Respiratory system auscultation

1. RESPIRATORY SYSTEM
AUSCULTATION
DR ANEES KURIKKAL
MD Internal medicine resident
2020/9/22

2. AUSCULTATION
 Listen to the chest with the diaphragm
chest sounds are relatively high pitched
diaphragm is more sensitive than the bell
 Ask the patient to take deep breaths in and out through the mouth
 Demonstrate what you would like the patient to do, and then check visually that
he is doing it while you listen to the chest
 If the patient has a tendency to cough, ask him to breathe more deeply than
usual but not so much as to induce a cough with each breath
 listen in comparable positions to each side alternately, and compare

3. VESICULAR BREATH SOUNDS
Breath sounds have intensity and quality.
The intensity (or loudness) of the sounds may be normal, reduced or increased.
The quality of normal breath sounds is described as vesicular.
Breath sounds will be normal in intensity when the lung is inflating normally

4. Breath sounds probably originate from turbulent airflow in the larger airways
Normal lung tissue makes the sound quieter and selectively filters out some of
the higher frequencies
The resulting sound is called a vesicular breath sound.
There is usually no distinct pause between the end of inspiration and the
beginning of expiration.

5. Breath sounds are reduced in
localized airway narrowing ,
destruction of lung parenchyma (emphysema)
pleural thickening or
presence of pleural fluid

6. BRONCHIAL BREATH SOUNDS
It is produced by passage of air through the trachea and large bronchi,
heard over an area of diseased, airless or consolidated lung interposed between
the bronchi and chest wall.
Character: The quality of the sound is rather harsh, the higher frequencies being
heard more clearly.
The expiratory sound has a more sibilant (hissing) character than the inspiratory
one
and lasts for most of the expiratory phase
There is a pause between inspiration and expiration.

7. TUBULAR : They are high pitched and present in:
• Pneumonic consolidation
• Collapsed lung or lobe when a large draining bronchus is patent
• Above the level of pleural effusion (in a partially collapsed lung with a patent
bronchus).
CAVERNOUS
They are low pitched and heard in the presence of thick walled cavity with a
communicating bronchus.
AMPHORIC
They are low pitched, with a high tone and a metallic quality and present in:
• Large superficial smooth-walled cavity
• Bronchopleural fistula
• Tension pneumothorax.

8. Absent Breath Sounds
a. Pleural effusion (massive)
b. Thickened pleura (fibrothorax)
c. Collapsed lung or lobe when bronchus is occluded
d. Pneumothorax
e. Near fatal asthma (silent chest)
f. Pneumonectomy
g. Agenesis of lung

10. ADDED SOUNDS
Added sounds are abnormal sounds that arise in the lung or in the pleura
From lungs : wheezes and crackles
Older terms such as
• râles to describe coarse crackles,
• crepitations to describe fine crackles and
• rhonchi to describe wheezes,
are poorly defined and have led to confusion and are best avoided.

11. Wheezes are musical sounds associated with airway narrowing.
Widespread polyphonic wheezes,
• heard in expiration,
• most common characteristic of diffuse airflow obstruction,
• in asthma and COPD
Wheezes
• related to dynamic compression of the bronchi,
• accentuated in expiration when airway narrowing is present
Fixed monophonic wheeze 
• localized narrowing of a single bronchus as in tumour or foreign body
FMW : can be inspiratory or expiratory

12. Wheezing generated in smaller airways should not be mistaken for stridor associated with
laryngeal disease
STRIDOR IS LIFE THREATENING AND NEED URGENT MANAGEMENT
In stridor : The noise is often both inspiratory and expiratory.
It may be heard at the open mouth without the aid of the stethoscope.
On auscultation of the chest, stridor is usually loudest over the trachea.

13. CRACKLES
Crackles are short, explosive sounds often described as bubbling or clicking.
It is more likely that they are produced by sudden changes in gas pressure
related to the sudden opening of previously closed small airways
In COPD , crackles at the beginning of inspiration characteristic
Localized loud and coarse crackles may indicate an area of bronchiectasis
Also heard in pulmonary edema
In diffuse interstitial fibrosis, crackles are characteristically fine in character and
late inspiratory in timing


14. PLEURAL RUB : S/O pleural inflammation ,occurs in association with pleuritic
pain.
It has a creaking or rubbing character (said to sound like a foot crunching through
fresh-fallen snow)
EXCLUDE FALSE ADDED SOUNDS !!
Sounds resembling pleural rubs may be produced by movement of the stethoscope on
the patient’s skin or of clothes against the stethoscope tubing.
Sounds arising in the patient’s muscles may resemble added sounds: in particular, the
shivering of a cold patient makes any attempt at auscultation almost useless.
The stethoscope rubbing over hairy skin may produce sounds that resemble fine
crackles

15. VOCAL RESONANCE
Vocal resonance is the resonance within the chest of sounds made by the voice
VR is the is the detection of vibrations transmitted to the chest from the vocal
cords, when patient says words like “ ninety nine”
Compare corresponding sites on both sides
Consolidated lung conducts sounds better than air-containing lung,
• in consolidation the vocal resonance is increased and
• the sounds are louder and often clearer
Even during whispering ,the sounds can be heard clearly  WHISPERING
PECTORILOQUY
Above the level of a pleural effusion, or in some cases over an area of
consolidation, the voice may sound nasal or bleating; this is known as
AEGOPHONY

16. VOCAL FREMITUS
Vocal fremitus is detected with the hand on the chest wall
Even though it is a part of palpation ,its usually carried out after auscultation
Use the hand to feel for vibrations when patient say “ ninety nine”
Flat of the hands, even finger tips are more sensitive than lnar border of hand

17. OTHER SOUNDS
POST-TUSSIVE SUCTION:
• It is a sucking sound, heard over the chest wall during inspiration, following a
bout of cough, over the area of amphoric breath sound.
• It occurs in the presence of thin-walled superficial, collapsible,
communicating cavity.
SUCCUSSION SPLASH:
• Splashing sound heard over the chest either with the stethoscope or unaided
ear applied to the chest wall when the patient is shaken suddenly by the
examiner
• Heard in hydropneumothorax, diaphragmatic hernia

18. COIN SOUND:
• It is the metallic quality of a coin sound produced on one side of the chest, that
can be appreciated on the diametrically opposite side of the chest wall, by use
of a stethoscope on that side.
• heard in tension pneumothorax and at the air fluid level of
hydropneumothorax.
DeEspine’s sign:
• high pitched tubular breathing and whispering pectoriloquy over the thoracic
spine below T3 in adults and T4 in children and infants.
• Due to transmission of bronchial breath sound through a mass or central
pneumonia in the middle or posterior mediastinum.
• Bronchial breath sounds may be heard normally over the midline in the back
up to T3 in adults and T4 in children

19. PUTTING IT TOGETHER
Listening to the breath sounds, listening to the vocal resonance and eliciting vocal
fremitus are all doing essentially the same thing:
• how vibrations generated in the larynx or large airways are transmitted to the
examining instrument, the stethoscope and the fingers ??
In various pathological situations , the three should behave in similar ways
In consolidation , bronchial breathing is heard since the sounds are better
transmitted to the steth, they are louder and there is less attenuation of higher
frequencies
Similarly, the vocal resonance and the vocal fremitus are increased

20. In pleural effusion, the breath sounds are quieter or absent and the vocal
resonance and vocal fremitus are reduced or absent.
Why try to elicit all three signs ? ( If all behave similary ??)
Because it is often difficult to interpret the signs that have been elicited, and
three pieces of information are more reliable than one

22. YAHT K ON U