peak technique

Every breath you take: Making sense of breath sounds

MARGARET MCCORMICK, RN Director of Nursing Skills Lab Towson University Towson, Md.

ELAINE HARBISON, 20, has a history of asthma. Shes now in the emergency department (ED) complaining of shortness of breath that has been getting progressively worse after a cold. She says that a chronic cough has been keeping her up at night, and you notice that shes only able to speak in short phrases. She hasnt gotten any relief from her rescue inhaler. During your initial assessment, you nd that her oxygen saturation is 94% and that shes leaning forward in a tripod position. Shes becoming increasingly nervous and hyperventilating. You immediately take her vital signs and conduct a general survey of her physical appearance, body structure, mobility, and behavior. When you auscultate her lungs, you dont hear much. Whats going on with your patient? The answer isnt too hard to gure outif you understand the basics of interpreting breath sounds. In this article, Ill walk you through how to listen to breath sounds and what kinds of sounds you may hear. But rst, lets quickly review whats normal and what isnt.

over the manubrium (upper part of the sternum). The inspiratory phase is quieter and shorter than the expiratory phase. I Bronchovesicular breath sounds. These sounds are a mixture of bronchial and vesicular sounds. Theyre medium in loudness and pitch, and they can be heard anteriorly near the main stem bronchi, at the rst and second intercostals spaces, and posteriorly between the scapulae. The inspiratory and expiratory phases are equal in length. I Vesicular breath sounds. Relatively soft and low-pitched, these sounds are like sighing or a gentle rustling of leaves. They can be heard over most of the peripheral parts of the lung. The inspiratory phase is two and a half to three times longer than the expiratory phase, and theres no pause between the phases. See Qualities of normal breath sounds for a quick and visual overview.

Listen up... weve got the top tips for evaluating breath sounds.

This cant be right

Abnormal breath sounds include the absence of breath sounds or the presence of normal sounds in areas where they arent normally heard. For example, bronchial or tubular breath sounds are abnormal if theyre heard in the peripheral areas where only vesicular sounds are generally heard. Bronchial sounds heard in areas that are distant from their normal location generally indicate that the patient may have a consolidation, such as in pneumonia. Remember, dense tissue transmits sounds from the lung more efciently. Adventitious breath sounds (extra sounds that can be heard on top of normal sounds) are also abnormal. Examples include crackJanuary/February 2007 Nursing made Incredibly Easy! 7

Is that normal?
Normal breath sounds include the following: I Tracheal breath sounds. These sounds arent usually auscultated during a routine exam. Theyre very loud and highpitched, hollow, or harsh sounds. They can be heard over the extra thoracic portion of the trachea. The inspiration phase is equal to or slightly shorter than the expiratory phase. I Bronchial breath sounds. Loud and highpitched, they sound like air blowing through a tube. These sounds can be heard

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les, wheezes, pleural friction rub, and stridor. Lets take a closer look. Crackles, formerly known as rales, are caused by uid in the small airways. Theyre discontinuous soundsintermittent, nonmusical, and short. Usually heard on inspiration, crackles create popping sounds because air is being forced through respiratory passages that are narrowed by uid, mucus, or pus. This may indicate inammation or infection. Crackles that dont clear with coughing mean the patient has heart failure or acute respiratory distress syndrome. Fine crackles are soft, high-pitched, and short. To simulate the sound, try rolling a strand of hair between your ngers near your ear. Coarse crackles are louder, lower-pitched, and longer than ne crackles. They sound like youre ripping open a nylon hook-and-loop fastener. Wheezes are continuous sounds heard during inspiration or expiration. Wheezes may be high-pitched with a squeaking or musical quality (formerly called sibilant rhonchi), caused by air moving through constricted bronchial airways such as in asthma, or they may be low-pitched with a snoring or moaning quality (formerly called sonorous rhonchi), caused by excess secretions such as in bronchitis. A pleural friction rub is a low-pitched grating or creaking sound that occurs because of inamed pleural surfaces rubbing together during respiration. Its usually heard during inspiration but can also be heard during expiration. A pleural friction rub can best be heard over the lower lateral anterior surface of the thorax. To determine if the rub is pleural or pericardial, have your patient hold her breath. If you still hear the rub, its a pericardial rub. Stridor is a high-pitched harsh sound heard during inspiration. Its caused by an obstruction of the upper airway from a foreign body or epiglottitis. Stridor is a sign of respiratory distress and requires immediate attention.

Train your ear

Now, lets get back to Elaine, your patient in the ED. You need to perform a complete respiratory assessment to determine whats going on. Heres what to do. I Listen to the breath sounds in a quiet environment. I Have your patient sit upright and take

Qualities of normal breath sounds

Breath sound
Tracheal

Quality
Harsh, high-pitched

I:E ratio
I=E

Location
Above supraclavicular notch, over the trachea

Bronchial

Loud, high-pitched

I<E

Just above clavicles on each side of the sternum, over the manubrium Next to the sternum, between scapulae

Bronchovesicular

Medium in loudness and pitch

I=E

Vesicular

Soft, low-pitched

I>E

Remainder of lungs

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deep breaths through her mouth. I Use the diaphragm of your stethoscope to listen to a full inspiration and a full expiration at each point, starting at the apex of the lung (C7) and progressing to the base (T10). Remember to listen anteriorly, posteriorly, and laterally under the axilla to the seventh or eighth rib (see Chest auscultation sequence). Dont listen over a gown, chest hair, or bone. I Compare similar lung segments with one another; dont just go up and down one side. First concentrate on inspiration. Whats the length of inspiration? Compare it with expiration. Whats the length of expiration? Do you hear air moving? Are the sounds correct for that location? Do you hear any abnormal sounds? Normal ndings include: I relaxed posture I regular respiratory rate of 10 to 18 breaths/min I absence of cyanosis or pallor I ratio of the anterior and posterior chest diameter to the transverse diameter of 1:2 I symmetrical chest expansion during inspiration and expiration I tactile fremitus thats equal bilaterally when the chest is palpated. To test this, have the patient say 99. Decreased or absent fremitus is caused by a decrease in vibration transmission, such as in emphysema. An increase in fremitus occurs if vibrations are enhanced, such as in lung consolidation. I absence of palpable lumps or masses and no tenderness of the lungs I resonant sound on percussion I diaphragmatic excursion of 3 to 5 cm thats equal bilaterally I vesicular sounds heard over the peripheral lung elds on auscultation I bronchovesicular sounds heard parasternally and between the scapulae I absence of adventitious sounds. When you physically examine Elaine, you notice that her heart rate and respiratory rate are elevated. Her worsening shortness of

Normal breath sounds are music to our ears!

Chest auscultation sequence

Follow this sequence when listening for breath sounds.

Anterior

Posterior

1 2

1 2 3 4 5 6 7

3 4

5 6

4 7

10 Nursing made Incredibly Easy! January/February 2007

breath is causing her to use accessory muscles in her neck and retract her intercostal muscles. When you auscultate her lungs, you now hear wheezing. The expiratory phase of her breathing is labored and prolonged. Remember, even if you dont detect crackles or wheezing, your patient isnt necessarily OK. Diminished or absent breath sounds require prompt and immediate medical attention.

home with instructions to use a corticosteroid inhaler twice a day and levalbuterol as needed for wheezing.

Sound advice
By carefully listening to breath sounds and recognizing the difference between whats normal and whats abnormal, youll be better able to accurately assess your patients condition and provide the best care possible. I

Breathing easy again

You suspect that Elaine is having an asthma attack, which is conrmed by the ED physician. He orders a nebulizer treatment with levalbuterol (Xopenex), a fastacting bronchodilator, and prednisone, 40 mg by mouth. After her treatment, Elaine begins to breathe easier. Shell continue taking prednisone for 10 days. Shes also sent

Learn more about it

Smeltzer SC, Bare BG. Brunner & Suddarths Textbook of Medical-Surgical Nursing, 10th edition. Philadelphia, Pa., Lippincott Williams & Wilkins, 2004. Surgical Care Made Incredibly Visual! Philadelphia, Pa., Lippincott Williams & Wilkins, 2007. Weber JR, Kelley J. Health Assessment in Nursing, 2nd edition. Philadelphia, Pa., Lippincott Williams & Wilkins, 2003. Weber JR. Nurses Handbook of Health Assessment, 5th edition. Philadelphia, Pa., Lippincott Williams & Wilkins, 2005.

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