Normal Breath Sounds

Normal Breath Sounds

Clinical Characteristics

  • Nonmusical 
  • Soft
  • Heard on inspiration and on early expiration

Clinical Correlations

  • Diminished by factors affecting sound generation (e.g., hypoventilation, airway narrowing) or sound transmission 
  • Assessed as aggregate score with normal breath sound*
  • Rules out clinically significant airway obstruction*

Patients should be instructed to breathe deeply in and out through the open mouth.

Misnomer of the term “vesicular”. Note the longer inspiratory phase relative to the expiratory phase during normal breathing. It is a waltz cadence.


Tracheal Breath Sounds

Tracheal Breath Sounds

Clinical Characteristics

  • Hollow
  • Nonmusical
  • Heard clearly in both phases of respiratory cycle

Clinical Correlations

  • Represents intrapulmonary sounds
  • Can be disturbed (e.g., become noisier or even musical) if upper-airway patency is altered
  • Indicates upper-airway patency
  • Serves as good model of bronchial breathing

Bronchial Breathing

Bronchial Breathing

Clinical Characteristics

  • Soft
  • Nonmusical
  • Heard on both phases of respiratory cycle (mimics tracheal sound)

Clinical Correlations

  • Indicates patent airway surrounded by consolidated lung tissue (e.g., pneumonia) or fibrosis

Stridor

Stridor

Clinical Characteristics

  • Musical
  • High-pitched
  • May be heard over upper airways or at a distance without a stethoscope

Clinical Correlations

  • Indicates upper-airway obstruction
  • Associated with extrathoracic lesions (e.g., laryngomalacia, vocal-cord lesion, postextubation) when heard on inspiration
  • Associated with intrathoracic lesions (e.g., tracheomalacia, bronchomalacia, extrinsic compression) when heard on expiration.

Wheezing

Wheezing

Clinical Characteristics

  • Musical
  • High pitched
  • May be heard on inspiration, expiration, or both (However, it is very uncommon to hear inspiratory wheezing in the absence of expiratory wheezing).

Clinical Correlations

  • Suggests airway narrowing or blockage (e.g., foreign body, tumor) when localized
  • Associated with generalized airway narrowing and airflow limitation when widespread (e.g., in asthma, chronic obstructive pulmonary disease [COPD])
  • •Allows determination of extent of airflow limitation; the greater the number of airways generating wheezes, the greater the degree of overall airflow limitation

Rhonchus

Rhonchus

Clinical Characteristics

  • Musical, similar to snoring
  • Lower in pitch than wheeze
  • May be heard on inspiration, expiration, or both

Clinical Correlations

  • Associated with rupture of fluid films and abnormal airway collapsibility
  • Often clears with coughing, suggesting a role for secretions in larger airways
  • Is nonspecific
  • Often occurs with airway narrowing caused by mucosal thickening or edema or by bronchospasm (e.g., bronchitis, COPD) 

Crackles

As a general rule, the higher the pitch of a crackle the more distal it is in origin.

Early inspiratory

  • Somewhat coarse
  • Not plentiful
  • Associated sounds
    • Squeaks (Laennec’s “cris d’un petit oiseau”)
    • Squawks
  • No change with a change in position
  • Heard in chronic bronchitis, emphysema, asthma

Late inspiratory

  • Fine
  • Plentiful
  • Diminish or disappear with a change in position of the bases of the lung relative to the heart
  • Heard in heart failure, pneumonia, interstitial lung disease, atelectasis, sarcoidosis, others

Fine Crackles

Fine Crackles

Clinical Characteristics

  • Nonmusical
  • Short and explosive
  • Heard on mid-to-late inspiration and occasionally on expiration
  • Unaffected by cough
  • Gravity-dependent
  • Not transmitted to mouth

Clinical Correlations

  • Is unrelated to secretions
  • Associated with various diseases (e.g., interstitial lung disease, congestive heart failure, pneumonia
  • Can be earliest sign of disease (e.g., idiopathic pulmonary fibrosis, asbestosis)
  • May be present before detection of changes on radiography (One cannot see a crackle on a chest x-ray)

If the fine crackles are very plentiful, they are termed “Velcro-type crackles” and usually indicated pulmonary fibrosis of any etiology.

Coarse Crackles

Coarse Crackles

Clinical Characteristics

  • Nonmusical
  • Short and explosive
  • Heard on early inspiration and throughout expiration
  • Affected by cough
  • Transmitted by mouth

Clinical Correlations

  • Indicates intermittent airway opening
  • May be related to secretions (e.g., in chronic bronchitis

Velcro-like Crackles (mid-to-late inspiratory crackles)

Velcro-like crackles (mid-to-late inspiratory crackles)

Special instance of velcro-like crackles

  • Very fine
  • Quite plentiful
  • No change with position
  • Heard in pulmonary fibrosis of any etiology

Pleural Friction Rub

Pleural friction rub

Clinical Characteristics

  • Nonmusical
  • Explosive
  • Usually biphasic
  • Typically heard over basal regions

Clinical Correlations

  • Associated with pleural inflammation or pleural tumors

Inspiratory Squawk

Inspiratory squawk

Clinical Characteristics

  • Mixed, with short musical component (similar to a short wheeze)
  • Accompanied or preceded by crackles

Clinical Correlations

  • Associated with conditions affecting distal airways.
  • May suggest hypersensitivity pneumonia or other types of interstitial lung disease in patients who are not acutely ill.

•May indicate pneumonia in patients who are acutely ill.

According to Mangione, these are heard in bronchiolitis obliterans, pulmonary fibrosis and allergic alveolitis.


Bronchophony

Bronchophony

Bronchophony describes lung sounds heard over an area of consolidation. Normally, spoken words are no well heard when listening to the chest with a stethoscope. However, in the presence of consolidation, these sounds are clearly heard. In this example, the patient is saying “ninety nine”. However, asking the patient to say “boy toy” each and every time the stethoscope is applied to the chest is more effective.


Egophony

Egophony

Egophony is a form of bronchophony in which the spoken syllables have a nasal or bleating quality. The patient is asked to say the letter e.

In egophony, this will be heard as a nasal letter a (as in the English pronounciation “ah” rather than the American pronounciation “ay”)


Whispering pectoriloquy

Whispering pectoriloquy

Heard in lung consolidation as with bronchophony and egophony. Again, whispered sounds are more clearly heard and louder when auscultated in a patient with lung consolidation. In the above example, the patient is whispering, “one, two, three”. Whispering, “sixty six whiskies please” may be a bit more effective and will bring a smile to your patient’s face.

Amphoric breath sounds

Amphoric breath sounds

In this example, shortly after inspiration, one hears a hollow sound analogous to a sound generated when one blows across the top of a wide mouthed jar. Amphora is the Latin for jar. During expiration, one hears high pitched crackles and wheezing.

Amphoric breath sounds are produced in the setting of a cavern, hole, cyst, bleb or other air containing structure which is in communication with the bronchial system.

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