Lecture 6 - Auscultation & voice sounds

Question 1

What are the steps for auscultations?

Answer 1

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

Question 2

Tracheal breath sounds:

• where?
• quality
• I:E
• pause

Answer 2

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

Question 3

Vesicular breath sounds:

• where?
• quality
• I:E
• pause
• particularities?

Answer 3

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.

Question 4

Bronchial breath sounds

• where?
• quality
• I:E
• pause
• particularities?

Answer 4

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).

Question 5

Bronchiovesicular breath sounds

• where?
• quality
• I:E
• pause

Answer 5

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.

Question 6

When would we have a decreased A/E?

Answer 6

atelectasis, emphysema, hemothorax, ARDS, asthma, pulmonary fibrosis, neuromuscular weakness, musculoskeletal deformities, pain, pneumothorax, obesity.

Question 7

when would we hear a bronchial breathing

Answer 7

• 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.

Question 8

Crackles:

• continuity
• musicality
• brief/long
• inspi/expi

Answer 8

Discontinuous, non-musical, brief sounds

heard more commonly on inspiration.

Question 9

Fine crackles

• pitch
• soft/loud
• brief/long
• where
• examples

Answer 9

high-pitched, soft, very brief
opening of previously closed alveoli and small airways during inspiration.
atelectasis, interstitial pulmonary fibrosis

Question 10

Coarse crackles

• pitch
• soft/loud
• brief/long
• where
• examples

Answer 10

low pitched, louder, last longer vs. fine crackle

air bubbles though secretions or incomplete closed airways during expiration

Question 11

examples of conditions with crackles

Answer 11

asthma, bronchiectasis, chronic bronchitis, consolidation, pneumonia, early CHF, interstitial lung disease, interstitial pulmonary edema.

Question 12

Wheeze:

• continuity
• musicality
• brief/long
• inspi/expi

Answer 12

Continuous, high-pitched sounds heard

 normally on expiration but sometimes also on inspiration

Question 13

Wheezing mechanical basis?

Monophonic meaning what?

Polyphonic meaning what?

Answer 13

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

Question 14

Wheezing conditions

Answer 14

Asthma, chronic bronchitis, COPD, cardiogenic pulmonary edema.

Question 15

Lo pitched wheeze/ronchi:

• musicality
• continuity
• inspi/expi

Answer 15

continuous musical sounds , both inspiratory and expiratory

Question 16

Mechanical basis of ronchi?

• where?

Answer 16

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.

Question 17

Stridor:

• musicality
• inspi/expi
• where

Answer 17

Inspiratory musical wheeze heard loudest over the trachea during inspiration.
It is often heard w/out a stetoscope

Question 18

Mechanical basis of stridor

Answer 18

Caused by upper airway obstruction (e.g.,trachea or larynx)

May be life-threatening – no physio – consult MD

Question 19

Pleural friction rub

• continuity
• quality
• inspi/expi

Answer 19

Discontinuous or continuous creaking sound.
Usually localized to a particular place on the chest wall
Heard during both inspiration and expiration

Question 20

Mechanical basis pleural friction rub

Answer 20

Inflammation or roughening of the pleural surfaces – sound produced when they rub against each other.

Question 21

What to chart (6) about breath sounds?

Answer 21

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.

Question 22

Evaluation of voice sounds

Answer 22

Evaluated as decreased, normal, or increased

Question 23

(no) Bronchophony in healthy lungs

Answer 23

In healthy lung sound transmitted through the chest are heard as muffled and indistinct

Question 24

When bronchophony abnormal (heared)

• what do we hear
• what does it mean

Answer 24

When Sounds are clear and loud = bronchophony

indicates underlying tissue is relatively airless - i.e. sound is transmitted better through non air-filled lung

Question 25

(no) Egophony in healthy lungs

Answer 25

In healthy lung hear muffled long E sound

Question 26

When Egophony abnormal (heared)

• what do we hear
• what does it mean

Answer 26

Over consolidated lung areas, the sound is heard as an “A” (aaay).

Question 27

(no) Egophony in healthy lungs

Answer 27

In healthy whispered voice heard faintly and indistinctly

Question 28

When Egophony abnormal (heared)

• what do we hear
• what does it mean

Answer 28

When loud and clear whispered sound heard = whispered pectoriloquy - Heard in consolidation

Question 29

Vocal femitus

• normal?
• decreased, exs
• increased, exs

Answer 29

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.