Kursk State Medical University Department of propaedutics of inner diseases

Auscultation of the lungs Main and additional respiratory sounds

AUSCULTATION
Auscultation (Latin auscultare to listen) - listening to the sounds inside the body. Mediate auscultation was 1st developed by the French physician Rene Theophile Hyacinthe Laennec in 1816.
1782-1826

In 1819 it was described and introduced into medical practice.

 1st stethoscope introduced by Rene Laennec

(Greek stethos - chest, skopein- to examine)

Development of auscultation technique

Improvement of stethoscope (Piorri, Yanovsky)
Invention of the binaural stethoscope (Filatov) Invention of the phonendoscope & study of the physical principles of auscultation (Skoda, Ostroumov, Obraztsov)
Immediate auscultation by Laennec

Types of auscultation

Immediate (direct) auscultation when the examiner presses his ear to the patients body Mediate (indirect / instrumental) auscultation using of a) stethoscope b) phonendoscope Bronchophony auscultation of the voice sounds

Rules of the using of different instruments

The diaphragm of phonendoscope with deep pressure to the surface for high frequency sounds The bell of stethoscope with soft pressure for lower frequency sounds in patients with hairy chests (to reduce crackling sounds produced by movement of hair) in very thin patients (difficult to flatten the diaphragm to the chest wall)

The rules of auscultation

Silence in the room Warm room Position: sitting / standing (in grave condition lying in bed)

Better to sit up on a chair with hands on the laps (deep breathing due to hyperventilation may cause vertigo - the patient may faint)

The rules of auscultation

Use warm instrument for auscultation Auscultation in each point of 2-3 respiratory cycle Auscultation of the main sounds - breathing through the nose Auscultation of the additional sounds - breathing through the mouth Ask to cough, to make forced expiration (after cough and expectoration the sputum rales may disappear / change their properties) Use the accustomed instrument (to differentiate the sounds of a stethoscope itself or the sounds generated in the human body)

The plan of auscultation

Comparative auscultation Symmetrical points of the chest sides 1. Anterior wall: from upper part in the supra- and subclavian region and then downward and laterally 2. Lateral parts (in the axillary regions patients hands on the back of the head) - from up to down 3. Posterior wall (patients arms crossed on the chest for displacement of the shoulder blades laterally to the spine)

Anterior surface

Lateral surface

Posterior surface

Physical grounds

A stethoscope - closed acoustic system (air - transmitting medium for sounds) The human ear perceives vibrations: 16-20 20 000 Hz The highest sensitivity of the ear - 2 000 Hz The sensitivity decreases sharply with the decreasing frequency A weak sound is perceived difficultly after a loud sound Auscultation sounds are noises (a mixture of various frequencies sounds) Auscultation noises of the lungs are mostly vibrations 20 - 600 Hz: bronchial respiration 240 1 000 Hz friction sounds 75 - 500 Hz

Auscultation must be done to note:

The type of breathing (main) sound Presence any of adventitious (added) sounds Vocal resonance (bronchophony)

Main breath sounds

classified into categories according to their intensity, pitch & relative duration of inspiratory and expiratory phases:

Vesicular Bronchial

Vesicular breathing

Turbulent airflow transmitted to the chest wall, filtered by normally inflated alveoli vesicles (result - loss of the higher frequency) Rustling noise, louder and more prolonged in inspiration than in expiration - ratio 3:1 (active inspiration due to the passage of air into the bronchi and alveoli followed without a pause by passive expiration due to elastic recoil of the alveoli - maximal in the early phase of short expiration) Soft intensity & relatively low pitch of expiratory sound

Timing of vesicular breathing

Breathing sounds in normal lung

The square marks the area of bronchovesicular breathing

(anteriorly & posteriorly)

Over other areas normal vesicular breathing

Mechanism of vesicular breathing sounds

A) Tubular phase B) Alveolar phase on inspiration C) Alveolar phase on expiration Long soft blowing noise (as F ) Is heard during the entire inspiratory phase (gradually increasing intensity) Alveolar wall still vibrate at the initial stage of expiration (only during the 1/3) vibrations quickly dampened

Normal variations of vesicular breathing

Normal vesicular breathing is better heard over the anterior surface of the chest below the 2nd rib laterally of the parasternal line, in the axillary region, below the scapular angles (the largest masses of the pulmonary tissue are located) Vesicular breathing is heard worse at the apices of the lungs and their lowermost parts (the masses of the pulmonary tissue are less abundant) Expiration sounds are louder and longer in the right lung (better conduction of the laryngeal sounds by the right main bronchus, which is shorter and wider). The sound may become bronchovesicular over the apex (more superficial and horizontal position of the right apical bronchus)

Physiological Vesicular Breathing Alterations

-

Weakening excessively developed muscles / subcutaneous fat Intensification undeveloped muscle / subcutaneous fat children with thin chest wall, good elasticity of alveoli and interalveolar septa -puerile respiration (Latin puer child) during exercise (respiratory movements become deeper and more frequent)

Physiological vesicular respiration always involve both parts of the chest, respiratory sounds are equally intensified / weakened at the symmetrical points of the chest

Pathologically decreased vesicular respiration

Pulmonary emphysema (alveoli loss elasticity, their walls become incapable of quick distension - insufficient vibrations) Lobar pneumonia - early & final stage (inflammation & swelling of the walls in a part of the lung, decrease amplitude of their vibration during inspiration) Tumor (insufficient delivery of air to the alveoli through the airways -mechanical obstruction) Inflammation of the respiratory muscle, intercostal nerves, rib fracture, extreme asthenia & adynamia (markedly weakened inspiration phase) Pleural layers thickening, pneumothorax, hydrothorax (obstructed conduction of sound waves from the source of vibration to the chest surface)

Pathologically increased vesicular respiration

(increased expiration or both phases)

Obstructive breathing - increased expiration (obstruction to the air passage through small bronchi or their contracted lumen - inflammatory edema of the mucosa, bronchospasm) Harsh breathing - increased inspiration & expiration (marked & non-uniform narrowing of the lumen in small bronchi & bronchioles - inflammatory edema of the mucosa) In bronchial asthma, acute bronchitis, COPD

Timing of harsh breathing

Deeper vesicular breathing with intensification of both respiratory phases

Timing of cogwheel (interrupted) breathing

Short, jerky inspiration efforts interrupted by short pauses non-uniform contraction of respiratory muscles
Interrupted breathing over a limited part of the lung difficult passage of air from small bronchi to the alveoli & uneven unfolding of the alveoli (pathology in fine bronchi, more frequently at the apices of the lungs - tuberculous infiltration)

Bronchial breathing (laringotracheal)

Arise in the larynx & trachea as air passes through the vocal slit during inhalation & exhalation Exhalation sound louder, harsher, longer (2:1) vocal slit more narrow during exhalation (intense turbulence of air through the vocal slit in vortex-type motion) Expiration and inspiration separated by pause

Mechanism of bronchial breathing sounds

A) Tubular phase on inspiration B) Silent gap (absent alveolar phase) C) Tubular phase on expiration

Loud, harsh, long sound (as H ) - hollow blowing quality Turbulence in the large airways without filtering by the alveoli Expiratory sound higher pitch & intensity than the inspiratory sound Inspiration/expiration ratio 1:2 Silent gap between inspiration & expiration

Timing of bronchial breathing

Bronchial breathing sounds in norm

Over the larynx & trachea

Anterior - over the manubrium sterni (junction point) Posterior - 3rd & 4th thoracic vertebrae in the interscapular space

Pathological bronchial breathing over the lungs location in the chest

3 main reasons:

Lung consolidation Compressive atelectasis Cavity in the lung communicated with bronchus

Pathological bronchial respiration (indurative tubular)

Breath sounds in solid lungs: Lobar pneumonia (2nd stage) Tuberculosis Lung infarction Tumor Pneumosclerosis, carnification Lung alveoli airless, bronchi patent, breath sounds bronchial (tubular, high-pitch)

Pathological bronchial respiration (in compressive atelectasis)

Compressive atelectasis (hydrothorax)

Soft & low-pitch sound, faint Resembles echo (far from the ear)

Pathological bronchial respiration (amphoric)

Amphoric Greek amphoreus - jar More intense & highpitch Musical character Imitated by blowing over the narrow neck of a bottle

Pathological bronchial respiration (amphoric)

Large smooth-wall cavity (D>5-6 cm) communicated with a large bronchus

(abscess, cavern)
Additional high overtones (strong resonance) with the main low-pitch laringotracheal breathing

Pathological bronchial respiration (cavernous)

Cavernous sound over the cavity Low-toned form of bronchial breathing (more hollow in quality) Imitated by breathing into a tumbler

If the cavity is well filled, no abnormal breath sounds will be heard, though breathing may be faint

Pathological bronchial respiration (metallic)

Large open pneumothorax

Loud & high Resembles the metal struck

Stenotic respiration Stridor

Exaggerated laringotracheal breathing partial obstruction of the airway in the neck (larynx or trachea) by tumor/foreign body Predominantly inspiratory (louder on inspiration) Louder in the neck than over the chest wall Low-pitch sound Resembles voice sound (wheeze) Simulated by partial closure of vocal cords while breathing deeply

Bronchovesicular respiration
F H

Mixed respiration Inspiration as vesicular (F) Expiration as bronchial (H)

In lobular pneumonia Infiltrative tuberculosis Pneumosclerosis

Bronchovesicular respiration
Mechanism - mixture of bronchial & vesicular: Weak bronchial breathing in small region of deeply located consolidation focus projection Vesicular breathing of near located unchanged alveoli

Characteristics of Breath Sounds

DURATION OF SOUNDS
VESICULAR

INTENSITY OF EXPIRATORY SOUND

PITCH OF EXPIRATORY SOUND

LOCATION WERE HEARD NORMALLY

Inspiratory sounds last longer than expiratory ones. Inspiratory and expiratory sounds are about equal. Expiratory sounds lasts longer than inspiratory ones. Inspiratory and expiratory sounds are about equal

Soft

Relatively low

Over most of both lungs

Often in the 1st and 2nd interspaces anteriorly and between scapulae

BRONCHOVESICULAR

Intermediate

Intermediate

BRONCHIAL

Loud

Relatively high

Over the manubrium, if heard at all. Over the trachea in the neck

TRACHEAL

Very loud

Relatively high

The thickness of the bars indicates intensity; the steeper their incline, the higher the pitch

Adventitious (added) lung sounds

Classification

1. 2.

Rales: Discontinuous (cracles) Continuous (wheezes, ronchi) Crepitation Pleural friction rub

Discontinuous sounds - Cracles

intermittent nonmusical brief (like dots in time) simulated by rolling hair between fingers close to the ear

2 subgroups (intensity, pitch and duration): Fine crackles (..) soft high-pitched very brief (5-10 msec)

Coarse & medium crackles (..) louder lower in pitch not quite so brief (20-30 msec)

Crackles
Places of appearance: Bronchial tree Lung cavity (communicated with the large bronchus) Mechanism: Liquid secretion (sputum, edematous fluid, blood) Time of appearance: Both respiratory phases (better audible on inspiration)

Crackles
Simulated by bubbling air through water using a fine tube

Crackles formation

Fine in fine bronchi

Medium medium size bronchi Coarse large caliber bronchi large bronchiectasis pulmonary cavities

1.

2.
3.

Crackles

Consonating: Lung consolidation Lung cavity

Non-consonating: Bronchitis Lung edema

Metallic character of crackles

In superficially located large cavity (D>5-6 cm)

Gutta cadens falling-drop sound

In lung or pleural cavities with liquid pus & air Pus sticks to the surface of the cavity in changing patients position pus falls down in drops at the bottom (one by one)

Continuous sounds - Dry rales

Notably longer than as dashes in time (>250 msec) Not persist throughout the respiratory cycle Musical quality Audible in both respiratory phases (better on expiration)

Continuous sounds - Dry rales

Two subgroups: Wheezes relatively high-pitched (400 Hz & >) hissing or shrill quality formatted in small bronchi Ronchi relatively low-pitched (200 Hz & <) snoring quality
formatted in medium & large bronchi

Mechanism of dry rales

Spasm of smooth muscles of the bronchi Inflammatory swelling of bronchial mucosa Accumulation of viscous sputum in bronchi with narrowing lumen Formation threads from the sputum (from wall to wall)

Crepitation (Fine late inspiratory crackles)

Alveoli

Places of appearance:

Mechanism: Small amount of liquid secretion in alveoli Time of appearance: End of inspiration Conditions: Lobar pneumonia (1st & 3rd stages) Infiltrative tuberculosis Lung infarction Cardiac asthma Imitated by rubbing a lock of hear

Pleural friction rub

Reasons: Inflammation of pleural surfaces with fibrin deposition Uric acids crystals deposition (uremia) Mechanism: Inflamed & roughened pleural surfaces Auscultation: relatively small area of the chest wall in both phases of respiration (sometimes only inspiration) intensified in tight stethoscope pressing if surfaces separated by fluid - the rub disappears

Hippocratic succusion sound

Splashing sound in hydropneumothorax (serous fluid & air in the pleural cavity)
The physician presses his ear against the chest and shakes the patient suddenly

Respiratory Sounds

Respiratory music

Bronchophony

Voice conduction by the larynx to the chest determined by the auscultation

Increased bronchophony: Pulmonary consolidation Lung cavity

1. 2.

Normal and Altered Breath and Voice Sounds

NORMALLY AIR-FILLED LUNG AIRLESS LUNG, AS IN LOBAR PNEUMONIA

BREATH SOUNDS vesicular

Predominantly

Bronchial and bronchovesicular over the involved area

Spoken words louder, clearer (bronchophony) Spoken ee heard asay (egophony) Whisperd words louder, clearer (whispered pectoriloquy)

TRANSMITED VOICE Spoken words SOUNDS muffled an indistinct Spoken ee heard as ee Whispered words faint and indistinct TACTILE FREMITUS Normal

Increased