Breath sounds

Normal breath sounds are generated by turbulent airflow in the trachea and large airways. These
sounds, which can be heard directly over the trachea, comprise high, medium and low frequencies.
The higher frequencies are attenuated by normal lung tissue so that breath sounds heard over the
periphery are softer and lower pitched. Originally it was thought that the higher-pitched sounds
were generated by the bronchi (bronchial breath sounds) and the lower ones by airflow into the
alveoli (vesicular breath sounds). It is now known that normal breath sounds (previously called
'vesicular') simply represent filtering of the 'bronchial' breath sounds generated in the large airways.
Although technically incorrect, normal breath sounds are still sometimes referred to as 'vesicular' or
'bronchovesicular'.

Normal breath sounds are heard all over the chest wall throughout inspiration and for a short period
during expiration sounds. Normal breath sounds are generated by turbulent airflow in the trachea
and large airways. These sounds, which can be heard directly over the trachea, comprise high,
medium and low frequencies. The higher frequencies are attenuated by normal lung tissue so that
breath sounds heard over the periphery are softer and lower pitched. Originally it was thought that
the higher-pitched sounds were generated by thebronchi (bronchial breath sounds) and the lower
ones by airflow into the alveoli (vesicular breath sounds). It is now known that normal breath sounds
(previously called 'vesicular') simply represent filtering of the 'bronchial' breath sounds generated in
the large airways. Although technically incorrect, normal breath sounds are still sometimes referred
to as 'vesicular' or 'bronchovesicular'.

Normal breath sounds are heard all over the chest wall throughout inspiration and for a short period
during expiration.

BRONCHIAL

BRONCHOVESICULAR

VESICULAR

Diminished sounds occur when there is a reduction in the initial generation of the sound or when
there is an increase in sound attenuation. As the breath sounds are generated by flow related
turbulence, reduced flow causes less sound. Thus, patients who will not (e.g. due to pain), or cannot
(e.g. due to muscle weakness) breathe deeply, will have globally diminished breath sounds. Similarly,
diminished breath sounds are heard in some patients with emphysema where the combination of
parenchymal destruction and hyperinflation cause greater attenuation of the normal breath sounds.
Locally diminished breath sounds may represent obstruction of a bronchus by tumour or large
sputum plugs. Localized accumulation of air or fluid in the pleural space will block sound
transmission so that breath sounds are absent.

Abnormal Breath Sounds

Abnormal breath sounds can be described as when the sound transmission changes as a result of an
underlying pathologic process. Sound is filtered by the lung tissues because these organs are air-
filled; thus there is dampened sound transmission over the bases versus the apices. On the other
hand, sound transmission is enhanced when a liquid or solid is the medium. Certain lung pathologies
produce abnormal lung sounds. Abnormal sounds can be divided into three types: bronchial,
decreased, and absent. Bronchial sounds occur in peripheral lung tissue when it becomes airless-
either partially or completely. In a consolidation type of pneumonia, the lung tissue is Hairless"
because of the complete obstruction of segmental or lobar bronchi by secretions. Sound from the
adjacent bronchi is enhanced and becomes more high-pitched and the expiratory component louder
and more pronounced. Compression of lung tissue from an extrapulmonary source also produces
bronchial sounds. Examples include compression secondary to increased pleural fluid (pleural
effusion) or tumor. Tubular breath sounds is a term used synonymously to describe abnormal
bronchial breath sounds. Decreased or absent breath sounds occur when sound transmission is
diminished or abolished. Decreased breath sounds are when the normal vesicular sounds are further
diminished. Absent sounds are when no sounds are audible. Decreased or absent sounds can be
caused by an internal pulmonary pathology or can be secondary to an initially non-pulmonary
condition. Hyperinflation caused by emphysema causes decreased sound transmission as a result of
the destruction of the acinar units and increased air as a result of loss of normal lung structure. The
loss of lung compliance resulting from pulmonary fibrosis also may produce decreased or absent
breath sounds. Extrapulmonary causes include tumors, neuromuscular weakness (i.e, muscular
dystrophy), and musculoskeletal deformities (i.e., kyphoscoliosis). Pain is a common cause for
decreased or absent breath sounds. When the patient attempts to take a deep breath, the volume is
limited because of the onset of pain. The etiologic factors of the pain can be varied-from incisional
(i.e., midsternotomy) to traumatic (fractured ribs). Given that no underlying pathologies are present,
decreased breath sounds may also be a reflection of the depth of respiration and/or the thickness of
the chest wall (e.g., in obesity or with the presence of bandages). The skill of auscultation lies in the
differentiation between normal and abnormal breath sounds.

Added sounds.

Wheezes, previously called 'rhonchi'. Are musical tones produced by airflow vibrating a narrowed or
compressed airway. A fixed, monophonic wheeze is caused by a single obstructed airway, while
polyphonic wheezes are due to widespread disease. Any cause of narrowing, for example,
bronchospasm. mucosal oedema, sputum or foreign bodies, may cause wheezes. As the airways are
normally compressed during expiration, wheezes are first heard at this time. When airway narrowing
is more severe, wheezes may also be heard during inspiration. The pitch of the wheeze is directly
related to the degree of narrowing, with high-pitched wheezes indicating near total obstruction.
However, the volume of the wheeze may be misleading as the moderate asthmatic may have loud
wheezeswhile the very severe asthmatic may have a 'quiet chest' because he is not generating
sufficient airflow to cause wheezes. Low-pitched, localized wheezes are caused by sputum retention
and can change or clear after coughing.

Crackles, previously called 'crepitations' or 'rales', are clicking sounds heard during inspiration .They
are caused by the opening of previously closed alveoli and small airways during inspiration. Crackles
are described as 'early' or 'late', 'fine' or 'coarse', and 'localized' or 'widespread'. Coarse, early
inspiratory crackles occur when bronchioles open (often heard in bronchiectasis and bronchitis),
whilst fine, late inspiratory crackles occur when alveoli and respiratory bronchioles open (often
heard in pulmonary oedema and pulmonary fibrosis). When severe, the late inspiratory crackles of
pulmonary oedema and pulmonary fibrosis may become coarser and commence earlier in
inspiration. Localized crackles may occur in dependent alveoli which are gradually closed by
compression .Compression from the lung above. This early feature of subsegmental lung collapse
resolves when the patient breathes deeply or coughs. The crackles of pulmonary oedema are also
more marked basally, but only clear transiently after coughing. The differentiation between
subsegmental lung collapse and pulmonary oedema may be difficult, and sometimes auscultation
will not clarify the situation. Elevation of the jugular venous pressure and peripheral oedema suggest
pulmonary oedema, whereas ineffective cough, recent anaesthesia and pyrexia suggest sputum
retention which could lead to subsegmental lung collapse (Table 1.6). Postoperative and intensive
care patients may have a combination of both pulmonary oedema and sputum retention.

Pleural rub is the creaking or rubbing sound which occurs with each breath when the pleural
surfaces are roughened by inflammation, infection or neoplasm. Normally the visceral and parietal
pleura slide silently. Pleural rubs range from being localized and soft to being loud and generalized,
sometimes even palpable. In certain instances, they may be difficult to differentiate from crackles.
An important distinguishing feature is that pleural rubs are heard equally during inspiration and
expiration, with the sounds often recurring in reverse order during expiration. Vocal resonance.