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Learning Lung Sounds

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Laura Gray
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LEARNING LUNG SOUNDS:

OVERVIEW: Lung sounds provide important information in the diagnosis and monitoring of the clinical course of patients with lung disorders.

UNFAMILIAR TERM:

Sibilant- Making or having a sound like the letters ‘s’ or ‘sh’, a hissing effect (wheezing).

LUNG ANATOMY: Trachea branches off at the second rib into the right and left mainstem bronchi. - Right Main Stem Bronchus - Supplies right upper, mid and lower lobes - Left Main Stem Bronchus - Supplies left upper and lower lobes.

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AUSCULATORY SITES: During auscultatory examination --- Patient should be positioned comfortably and instructed to take deep breaths with mouth open. To avoid dizziness, let patient rest a few minutes. If they become dizzy, have patient hold their breath for a moment and this will correct the decrease in PCo2 caused by hyperventilation. This should remedy their dizziness. There are 11 recommended sites for auscultation if no known pulmonary problems. If patient does have history of respiratory disease, may need to listen at more sites.

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Technique: Diaphragm of stethoscope firmly placed onto chest/back.
Begin at upper right lobe then go to upper left lobe comparing the two sides. Go from side to side in all locations to compare. Front of chest and back as well as laterally, again, comparing side to side.

Listen for adventitious sounds and if heard, try to determine what “type”, i.e. wheezing, crackles, etc… Also listen to INTENSITY of sounds. **** Common Mistake*** Failure to notice that the normal vesicular sound has disappeared or is less intense. This may be the FIRST sign of a disease process. Pneumonia, atelectasis or collapsed lung are ALL often associated with decreased intensity of breath sounds. Pneumonia can be present hours or days before any adventitious sounds are heard.

Breath sounds heard at the lung bases are typically LESS intense, particularly in expiration, than those heard in the upper lungs.

At each site*** Ask yourself if the sound is bronchial or vesicular… THEN note the intensity, and finally note whether or not adventitious sounds are present.

If you hear adventitious sounds on auscultation, assess how these sounds change as the patient speaks. Voice assessment can provide important clues about respiratory abnormalities. Normal lungs are filled with air, and air does not transmit sound readily. Normally, transmitted voice sounds are difficult to hear – spoken words are muffled and indistinct and whispered words are usually not heard at all.

Bronchophony: While listening to the chest with a stethoscope, ask the patient to say "99" in a normal voice several times. The expected finding is that the words will be indistinct in a normal lung. Bronchophony is present (which means consolidation is present) if you can hear “99” more clearly.

Egophony: While listening to the chest with a stethoscope, ask the patient to say the vowel “e”. Over normal lung tissues, the same “e” (as in "beet") will be heard. If the lung tissue is consolidated, the “e” sound will change to a nasal “a” (as in "say"). Egophony has higher intensity over abnormal areas. Over healthy lung areas, egophony will not be present.

Whispering Pectoriloquy: While listening to the chest with a stethoscope, ask the patient to whisper the words “one-two-three”, and listen. In normal lungs, only faint sounds are heard. Over areas of tissue abnormality, the whispered sounds will be clear and distinct. The lung area is abnormal if the "1-2-3" sound is understood.
COMMON LUNG SOUNDS:

TRACHEAL/BRONCHIAL - “Air blowing through a cardboard tube”. Louder on expiration. Heard over trachea, axilla, between scapula. ABNORMAL to be heard at a distance from large airways, signifying consolidation

VESICULAR - “Wind blowing leaves in trees” - Most common sound. Louder on inspiration. Heard at sites a distance from large airways. Decreased in COPD and early pneumonia.

FINE CRACKLES - “Salt in a frying pan or wood burning” - Discontinuous/intermittent. Higher pitched and less intense. Caused by sudden airway opening and fluid in airways.

COARSE CRACKLES - “Bubbling sound” - Discontinuous. Caused by airway opening and secretions in airway.

WHEEZES - High-pitched, whistling. Caused by airway narrowing and/or secretions. Also can be seen with airway edema, endobronchial tumors or airway compression. Wheezes are higher pitched than rhonchi.

SQUAWKS - SHORT inspiratory wheeze. Seen with diffuse interstitial diseases, alveolitis and pneumonia.

RHONCHI - “Snore-like” sounds that are more continuous. Low-pitched. Caused by airway secretions and possibly with narrowing. Usually clear after coughing. Heard on inspiration and expiration.

PLEURAL RUB - “Two pieces of leather rubbed together”. Caused by inflamed pleural surfaces rubbing each other such as with pleural inflammation/disease. Have continuous and discontinuous portions and can be both on inspiration and expiration.

STRIDOR - Wheezing noise but more prominent during inspiration. Continuous sound heard with or without a stethoscope. Caused by upper airway obstruction. Accessory muscles can be seen being used. Heard loudest over mouth, neck and upper trachea. Survey mouth for foreign object, trachea for deviation, accessory muscles for use, masses in neck and skin for hives as they can be signs for angioneurotic edema of the glottis (a cause of upper airway obstruction. If stridor is heard after extubation, reintubation may be necessary.

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