Lecture 6 - Auscultation & voice sounds Flashcards
What are the steps for auscultations?
quiet environment
patient sitting –
Posterior evaluation: - arms crossed on chest, if possible
warm stethoscope with hand before placing it on the skin
stethoscope placed directly on bare skin
patient should breathe through the mouth - slightly deeper than normal breaths (makes the sounds louder to hear) - be sure patient doesn’t hyperventilated
evaluate at least one breath in each pulmonary segment.
compare intensity, pitch and quality of the breath sounds between lungs
Tracheal breath sounds:
- where?
- quality
- I:E
- pause
normally heard over the trachea.
loud, harsh, tubular
inspiratory and expiratory sounds
more or less equal in length
I:E = 5:6
distinct pause during the transition from inspiration to expiration
Vesicular breath sounds:
- where?
- quality
- I:E
- pause
- particularities?
found over most of the thorax
soft, low-pitched sound
inspiration louder and
longer than
expiration - I:E ratio = 3:1
no pause between inspiration and expiration
sound may be harsher in kids, thin-walled adults, and after exercise.
diminished sound in thick-walled adults (muscular or obese), elderly and emphysema.
Bronchial breath sounds
- where?
- quality
- I:E
- pause
- particularities?
heard over the manubrium
(no alveoli present).
very loud, high-pitched and tubular
louder on expiration
expiratory longer than inspiratory sound I/E = 2:3
distinct pause between inspiration and expiration
If heard anywhere other than the manubrium, usually indicates an area of consolidation exists (space that contains fluid or solid lung tissue).
Bronchiovesicular breath sounds
- where?
- quality
- I:E
- pause
heard best in the 1st and 2nd ICS (anterior chest) and between scapulae (posterior chest).
a mixture of bronchial and vesicular
intermediate pitch and intensity-
muffled blowing
sound
no pause between insp.& exp.
When would we have a decreased A/E?
atelectasis, emphysema, hemothorax, ARDS, asthma, pulmonary fibrosis, neuromuscular weakness, musculoskeletal deformities, pain, pneumothorax, obesity.
when would we hear a bronchial breathing
- considered abnormal when heard in a region NOT normally expected - consolidation, lobar collapse.
- compression of lung tissue from extraplumonary source e.g. pleural effusion, tumour.
Crackles:
- continuity
- musicality
- brief/long
- inspi/expi
Discontinuous, non-musical, brief sounds
heard more commonly on inspiration.
Fine crackles
- pitch
- soft/loud
- brief/long
- where
- examples
high-pitched, soft, very brief
opening of previously closed alveoli and small airways during inspiration.
atelectasis, interstitial pulmonary fibrosis
Coarse crackles
- pitch
- soft/loud
- brief/long
- where
- examples
low pitched, louder, last longer vs. fine crackle
air bubbles though secretions or incomplete closed airways during expiration
examples of conditions with crackles
asthma, bronchiectasis, chronic bronchitis, consolidation, pneumonia, early CHF, interstitial lung disease, interstitial pulmonary edema.
Wheeze:
- continuity
- musicality
- brief/long
- inspi/expi
Continuous, high-pitched sounds heard
normally on expiration but sometimes also on inspiration
Wheezing mechanical basis?
Monophonic meaning what?
Polyphonic meaning what?
air flowing through airways narrowed by secretions, foreign bodies or obstructive lesions.
Monophonic: single/partial airway obstruction – consider sputum plug
Polyphonic: widespread airway involvement - consider bronchospasm
Wheezing conditions
Asthma, chronic bronchitis, COPD, cardiogenic pulmonary edema.
Lo pitched wheeze/ronchi:
- musicality
- continuity
- inspi/expi
continuous musical sounds , both inspiratory and expiratory
Mechanical basis of ronchi?
- where?
Imply obstruction of the larger airway by secretions
Rhonchi occur in the bronchi and are heard in over the bronchi, not over alveoli
Rhonchi usually clear after coughing.
Stridor:
- musicality
- inspi/expi
- where
Inspiratory musical wheeze heard loudest over the trachea during inspiration.
It is often heard w/out a stetoscope
Mechanical basis of stridor
Caused by upper airway obstruction (e.g.,trachea or larynx)
May be life-threatening – no physio – consult MD
Pleural friction rub
- continuity
- quality
- inspi/expi
Discontinuous or continuous creaking sound.
Usually localized to a particular place on the chest wall
Heard during both inspiration and expiration
Mechanical basis pleural friction rub
Inflammation or roughening of the pleural surfaces – sound produced when they rub against each other.
What to chart (6) about breath sounds?
Loudness, pitch and duration Number (few to many) Timing in the respiratory cycle Location on the chest wall Persistence from breath to breath Any change after cough, change in patient’s position or after physio Rx.
Evaluation of voice sounds
Evaluated as decreased, normal, or increased
(no) Bronchophony in healthy lungs
In healthy lung sound transmitted through the chest are heard as muffled and indistinct
When bronchophony abnormal (heared)
- what do we hear
- what does it mean
When Sounds are clear and loud = bronchophony
indicates underlying tissue is relatively airless - i.e. sound is transmitted better through non air-filled lung
(no) Egophony in healthy lungs
In healthy lung hear muffled long E sound
When Egophony abnormal (heared)
- what do we hear
- what does it mean
Over consolidated lung areas, the sound is heard as an “A” (aaay).
(no) Egophony in healthy lungs
In healthy whispered voice heard faintly and indistinctly
When Egophony abnormal (heared)
- what do we hear
- what does it mean
When loud and clear whispered sound heard = whispered pectoriloquy - Heard in consolidation
Vocal femitus
- normal?
- decreased, exs
- increased, exs
Since there is a wide range of “normal”, compare side to side. Can use both hands simultaneously or one at a time. Use ulnar part of hand.
Decreased fremitus: impeded transmission of vibrations
- pleural effusions and thickening, pneumothorax, emphysema, pneumonectomy (air does not transmit sound as well), and partial atelectasis.
Increased fremitus: increased transmission of vibrations
- solid or liquid filled diseases e.g. consolidation, pulmonary edema (i.e., fluid accumulation in alveoli- alveolar edema), tumour, pulmonary fibrosis.
