm of the
stethoscope, start auscultationanteriorly at the apices, and move
downward till no breathsound is appreciated. Next, listen to the back,
starting atthe apices and moving downward. At least one
completerespiratory cycle should be heard at each site.5. 6. Always
compare symmetrical points on each side.Listen for the quality of the
breath sounds, the intensity ofthe breath sounds, and the presence of
adventitious sounds.
