Auscultation Flashcards
Surface Marking of Lungs
> Anteriorly - 2.5cm above medial 1/3 of clavicle (trachea divides just below manubriosternal joint level) - 4th costo-sternal joint - 6th costosternal joint = right lung - 6th rib (mid-clavicular line) = left lung > Laterally - 8th rib = mid-axillary line > Posteriorly 2cm either side of T2-T10
Fissures
> Oblique (both sides) - separates upper/middle + lower
- Spinous processes of T3 round to 6th costal cartilage level (~7cm from midline) - costochondral junction
> Horizontal (right only) - separates upper + middle
- 4th costal cartilage meets oblique fissure @ mid axillary line
What is auscultation?
> Listening to and interpreting sounds produced within the thorax
used to verify observed + palpated findings before/during/after treatment
worth listening at the mouth before auscultation - identify any crackles heard here by coughing (prevent them masking other sounds)
Stethoscope
> Ear pieces - face forwards
Conducting tube (~35-40cm)
Chest piece
- Diaphragm: high frequency sounds (lungs)
- Bell: lower frequency sounds (heart)
: smaller patients - distinguish between lobes
Procedure
- Clean stethoscope + make sure tuned to diaphragm
- Explain process
- removal of clothing to get good contact on skin
- areas that will be listened to
- position patient - access all areas if poss
- If not feeling well - how they can get physios attention
- open mouth breathing to create more turbulence
- otherwise as quiet as possible (clear throat/nose)
- don’t talk unless need my attention because not feeling well - Document informed consent (patient shows understanding)
- Systematically
- Upper lobes = anteriorly (less muscle/scapula in way)
- Middle lobes/area = Laterally (no middle lobe on left)
~around nipple level just in front of armpit with arm across chest
- Lower lobes = posteriorly - base + slightly higher
(slide under patient if they can’t sit up)
At least one respiratory cycle in each area - Document findings + clean up
What are we looking for?
> Breath sounds
- normal
- increased (bronchial)
- Decreased/absent
> Added Sounds
- Crackle
- Wheeze
- Rub
Breath Sounds - How are they generated
> Generated by turbulent air in airways
Only in first 4-5 generations (more laminar flow after that) *primary bronchi to bronchioles
Lung tissue is a better sound conductor than air
> Listening for:
- Intensity (more turbulent = louder)
- Quality
- Duration
- Pitch
Normal Breath Sounds
> Heard over entire lung (quieter the further we get from trachea)
Muffled quality
Inspiration is louder (more turbulent) and longer (expiration lasts longer but is less turbulent so less audible)
No pause between inspiration + expiration
Increased (Bronchial) Breath sounds
> Darth Vader like
Louder + more coarse than normal
Inspiration + Expiration
- Same pitch
- Same duration
- Same intensity
Definite pause between inspiration/expiration
*Lung tissue becomes more dense due to pathology
e.g consolidation (mucus/fluid/pus in airways) /collapse/large mass
Decreased/Absent Breath sounds
> Much quieter (can affect any lobe or complete lung)
Due to:
- Decreased ventilation (less air = less turbulence)
e.g collapse/consolidation
- Decreased mechanics of breathing/Chest wall movement
e.g: scoliosis/rib #’s/positioning/pain
- Decreases transmission of sound
e.g obesity/pleural effusion
+ Hyperinflation
+ Pneumothorax
+ ankylosing spondylitis (inflammation of joints around spine)
Added Sounds
> On top of breathing sounds (can mask breath sounds)
HAVE TO BE RESPIRATORY IN ORIGIN (eliminate all other causes)
Can occur in either inspiration/expiration - document when and during what stage - early/mid/late as can inform area affected
> Crackle
Wheeze
Rub
Added Sounds - Crackle
> Due to:
- explosive equalisations of gas pressure (closed section of airway suddenly opens)
- secretions as air passes over/through them (absence of crackles doesn’t mean absence of sputum)
*If heard on expiration - sputum related
* If collapse will likely be in late inspiration (max pressure build up)
Timing indicates position especially for sputum (early = proximal, late = peripheral)
Cause:
- Collapse
- Atelectasis (collapse/closure of whole lobe/lung)
- sputum
- pulmonary oedema
- fibrosis (scarring + stiffening)
Added Sounds - Wheeze
> Whistling = narrowed airway - monophonic = single airway - polyphonic = several airways *greater narrowing = higher pitch > Cause - Bronchospasm (contraction of bronchioles) - Oedema - Sputum - Tumour - Foreign Body
- Stridor = narrowing of upper airway
- sounds like choking
Added Sounds - Rub
> Creaky
Pleural Surfaces rubbing together = inflamed
*usually during late inspiration + early expiration (identical sound)
Things that can interfere with auscultation
> Movement of stethoscope on skin
Oral cavity sounds (clear throat + nose 1st) - no talking
Clothing/ sheets in the way
Hairy skin (use bell instead of diaphragm)
Water in tubing (humidified O2 - empty water first)
Shivering
External sounds - environment
- we need:
- firm skin contact
- cough/blow nose 1st
- patient has a way of getting therapists attention
