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Pulmonary Auscultation
Bernard Karnath, MD
Michael C. Boyars, MD
Table 2. Adventitious (Extra) Breath Sounds tion can transmit bronchial breath sounds to the
periphery. Tracheal breath sounds are high pitched
Discontinuous (nonmusical) and loud. They have a tubular quality. Tracheal breath
Crackles (generally high-pitched, discontinuous sounds) sounds are heard best in the neck region.
Coarse: loud, low-pitched sounds
Adventitious Breath Sounds
Fine: soft, high-pitched sounds
Adventitious breath sounds are superimposed on
Pleural friction rubs (grating sound)
normal breath sounds and usually indicate disease.
Continuous (musical) Adventitious breath sounds can be classified as contin-
Wheezes (high-pitched sounds that are musical in quality) uous or discontinuous. Continuous breath sounds are
Rhonchi (sounds with a “snoring” or “gurgling” quality) uninterrupted musical sounds, whereas discontinuous
Stridors (sounds heard over the trachea) breath sounds are explosive, sharp, discrete bursts of
sound. The detection of adventitious breath sounds
can help in diagnosing a disorder.
BREATH SOUNDS There has been some inconsistency in the use of
Breath sounds are generated by turbulent airflow proper terminology for adventitious breath sounds;
through the respiratory tree. Characterized by their pitch, these sounds include crackles, wheezes, rhonchi, pleur-
intensity, qualities (eg, harshness or loudness), and dura- al friction rubs, and stridors (Table 2). Crackles are
tion (of the inspiratory and expiratory phases), breath sometimes referred to as rales; the term rale (and later
sounds should be auscultated with the diaphragm of the the term rhonchus) was originally used by Laennec to
stethoscope. The qualities of the breath sounds are modi- describe all adventitious pulmonary sounds.7 Crackles,
fied as they filter through the respiratory tree (Figure 2). wheezes, and rhonchi are the most common adventi-
tious breath sounds.
Normal Breath Sounds Crackles are discontinuous adventitious breath
Normal breath sounds can be classified as tracheal, sounds and can be classified as fine or coarse. Coarse
bronchial, bronchovesicular, or vesicular (Table 1). crackles are loud and low pitched. Fine crackles are
Typically, the breath sound auscultated depends on the soft and high pitched. A crackle is generated when an
area of the thorax being examined (Figure 2). abnormally closed airway snaps open during inspira-
Vesicular breath sounds are soft, low-pitched sounds tion or closes at the end of expiration.8 Crackles can
and can be heard over the periphery of both lung also be described based on the timing of the sound
fields; with regard to these breath sounds, the inspira- during inspiration and expiration (eg, late inspiratory
tory phase lasts longer than the expiratory phase. crackles versus early inspiratory crackles). Pleural fric-
Bronchovesicular breath sounds are soft and high tion rubs are also discontinuous sounds. Pleural fric-
pitched. These sounds are heard best between the tion rubs are generated when the 2 serous membranes
scapulae. Bronchial breath sounds are loud, hollow, of the pulmonary pleura rub together.
harsh sounds; they are heard best over the manubri- Wheezes and rhonchi are continuous adventitious
um. Bronchial breath sounds are an abnormal finding breath sounds, which are generated by air flowing
if heard in the peripheral lung fields. Lobar consolida- through a narrowed airway. Wheezes are high pitched
Copyright 2002 by Turner White Communications Inc., Wayne, PA. All rights reserved.