Know What You Hear: A Basic Review of Pulmonary Auscultation
A comprehensive pulmonary assessment is an incredibly valuable tool nurses have in their arsenal of skills. A thorough and skilled assessment allows you to obtain descriptions about your patient’s symptoms and discover any associated physical findings that will aid in the development of differential diagnoses.
When conducting a focused pulmonary assessment on your patient, it is important to document the respiratory rate & rhythm, depth of respirations, paradoxical chest movement & symmetry of respirations. Also note the use of accessory muscles, nasal flaring, tracheal deviation & cough.
After a thorough chest inspection, auscultate anterior and posterior lung fields. Have your patient breathe slightly deeper than normal through their mouth, then auscultate from C-7 to approximately T-8, in a left to right comparative sequence. You should auscultate between every rib, listening for vesicular, bronchial and bronchovesicular breath sounds.
Bronchial sounds are high pitched & usually heard over the trachea. Timing includes an inspiratory phase that is less than the expiratory phase. If bronchial sounds are heard in the actual lung fields, this may indicate consolidation. Vesicular sounds are low pitched, normal breath sounds heard in the periphery of the lungs, and have an inspiratory phase that is greater than the expiratory phase. Lastly, bronchovesicular sounds are medium pitched sounds that have a muffled quality, and the inspiratory phase is equal to the expiratory phase.
It is also important to recognize ‘abnormal’ breath sounds. The most common deviations may include:
- Decreased breath sounds. This may be caused by the accumulation of fluid, air or increased tissue that interferes with transfer of sound to chest wall. Absent breath sounds are often caused by major or minor airway obstruction that results in no air flow.
- Crackles. These sounds are heard during inspiration, and may be classified as fine or coarse crackles. Fine crackles sound like the rubbing of strands of hair together next to your ear, and are easily cleared upon coughing. Conversely, coarse crackles have a bubbling sound, similar to carbonated soda; and are not usually cleared with coughing.
- Wheezing. This is a high pitched sounds that may be heard during inspiration or expiration.
- Rhonchi. Are low coarse sounds with a snoring quality. Generally clears with coughing.
- Pleural friction rub is a harsh, grating sound located in area of intense chest wall pain.
- Bronchophony is the abnormal transmission of sounds from the lungs or bronchi. Upon auscultation, the patient is instructed to repeat the phase ‘ninety nine.’ In healthy patients, the sound of the patient’s voice would become less distinct as the auscultation moves peripherally. However, with bronchophony, the patient's voice remains loud and distinct, indicating lung consolidation.
- Whispered pectoriloquy is extreme bronchophony and egophony, which occurs when the spoken word assumes a nasal quality. When the patient is instructed to say "E", it is heard as "A" indicating consolidation or pleural effusion.
Documenting the information, and then sharing your findings with the physician adds to your value as a healthcare team member, and ultimately a better patient care provider. To further refresh your skills in performing a comprehensive lung assessment, visit RN.com’s course: Focused Exam for the Acute Care Setting.
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