Pulmonary Sounds

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I
Basic Respirations
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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?

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Respiratory Review

• Mouth
• Epiglottis

• Nasopharynx
• Oropharynx
• Larynx
• Trachea
• Lung
• Bronchi
• Diaphragm

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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

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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

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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

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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

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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?

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Breath Sound 1

• Listen Carefully
• Write Down What You Think It Is

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Breath Sound 2

• Listen Carefully
• Write Down What You Think It Is

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Breath Sound 3

• Listen Carefully
• Write Down What You Think It Is

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Breath Sound 4

• Listen Carefully
• Write Down What You Think It Is

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Breath Sound 5

• Listen Carefully
• Write Down What You Think It Is

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Breath Sound 6

• Listen Carefully
• Write Down What You Think It Is

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Breath Sound 7

• Listen Carefully
• Write Down What You Think It Is

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Breath Sound 8

• Listen Carefully
• Write Down What You Think It Is

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Breath Sound 9

• Listen Very Carefully
• Write Down What You Think It Is

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Answer KeyNumber 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

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Number 2 is

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

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Wheezing Pathology

• Lower partial airway obstructions
• Asthma
• COPD
• Edema
• Upper partial airway obstruction
• Croup (progresses to stridor)
• Foreign body
• Edema

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Number 3 is

• Expiratory wheezing with inspiratory crackles
  (Coarse Rales)

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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

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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

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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

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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)

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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

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Rhonci Pathology

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

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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

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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

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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.

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Grunting Pathology

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

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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

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Crepitus Pathology

• Trauma

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