BREATH SOUNDS

NORMAL Vesicular These are the normal breath sounds that would be heard over all areas of normally ventilated lungs. They have been described as "leaves rustling" or "like a gentle breeze". The inspiratory-to-expiratory phase ratio is about 3:1. The inspiratory sound is louder than the expiratory sound and there is no pause between inspiration and expiration. Bronchial They are also called tubular. These normal breath sounds would be heard over the trachea and main bronchi. It is a very loud and high pitched. The I:E ratio is about 1:1 and there is a distinct pause between the phases. Bronchial breath sounds are abnormal if heard in any other areas. When bronchial sounds are heard over areas that should be normally vesicular, it is a sign of consolidation or atelectasis. There is often reference to a bronchovesicular sound which is a cross between bronchial and vesicular breath sounds and are found in the apexes of the lungs near the large airways. Decreased Breath Sounds These are most commonly caused by a pleural effusion, hemothorax or empyema because of fluid between the lung and the stethoscope. Other reasons include pulmonary fibrosis and emphysema due to decreased air flow, also pleural thickening dampens the normal sounds Absent breath sounds are due to pneumothorax and having the lung being forced away from the chest wall and atelectasis because no air moves into the collapsed area. Unequal normal breath sounds are caused by pneumonia, consolidation or atelectasis that decreases airflow into a segment or lobe. Foreign body obstruction or tumour in a bronchus decreases air flow to the distal portion of the lung.

ABNORMAL (ADVENTITIOUS SOUNDS) Wheezes These are continuous sounds. They are more commonly heard on expiration then inspiration. They often are high pitched, musical sounds are associated with narrowing of the small airways. Coughing or suctioning will NOT cause the sounds to be modified or eliminated. Fine Crackles (Rales or Creps) These are discontinuous sounds. They are heard more commonly on inspiration than expiration. They are caused by the sudden opening of collapsed airways. They are the same sound a rubbing you hair near your ear with your finger and thumb. They are heard in patients with obstructive lung disease. The sounds will clear if pulmonary edema is corrected. Coarse Crackles (Rhonchi) These are louder and harsher then the fine crackles. They are associated with excessive secretion in the upper airways. They are often cleared with suctioning and/or effective coughing. They are heard in patients with bronchitic type diseases. Strider This is a harsh, high pitched inspiratory sound over the larynx. It can often be heard without the stethoscope and are caused by croup, epiglottitis or post extubation laryngeal edema. When strider is heard on inspiration and expiration, it is commonly caused by an aspirated foreign body, tracheal stenosis or laryngeal tumour. Severe strider is a respiratory emergency because the airway may rapidly close completely. Friction rub The sound is described as a loud grating, or creaking of old leather. It is best heard posteriorly in the lower lobes of the lungs. Coughing does not affect the sound. It is caused by the rubbing together of the parietal and visceral pleura as seen in pleurisy.

Changes in Lung sounds with Disease Lung Disease Pneumonia Atelectasis Pneumothorax Emphysema Chronic Bronchitis Pul Fibrosis CHF Pleural effusion Asthma Breath Sounds Bronchial or absent Harsh/Bronchial Absent Diminished Normal Harsh Diminished Diminished Diminished Adventitious Lung Sounds Inspiratory crackles Late-inspir crackles None Early inspir crackles Wheezes and crackles Inspir crackles Inspir crackles None Wheezes

ANATOMICAL LANDMARKS Left lung is smaller - only 2 lobes (and lingula) heart takes up space on that side Right lung is higher (elevated by the liver) Apex of Lung - as high as T1 - above 1st rib Base of Lung - resting on diaphragm Diaphragm - 6th rib mid clavicular line in front to 8th rib mid axillary line on the side to 10th rib posteriorly - excursion about 2 ribs up and down (approx 9 - 12th rib) Scapulae - from 1st to 8th rib, mid clavicular line is normal positioning but will move forward and up. When raising arms, approximates the oblique fissures on back (at T3) T2 position on the back approximates the upper lobes. Below T2 are the lower lobes (best to listen to lower lobes posteriorly) Cardiac Apex - 5th intercostal space on mid-clavicular line Angle of Louis - at 2nd rib - anteriorly between manubrium and body of sternum Tracheal Bifurcation - behind Angle of Louis at T4 posteriorly Nipples - 4th intercostal space mid-clavicular line

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