Physical Exam of the Chest: Auscultation Steve S. Kraman, M.D. Professor of Pulmonary, Critical Care & Sleep Medicine, University of Kentucky

Figure p Mechanics of Respiration

Figure p Anterior Location of Lungs

Figure p Posterior Location of Lungs

Figure p Right Lateral Location of Lung

Figure p Left Lateral Location of Lung

Brief Survey of Chest and Respiration Is the patient in distress? Observe the rate, rhythm,and depth of respiration. Audible sounds? Respirations should be easy, quiet, and regular.

Figure p Symmetric Chest Expansion

Tactile Examination of the Chest Tactile fremitus Palpable vibration of the chest wall from sounds transmitted from the phonating larynx. “Ninety-nine.” Compare symmetry. Abnormality MAY be  ‘ed or  ‘ed.

Figure p Tactile Fremitus

Figure p Assess Tactile Fremitus

Percussion Systematic Progress from apices to base Side to side Intensity, duration, and pitch Normal = resonance Note location of abnormalities

PERCUSSION RESONANCE - NL HYPERRESONANCE - too much air such as emphysema or pneumothorax DULLNESS - abnormal density due to possible pneumonia, pleural effusion, atelectasis or tumor These are subtle and often equivocal findings

Figure p Sequence for Percussion

Figure p Sequence for Percussion

Figure p Expected Percussion Notes – Posterior Chest

Figure p Expected Percussion Notes

Figure p Diaphragmatic Excursion

Bronchophony: Voice sounds are increased and clearer, even though one can not understand words. Heard under similar circumstances as bronchial breath sounds, such as when there is consolidation of the lung but the airways leading into the consolidation are open.

Whispered pectoriloquy Pectoriloquy means “chest speaking.” When a person with normal lungs whispers it is poorly heard with a stethoscope. With whispered pectoriloquy one can hear words that are whispered with the stethoscope. This is usually heard under the same circumstances as bronchial breath sounds and broncophony has similar significance.

Egophony The word egophony means "goat sound" from the Greek root "ego" (goat). This term describes a high-pitched bleating sound heard through an area of parenchymal consolidation

Egophony: When a normal (healthy) individual says "E" it is heard under normal circumstances as an "E" with a stethoscope. With egophony this "E" becomes "A" when listening through a stethoscope. Usually heard under the same conditions as bronchial breath sounds and bronchophony and has similar meanings.

What you hear When listening to lung sounds, you hear: –Lung sounds –Heart sounds –Muscle sounds (respiratory muscles) –Breath sounds transmitted through the air from the mouth

General Principals and Practice A word about stethoscopes –Acoustic –Electronic Integrity Practice

Generally Accepted Nomenclature

Observer Variability Sensitivity of the human ear

A Way to Think About Lung Sounds The acoustic repertoire of the respiratory system. –The thorax as a damped drum –The airways and parenchyma as noise makers continuous noises impulse noises

A Way to Think About Lung Sounds Sounds created within the chest, or introduced from outside (e.g., percussion), are colored by the damped resonant behavior of the thorax. E.g., normal voice transmission.

Anatomy of the Thorax

“1-2-3” ChestMouth

Normal Lung Sounds Vesicular sounds –what do they mean? –Where do they come from? –How far do they travel? Bronchial sounds Tracheal sounds Normal crackles?

Origin of Normal Lung Sounds

Vesicular sounds: Not from Alveoli |-- 1mm-- |

SEM of Metallic Injection of Alveoli

Normal Variation Dosani and Kraman. Chest 1983;83:

Normal Lung Sounds Normal Crackles

Abnormal Lung Sounds Too-faint vesicular sounds (more later) Bronchial sounds (where abnormal) Wheezes Rhonchi Crackles Pleural sounds Stridor Squawks

Abnormal Lung Sounds Wheeze InspirExpir Multiple Single Trachea Mouth

Wheeze v. Obstruction

Abnormal Lung Sounds Rhonchus InspirationExpiration

Abnormal Lung Sounds Crackles Murphy, RLH. Sem. Respir. Med. 1985:6: Fine Course

Abnormal Lung Sounds Fine Crackles; how are they made?

Fine Crackles Why not always? Ideopathic Pul. Fibrosis Sarcoidosis (Baughman, et al, Chest 1991;100:96-101)

Crackles in Asbestosis Prevalence of Crackles Related to Age Crackles (%) Age (Years) From Shirai et al, Br J Dis Chest 1981;75:386-96

Coarse Crackles

Abnormal Lung Sounds Pleural Rubs InspirationExpiration

Abnormal Lung Sounds Stridor and “VC Dysfunction Syndrome” Tracheal tumor Baby with croup

Death Rattle The rattle, or death rattle, is a sound heard near the mouth of a patient who is too debilitated to be able to clear his own secretions. For this reason it is often associated with dying patients. When listened to with a stethoscope over the neck or chest, the rattle sounds like rhonchi or coarse crackles. Coarse crackles heard at the mouth (death rattle)

Squawks (Squeaks) Squawks are short, inspiratory wheezes that appear to occur principally in allergic alveolitis and interstitial fibrosis but are also heard in pneumonia. Squawks are often heard in association with fine crackles and the squawk itself may be noticed to be initiated with a crackle. It is believed that this sound is caused by the explosive opening and fluttering of the unstable airway which causes the short wheeze. Squawk in allergic alveolitis Inspiratory and expiratory crackles are also audible

lungsound.pps Free PowerPoint presentation including most of the sounds used in this lecture. 15 MB file that downloads immediately. Runs about 20 minutes