Lung Sounds: The Good, the Bad and the Ugly Jackie Zolotsky Bridges, RN, MSN, CRNP, CSN Parkland School District Certified School Nurse Voices of School Health Conference August 8 & 9, 2017

Objectives Describe the purpose of the lungs Describe the basic anatomy and pathophysiology of the lungs Learn the history of auscultation of the lung Learn how to auscultate lung sounds Identify the basic landmarks of the anterior and posterior thorax Learn how to differentiate normal lung sounds vs. adventitious sounds Provide possible differential diagnoses based on auscultation

Lungs – What do they do? MAIN function: help oxygen from the air we breathe enter the red cells in the blood. Red blood cells then carry oxygen around the body to be used in the cells found in our body. The lungs also help the body to get rid of CO2 gas when we breathe out.

Lungs – What do they do (part 2) Change the pH of blood (whether the blood is more acid or alkali) by increasing or decreasing the amount of CO2 in the body. Filter out small gas bubbles that may occur in the bloodstream. Convert a chemical in the blood called angiotensin I to angiotensin II (chemicals that help control of blood pressure).

Fun Lung Facts The lungs are not the same size. The right lung is a little wider than the left lung, but it is also shorter. According to York University, the right lung is shorter because it has to make room for the liver, which is right beneath it. The left lung is narrower because it must make room for the heart.

More Fun Lung Facts The right lung is divided into three different sections, called lobes. The left lung has two lobes. The lobes are made of sponge-like tissue that is surrounded by a membrane called pleura, which separates the lungs from the chest wall. Each lung half has its own pleura sack. This is why when one lung is punctured, the other can still work.

What happens when we breathe? As we breathe, air travels down the throat and into the trachea. The trachea divides into smaller passages called the bronchial tubes. The bronchial tubes go into each lung. The bronchial tubes branch out into smaller subdivisions throughout each side of the lung. The smallest branches are called bronchioles and each bronchiole has an air sac, also called an alveoli. There are around 480 million alveoli in the human lungs, according to the Department of Anatomy of the University of Göttingen.

Anatomy of the Lungs Respiratory tract extends from mouth/nose to alveoli. Upper airway filters airborne particles, humidifies and warms inspired gases. Lower airway serves for gas exchange.

Lung Anatomy

Lung Anatomy & Physiology

Respiratory Exam Need a quiet space! Proper positioning Patient should be in a comfortable, relaxed position. Nurse should warm her hands and diaphragm of stethoscope. Exam should be done on bare skin. NOT POSSIBLE IN SCHOOL SETTING. Keep in mind – clothes, hair and other foreign objects will make additional sounds while you listen. Inspect Palpate Percuss Auscultate

AUSCULTATION

History of listening to lung sounds – “Auscultation” Hippocrates discovered the concept of auscultation by placing his ear to the patient's chest to hear transmitted breath sounds. He described this as a method of “direct auscultation”. In 1816, Rene Theophile Hyac invented the stethoscope. His first stethoscope consisted of a rolled paper cone. He later utilized a wooden tube. The modern stethoscope had undergone several modifications before being molded into the current shape.

Overview of Auscultation Auscultation is cheap, noninvasive, safe, easy-to-perform. One of the oldest diagnostic techniques used by health care professionals. Technology is great – but has reduced our bedside assessment skills. Helps in differentiating normal respiratory sounds from abnormal ones (e.g. crackles, wheezes, and pleural rub). Need to understand the underlying pathophysiology of various lung sounds to better understand disease processes.

Auscultation Auscultation is the process of listening to the sounds of air passing through the tracheobronchial tree and alveolar spaces. Alterations in airflow and ventilation effort result in distinctive sounds within the chest that may indicate pulmonary disease or dysfunction.

How Auscultation is performed The patient should be seated or lying comfortably in a position that allows access to all lung fields. Auscultation is done in a systematic, side-to- side and cephalocaudal (head to toe) fashion. Breath sounds should always be compared symmetrically (e.g. listen first to left side and then the right side). Sounds should be auscultated on the anterior and posterior segments of the chest wall. (In full pulmonary examinations, the lateral side is auscultated as well).

How Auscultation is performed The diaphragm (flat side) of the stethoscope should be used for auscultation. Begin at the apices and compare left to right until you reach the bases of the lungs. Ask patient to perform full inspirations and expirations through the mouth, as the nurse listens to the entire cycle of respiration before moving the stethoscope to another lung segment.

Systematic Approach to Auscultation: Anterior Follow a systematic pattern beginning with just above the clavicle to down below the xiphoid process; along the right and left sides of the chest wall.

Anatomical Landmarks for Anterior Auscultation

Systematic Approach to Auscultation: Posterior Follow a systematic pattern and place stethoscope against thoracic landmarks (T2, T4, T6, T10) along the right and left sides of the chest wall

Anatomical Landmarks for Posterior Auscultation

Physics of Lung Sounds Lung sounds have three major characters; pitch, intensity, and quality (timber). Pitch– perceptual quality of sound that depends on frequency of the sound wave. Intensity – subjective assessment to determine whether a sound is loud or soft. Quality – Differentiates two sounds with the same pitch and loudness.

What is that Sound?

Normal Lung Sounds Created by turbulent air flow Inspiration Air moves to smaller airways hitting walls More turbulence, Increased sound Expiration Air moves toward larger airways Less turbulence, decreased sound Normal breath sounds Loudest during inspiration, softest during expiration

Lung Sounds – The Good  There are 3 normal lung sounds Vesicular Bronchial Vesicular Bronchial Normal VESICUCLAR low pitch heard over most of normal lung BRONCRO-VESICULAR medium pitch  heard over mainstream bronchi BRONCHIAL-(TRACHEAL) high pitch normally heard over trachea

Normal Lung Sounds

Normal Lung Sounds Vesicular Bronchovesicular Soft, low pitched sound Inspiratory > Expiratory sounds Heard over most of lungs Bronchovesicular Intermediate intensity, intermediate pitch Inspiratory = Expiratory sound duration Heard best 1st and 2nd ICS anteriorly, and between scapula posteriorly If heard in any other location suggestive of consolidation

Normal Lung Sounds Tracheal Bronchial Very loud, high pitched sound Inspiratory = Expiratory sound duration Heard over trachea Bronchial Loud, high pitched sound Expiratory sounds > Inspiratory sounds Heard over manubrium of sternum If heard in any other location suggestive of consolidation

Normal Lung Sounds Let’s listen www.easyauscultation.com

Lung Sounds: The Bad and Ugly These are called adventitious sounds. They are not normally heard in the lungs. They are caused by moving air colliding with secretions in the tracheobronchial passageways or by “popping open” of previously deflated airways. Major types: Crackles (rales), Rhonchi, Wheezes, Stridor, and Pleural Rub.

Crackles (Rales) Discrete, non-musical, non-continuous sound, produced by moisture in the lung tissues. Can be fine in quality or coarse. Crackles sound like cellophane being crumpled. Heard more commonly with inspiration as the result of of secretions moving in the airways or closed airways that are rapidly re-opening. Many possible causes: pulmonary edema, early CHF, asthma, chronic bronchitis

Crackles – Let’s listen www.easyauscultation.com Fine crackles Course crackles

Rhonchi Continuous sounds produced by air being forced through narrowed passages, narrowed by secretions and/or constriction of the air passage. Similar to wheezes Rhonchi are low pitched, snoring quality, continuous, musical sounds. Implies obstruction of larger airways by secretions Possible cause – acute bronchitis

Rhonchi – Let’s listen www.easyauscultation.com

Wheezes Continuous musical sounds produced as air is forced through narrowed passages. Like rhonchi, can occur in inspiration or expiration. With rales, may change character after coughing. High pitched sounds are usually called wheezes, low pitched – snoring sounds are usually referred to as rhonchi. Possible causes – asthma, COPD, smoking.

High Pitched Wheeze – Let’s listen www.easyauscultation.com

Stridor Loud musical sound of constant pitch, most prominent during inspiration. Can be heard very well at a distance due to its loud intensity – NO STETHOSCOPE NEEDED. Suggests obstructed trachea or larynx. This is a medical emergency requiring immediate medical attention. Possible cause – inhaled foreign body.

Stridor – Let’s Listen www.easyauscultation.com

Pleural Rub Non-musical sound, usually longer and lower pitch than lung crackles. Discontinuous or continuous brushing sounds. Occurs during inspiration and expiration. Sounds like the creaking of old leather. Caused by coarsened surface of the normal pleura, due to fibrin deposits, thickened or inflamed or with neoplastic cells

Pleural Rub – Let’s Listen www.easyauscultation.com

Conclusion The respiratory system is an essential and complicated system within the human body. There are several components of the pulmonary assessment including Inspection, Palpation, Percussion and Auscultation. Auscultation has become a lost art and is one assessment that we as school nurses can utilize to evaluate the student’s respiratory complaint. Being able to differentiate normal vs. adventitious lung sounds is an invaluable skill for the school nurse to possess in an academic setting.

Conclusion Having a basic knowledge of the anatomy and physiology of the lungs and their external landmarks will enable the school nurse to perform a basic, yet helpful assessment when a student has a respiratory complaint. There are plenty of resources on the internet to practice and learn more about lung sounds and how to assess them.

References https://www.easyauscultation.com/lung-sounds https://www.livescience.com/52250-lung.html https://musculoskeletalkey.com/pulmonary-system/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4518345/ https://www.patient.info/health/the-lungs-and-respiratory- tract

Thank you!