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Basic Respirations

Overview
Intended to review and familiarize you with commonly heard breath sounds encountered in the field. How many of you were taught breath sounds, but never had an audio or clinical opportunity to validate cognitive objectives?

Respiratory Review
Mouth Epiglottis
Nasopharynx Oropharynx Larynx Trachea Lung Bronchi Diaphragm

Characteristics of Normal Breathing

Normal rate and depth Regular inhalation and exhalation pattern Audible on each side of chest Equal rise and fall of each side Movement of the abdomen

Normal Respirations Rates

Adult Over 8 Years Old
12 to 20 rpm

Child 1 to 8 Years Old

15 to 30 rpm

Infant Birth to 1 Year Old

25 to 50 rpm

Sign of Abnormal Breathing

Rate slower than 8 per minute or faster than 24 per minute Muscle retractions above clavicles, between ribs and below rib cage (especially in children) Pale or cyanotic skin Shallow or irregular Pursed lips Nasal flaring

Auscultation Points
Anterior and Posterior of Patient
Apices under the clavicular line midpoint Mid-axillary lines (armpit at nipple line) Bases lower border of rib cage

Breath Sounds
Practice run! How many can you identify? Take out a pen and paper Make a list numbered 1 to 9 Are you ready?

Breath Sound # 1

Listen Carefully & Write Down What You Think It Is

Breath Sound # 2

Listen Carefully & Write Down What You Think It Is

Breath Sound # 3

Listen Carefully & Write Down What You Think It Is

Breath Sound # 4

Listen Carefully & Write Down What You Think It Is

Breath Sound # 5

Listen Carefully & Write Down What You Think It Is

Breath Sound # 6

Listen Carefully & Write Down What You Think It Is

Breath Sound # 7

Listen Carefully & Write Down What You Think It Is

Breath Sound # 8

Listen Carefully & Write Down What You Think It Is

Breath Sound # 9

Listen Very Carefully & Write Down What You Think It Is

Answer Key
Number 1 is. Normal. (soft and low pitched)
Regular inhalation and exhalation Rate is 20-24 If we could see this patient, there would be equal rise and fall and movement of the abdomen

Number 2 is

Expiratory wheezing
Wheezing is described as a whistling or sighing sound during exhalation

Wheezing Pathology
Lower partial airway obstructions
Asthma COPD Edema

Upper partial airway obstruction

Croup (progresses to stridor) Foreign body Edema

Number 3 is

Expiratory wheezing with inspiratory crackles (Coarse Rales)

Number 4 is. Rales (medium with no expiratory wheeze)

Due to presence of fluid in smaller airways
Bronchioles

Rales can be heard on inspiration and exhalation Rales are also referred to as crackles Rales are coarse,medium or fine

Rales Pathology
Initially occurs in the lower lobes, but can advance to upper areas (in the alveoli, but below bronchioles) Pulmonary Edema CHF Near drowning Toxic inhalation Advanced COPD Others

Number 5 is. Subcutaneous emphysema

SCE is the presence of air in soft tissues around upper chest and neck It is often felt and heard during examination of the upper chest and lower neck while palpating and auscultating. It is often described as rice crispies

Subcutaneous Emphysema Pathology

SCE is usually seen in chest trauma
Flail chest Tracheal tears Penetrating chest and neck trauma Others (spontaneous pneumo, missed ET and crichs)

Number 6 is

Rhonci
Coarse breath sounds heard in patients with chronic mucus in the upper airway (bronchi) Rhonci is most pronounced during expiration Low pitched rhonci occur in the larger bronchi and occur early in expiration, while high pitched occur in the terminal bronchi and are late in expiration

Rhonci Pathology
Rhonci commonly occur in both acute and chronic bronchitis and bronchiolitis Can occur in bronchial asthma patients

Number 7 is

Stridor
On inspiration is a high pitched brassy sound ..and a forceful expiration creates a barking cough Often referred to as a seal like bark

Stridor Pathology
Laryngeal edema from croup or epiglottitis
Croup is laryngealtracheobronchitis Epiglottitis is inflammation of the epiglottis

Stridor is more pronounced in children because of smaller airways Others

Toxic inhalation Cancer Foreign body obstruction

Number 8 is

Pediatric Grunting
Grunting is a sound that occurs primarily in neonates when the infant exhales air against a partially closed epiglottis. Grunting is a natural function which generates back pressure to keep smaller airways open.

Grunting Pathology
Occurs because of underdeveloped accessory muscles Grunting occurs in all infant with respiratory distress, flu or infections

Number 9 is

A Bonus..
It is Crepitus from rib fracture Grating of the bone ends as they move back and forth against each other on inspiration and expiration

Crepitus Pathology
Trauma

Summary
Laryngeal-tracheal Stridor,Grunting,SubQ,Wheezing Tracheal-bronchiole Rhonci,Wheezing Bronchiol-alveoli Rales

 Use history along with pulmonary assessment to advise your Medical Control and treat patient.
Most on-line docs want to know if patient is wet or dry and where.