Breath Sounds – Advanced Assessment

by Stephen Holt, MD, MS

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    00:01 So, now that we've reoriented ourselves, to basic lung anatomy, with the upper lobe the middle lobe and the inferior lobe.

    00:09 As shown here and keep in mind, that on the left side of the chest, there's just an upper lobe and a lower lobe and then a smaller lingula in the middle.

    00:17 Now, we're going to talk about the different kinds of things you're actually trying to find, when you listen to the lungs.

    00:21 And the first I’m going to talk about is, just basic breath sounds.

    00:24 And the types of breath sounds and that you can auscultate with your stethoscope, again, the diaphragm, are either vesicular, bronchial or something in the middle, which you guessed it is called bronchovesicular.

    00:36 So, let's talk about the difference between these kinds of sounds.

    00:39 I encourage you to actually take a listen to yourself or, if you're with somebody else you guys can listen together and just start by putting your stethoscope, on the lower lung field in the back and listen and describe what you hear.

    01:04 So, vesicular breath sounds are light feathery and you may also note that, inhalation is somewhat louder than exhalation, the exhalation you may hear the beginning of it, but it trails off very quickly.

    01:20 Now, I want you to contrast that, with the sound that you might hear, just lateral to the sternum and I encourage you to make sure you're listening to the right side of the sternum, because on the left you're of course going to hear the heart, which will confound things.

    01:32 So, just listening to the right side of the sternum, either on yourself or again on a friend, take a few more deep breaths.

    01:47 Now, it's a subtle distinction, but you'll note that there's the beginning of something, that we would call, “Bronchial breath sounds.” While you're still hearing that feathery light vesicular breath sounds in the background, you're also now starting to hear something that's a little coarser, a little bit more robust and rougher around the edges.

    02:06 Still, you're hearing more inhalation than exhalation, but there's the beginning of a transition point there, that's because I’m listening over the main stem bronchi and the large airways of his lungs, in the anterior chest.

    02:18 The next step, is we're going to listen to the trachea.

    02:22 So, put your stethoscope, right over somebody's trachea in the anterior cartilage there.

    02:39 And again, you can do this on yourself, or you can do it with somebody else.

    02:42 And now, what we're hearing is very coarse harsh breath sounds and you'll note that, inspiration and exhalation, are essentially identical in volume and pitch, there's also less of a chorus of noise, it really is, more of a specific pitch that you're hearing and this is characteristic of tracheal breath sounds, but it's basically representing or another way of mimicking, so-called, “Bronchial breath sounds.” Now, vesicular breath sounds is normal, you should hear those in all the peripheral lung fields.

    03:13 Bronchovesicular, should only be heard here, at the areas just lateral to the sternum, but bronchial breath sounds, what we were just hearing over the trachea, is not normal, is abnormal everywhere in the chest, you should not be hearing bronchial breath sounds because, what they represent, is essentially, the sound of air, moving through the upper airways, but going directly through some sort of solid tissue, to the chest wall, where you're listening with your stethoscope, without any of those light feathery vesicular breath sounds along the way, which tells you that, there's something that is preventing air, passing through the normal lung parenchyma and producing those light feathery sounds and that's typically going to occur with either a cancer, a large mass in the chest, or potentially a socked in, low bar pneumonia, which is just transmitting those vibrations, in the large airways, all the way through the chest wall to your stethoscope.

    04:15 In addition, you also want to look for adventitious breath sounds.

    04:19 These are the sounds that, are in addition, to your simply description of the breath sounds themselves, you're looking for things like crackles, rhonchi and wheezing.

    04:29 Crackles, is a somewhat of a vague term, but it actually is describing the particular acoustics of what you're hearing and we typically describe crackles, as either, fine or dry crackles or wet, also known as coarse crackles and fine dry crackles, we associate with, interstitial pulmonary fibrosis and things of that nature, that is more of a chronic indolent progression of disease and they can be really replicated by just pulling pieces of velcro apart, they're very fine, crisp, there's many different crackles, that are occurring within a short span of time and they have a higher pitch, in general.

    05:06 In contrast, wet crackles, so-called, because they're oftentimes associated with heart failure, with just a little bit of extra fluid in the alveoli and they're snapping open when you take a deep breath.

    05:17 Those wet crackles, are fewer in number, they are a little bit higher in pitch, they're a little bit longer and you're going to correlate them, with how high they go up in the back of the chest, that may give a sense as to how significant, somebody's heart failure may be.

    05:35 The next part of, adventitious breath sounds is, "Rhonchi." And rhonchi essentially are, non-specific findings, that essentially just suggest that there's some mucus lining the upper airways, they don't have a lot of clinical or diagnostic significance and oftentimes simply coughing will clear those rhonchorous breath sounds.

    05:56 Lastly, wheezing.

    05:57 We always think of wheezing associated with asthma and COPD.

    06:01 And wheezing is essentially a chorus of sounds, that you're hearing, as there's increased turbulent flow, through all of those tight airways, that we were talking about before, that tend to collapse, particularly the setting of COPD.

    06:15 They should be fairly distributed throughout all lung fields and you can categorize them as, “Scattered wheezing” or “Diffuse wheezing,” when you're describing it on the chest.

    About the Lecture

    The lecture Breath Sounds – Advanced Assessment by Stephen Holt, MD, MS is from the course Assessment of the Respiratory System: Theory (Nursing).

    Included Quiz Questions

    1. Vesicular
    2. Bronchovesicular
    3. Bronchial
    4. Tracheal
    5. Bronchotracheal
    1. Inhalation is longer than expiration.
    2. They are light and feathery breath sounds.
    3. They are best heard on the anterior chest, just to the right of the sternum.
    4. They are abnormal and could indicate inflammation or infection.
    5. They are only considered normal when heard over the trachea.
    1. Wheezing
    2. Crackles
    3. Rhonchi
    4. Rales

    Author of lecture Breath Sounds – Advanced Assessment

     Stephen Holt, MD, MS

    Stephen Holt, MD, MS

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