physical exam of the chest: auscultation steve s. kraman, m.d. professor of pulmonary, critical care...

Physical Exam of the Chest:Auscultation

Physical Exam of the Chest:Auscultation

Steve S. Kraman, M.D.

Professor of Pulmonary,Critical Care & Sleep Medicine,

University of Kentucky

Figure 16-10. p. 454.

Mechanics of Respiration

Figure 16-6. p. 451.

Anterior Location of Lungs

Figure 16-7. p. 451.

Posterior Location of Lungs

Figure 16-8. p. 452.

Right Lateral Location of Lung

Figure 16-9. p. 452.

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 16-13. p. 461.

Symmetric Chest Expansion

Tactile Examination of the ChestTactile 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 16-14. p. 462.

Tactile Fremitus

Figure 16-22. p. 472.

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 16-15. p. 463.

Sequence for Percussion

Figure 16-23. p. 473.

Sequence for Percussion

Figure 16-16. p. 463.

Expected Percussion Notes – Posterior Chest

Figure 16-24. p. 473.

Expected Percussion Notes

Figure 16-17. p. 464.

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;83:628-631

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

• RhonchusInspiration Expiration

Abnormal Lung Sounds

• Crackles

Murphy, RLH. Sem. Respir. Med. 1985:6:210-219

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

0

10

20

30

40

50

60

~19 20~29 30~39 40~49 50~59

Workers

Controls

Crackles (%)

Age (Years) From Shirai et al, Br J Dis Chest1981;75:386-96

Coarse Crackles

Abnormal Lung Sounds• Pleural Rubs

Inspiration Expiration

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 alveolitisInspiratory and expiratory crackles are also audible

http://www.mc.uky.edu/pulmonary/lungsound.pps

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