Alternate (side to side).
Symmetrical
Comparative

Breath Sounds
Normal Sounds
Adventitious Sounds

Special Maneuvers Physical findings (Pulmonary Disorders)
Perform Auscultation:
1.- During Normal and force respiration (post-cough).
2.- Both Lung fields.
3.- Determine Sound Character:
  • Intensity

  • Pitch

  • Quality

  • Location in the Breathing cycle

  • Location on the Chest wall

  • Changes (after coughing, deep breathing)


    • BREATH SOUNDS: (table)
    NORMAL Sounds: (table)
  • Vesicular Breath Sounds (VBS):

    • VBS are breezy or swishy, high-pitched sound (100-500MHz), mainly inspiratory. There is a silent pause between inspiration and expiration. Expiration is short , fainter, lower-pitch puff less than 1/3 as long as inspiration.

  • Bronchial Breath Sounds (BBS):

    • BBS are heard over the trachea and main bronchi. Louder, tubular, harsh, higher-pitched sounds (75-1600MHz). Expiration is as long as Inspiration.

  • Bronchovesicular Breath Sounds :

    • These are the intermediate sounds, normally heard over the 2nd intercostal spaces (ICS) anteriorly.

  • Bronchophony :

    • Transmitted voice sounds are normal over the trachea and right upper lobe posteriorly.
    ADVENTITIOUS Sounds: (table)
  • Coarse Crackle (rales):

    • Discontinuous, interrupted, explosive sounds, <20msec, loud, low-pitched, early inspiration or expiration (in COLD).

  • Fine Crackles:

    • They are the same as the coarse crackles but less laud and of shorter duration, higher in pitch. Mid to late inspiration. They are not altered by a cough, more prominent in the bases.
    Velcro rales (in decreased ventilation).

  • Wheeze:

    • Continuous (>250msec), loud, high-pitched sounds (400MHz), hissing sound, inspiratory and expiratory (Asthma)

  • Rhonchus:

    • Continuous (>250msec), snoring, low-pitched sounds (200MHz), (secretions in the airway).

  • Pectoriloquy (whispering):

    • Exaggerated transmission of the voice when whispering (in consolidation).

  • Egophony:

    • Change in the quality of the spoken voice (E to A changes).

  • Murmurs (pulmonary):

    • In AV fistula and PE (pulmonary thromboembolism).

  • Rub (pleural friction rub):

    • Is a coarse, grating sound, heard in both, inspiration and expiration (low in pitch).
    SPECIAL MANEUVERS AND TESTS:
    *Always change Patient's position

  • Coin Test:

    • Use one coin (quarter), put it flat against the chest wall anteriorly, tap it gently with another coin, while you listen with the stethoscope posteriorly. Normally (and with bulla) the sound will be dull thudding.
    With Pneumothorax the sound (and note) will have a metallic ringing quality.

  • Scratch Sign:

    • Place the stethoscope on the chest wall, then lightly scratch on the skin with the fingernail/fingertip (10 cm away). The sound will be louder and harsh on the side of the Pneumothorax.

  • Mediastinal Crunch:

    • Also called Hamman's sign, it's a loud crunching or crackling sound (synchronous with the heart beat), heard along the left sternal border in Patients with a left Pneumothorax.

  • Hyppocratic Succussion:

    • In hydropneumothorax (air-fluid level on the roentgenogram) shaking the Patient carefully but vigorously may result in a succussion splash.

    Physical Findings (Pulmonary Disorders)
    DISORDER INS PAL PER AUS additional
    Consolidation dull VBS crackles
    pectoriloquy
    Pneumothorax 0 tympanic 0 scratch sign
    shifting away
    Pleural Effusion
    0    		 dull
    flat         		0 shifting away
    Atelectasis
    (lobar obstruction)         		dull
    flat         		0 shifting toward
    Asthma
    (bronchial)         		hyper-
    resonant         		--- expiratory
    wheezes
    Emphysema hyper-
    resonant         		crackles
    KEY: arrow down means decreased, arrow up means increased. 0 means absent . VBS= vesicular breath sounds.