1. I Basic Respirations

2. 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?

3. Respiratory Review Mouth Epiglottis Nasopharynx Oropharynx Larynx Trachea Lung Bronchi Diaphragm

4. 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

5. 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

6. 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

7. 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

9. 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?

10. Breath Sound # 1 Listen Carefully & Write Down What You Think It Is

11. Breath Sound # 2 Listen Carefully & Write Down What You Think It Is

12. Breath Sound # 3 Listen Carefully & Write Down What You Think It Is

13. Breath Sound # 4 Listen Carefully & Write Down What You Think It Is

14. Breath Sound # 5 Listen Carefully & Write Down What You Think It Is

15. Breath Sound # 6 Listen Carefully & Write Down What You Think It Is

16. Breath Sound # 7 Listen Carefully & Write Down What You Think It Is

17. Breath Sound # 8 Listen Carefully & Write Down What You Think It Is

18. Breath Sound # 9 Listen Very Carefully & Write Down What You Think It Is

19. 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

20. Number 2 is… Expiratory wheezing Wheezing is described as a whistling or sighing sound during exhalation

21. Wheezing Pathology Lower partial airway obstructions –Asthma –COPD –Edema Upper partial airway obstruction –Croup (progresses to stridor) –Foreign body –Edema

22. Number 3 is… Expiratory wheezing with inspiratory crackles (Coarse Rales)

23. 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

24. 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

25. 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”

26. 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)

27. 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

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

29. 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

30. 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

31. 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.

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

33. 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

34. Crepitus Pathology Trauma

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

36. 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.