History

Cough
Is cough productive or nonproductive?
If productive, what color is the sputum?
o Mucoid = translucent / white, or gray
o Purulent = yellow or green
o Hemoptysis = blood
What volume of sputum is produced?
o Large volumes may be present in bronchiectasis or lung abscess
Physical Exam
Vesicular:
rustling quality;
I:E of 3:1

Considered normal

Diminished vesicular sounds

rustling quality
I:E of 3:1

Significance: hear in obese, frail, muscular patients

Bronchial Breath Sounds

Hollow and tubular sounds
Auscultated over trachea where considered normal
Distinct pause between inspiration and expiration. But I:E is 1:3

Significance: Considered abnormal if heard over peripheral lung fields; consider pneumonia,
atelectasis, pleural effusions

Bronchovesicular Breath Sounds

Inspiration = Expiration: I:E = 1
Sounds are normal in mid-chest area or in posterior chest between scapula
Mixture of bronchial breath sounds heard near trachia and alveoli with vesicular sound

Significance: May indicate early infiltrate or partial atelectasis

Rhonchi = Low Pitched wheezes

Continuous, both inspiratory and expiratory
Low pitched, with snoring, gurgling or rattle-like quality
Rhonchi occur in the bronchi (not over the alveoli); usually clear after coughing

Fine Crackles (rales)

Brief, discontinuous, popping lung sounds that are high-pitched
Can be heard in both phases of respiration
Significance:
o Early inspiratory and expiratory crackles are hallmark of chronic bronchitis
o Late inspiratory crackles may mean pneumonia, CHF, or atelectasis
Course Crackles (rales)
Discontinuous, brief, popping lung sounds that are louder, lower in pitch, and last longer than fine
crackles (bubbling sound, rolling strands of hair close to ear)
Significance: heard in chronic bronchitis

Crackles: Early Inspiratory

Begin and end during the early part of inspiration. The pitch is lower than late inspiratory crackles.
A patient's cough may decrease or clear these lung sounds.
Significance: Early inspiratory crackles suggest decreased FEV1 capacity and are characteristic of
COPD; patients will present with noisy mouth breathing as well


Crackles: Late Inspiratory
Late inspiratory crackles (rales) begin in late inspiration and increase in intensity.
They are normally higher pitched and can vary in loudness.
These sounds are heard over posterior bases of the lungs.
They may clear with changes in posture or several deep breaths. They do not clear with coughing.

Significance: ssociated with with interstitial fibrosis, pneumonia, CHF or atelectasis.

III. Wheezes
Occur in partial airway obstruction from secretions and tissue inflammation in asthma, or from a
foreign body
Wheeze Expiratory
Wheezes are adventitious lung sounds that are continuous with a musical quality.
o Wheezes can be high or low pitched.
o High pitched wheezes may have an auscultation sound similar to squeaking.
o Lower pitched wheezes have a snoring or moaning quality.
Cause: Wheezes are caused by narrowing of the airways.

Significance: The proportion of the respiratory cycle occupied by the wheeze roughly corresponds
to the degree of airway obstruction.

Monophonic Wheeze
Monophonic wheezes are loud, continuous sounds occurring in inspiration, expiration or
throughout the respiratory cycle. The constant pitch of these sounds creates a musical tone.
The tone is lower in pitch compared to other adventitious breath sounds. The single tone suggests
the narrowing of a larger airway.

These lung sounds are heard over anterior, posterior and lateral chest walls. These sounds can be
more intense over lung areas affected by partial obstructions.

Significance: A fixed monophonic wheeze: same pitch, same place, may be an indication of
foreign body aspiration or tumor

Polymorphic Wheeze
Polyphonic wheezes are loud, musical and continuous.
The higher the pitch, the longer the wheeze, the greater the obstruction.
These breath sounds occur in expiration and inspiration and are heard over anterior, posterior and
lateral chest walls.

Significance: These sounds are associated with COPD and more severe asthma.

Stridor
Stridor is a loud, high-pitched crowing breath sound heard during inspiration but may also occur
throughout the respiratory cycle most notably as a patient worsens.
o Can be louder in supine position for children
Significance: Stridor is caused by upper airway narrowing or obstruction. It is often heard without
a stethoscope. It occurs in 10-20% of extubated patients.
o Causes of stridor are pertussis, croup, epiglottis, aspirations.