Karina Borges

Bridge Nursing Program

January 13, 2020

Common Lung Sounds

In this section the most commonly encountered lung sounds will be presented. The time
amplitude plots of these sounds will be displayed.

Time amplitude plots of lungs are generally made in two ways: expanded or unexpanded. The
unexpanded method is similar to a phonocardiograph time amplitude display. This allows an
overall view of the acoustic characteristics in real life. In the time expanded analysis, the time or
x-axis is stretched out so that the details of the acoustic phenomena can be examined more
carefully. In the following figure time domain plots are illustrated in both the time unexpanded
and time expanded modes. It is clear that the pattern differences between different types of lung
sounds are seen easily in the expanded mode.

 Amplitude-versus-time plots typical lungs sounds, showing that the expanded

time scales in the right column reveal visually distinct patterns not readily seen in
the plots at conventional speeds on the left.
 Time is on the horizontal axis, and amplitude on the vertical axis. The plots on the
right, reproduced here at a scale of 800 mm per second, are 0.1 sec long and are
sections from the 0.8-sec-long plots on the left shown here at 100 mm per second.

Bronchial Sounds

 These are the sounds heard over large airways.

 They have a "tubular" quality -the sound has been compared to the sound of air blowing
through a cardboard tube.

 Bronchial sounds are abnormal when heard at a distance from large airways.

Bronchial sounds are abnormal when heard at a distance from large airways.
Bronchial or tracheal sound are heard on the chest at sites which are close to large airways. In
contrast to vesicular sounds they are relatively louder in expiration than inspiration. They have a
tubular or blowing quality similar to air being blown through a tube. In the time amplitude in
expiration than inspiration. This type of breath sounds is heard best over the trachea.

Bronchial sounds are also heard on the back between the scapulae and at the lung apices
especially on the right. They may also be heard in the axillae. When they are heard in locations at
a distance from large airways, they signify consolidation. This is believed to be due to better
transmission of the centrally generated lung sounds through the consolidated lung. This is more
likely to occur during the expiratory phase because the expiratory phase has a more central
origin than the inspiratory phase.

Vesticular Sounds

 These are the sounds heard over the chest at a distance from large airways.

 The vesicular sound is a "soft " sound that has been compared to the sound of wind
blowing through the leaves of a tree.

 This is the most common sound heard in the absence of lung disease.

Vesicular sounds are the most common sound heard over the chest. They are present at sites that
are at a distance from large airways. While the term "vesicular" has been criticized because it is
unlikely that any sound is produce in the " vesicles" i.e. alveoli, it is still a useful term to describe
the sounds heard when the stethoscope is over lung parenchyma at a distance from large airways.
The vesicular sound is a soft sound that has been compared to that of wind blowing though trees.
It is louder in inspiration than expiration. In the time expanded waveform analysis an almost
random undulating pattern is seen in inspiration. The expiratory sound is of relatively low
amplitude. The vesicular sound is commonly decreased in chronic obstructive lung disease. It is
also decreased in chronic obstructive lung disease. It is also decreased over sites of pneumonia In
the early stage of the illness. It is usually, but no always, decreased of absent in conditions where
the ventilation to an area of lung is impaired.: e.g. pneumothorax, misplaced endotracheal tube,
mucus plugging.

Fine Crackles

 These are “discontinuous,” i.e. intermittent, “explosive sounds.

 Laenner described them as sounding like the crackling noise made when salt is heated on
a frying pan.

 They are caused by airway openings.

Crackles are intermittent explosive sounds that have been described as being similar to the
crackling sound heard as wood burns. Crackles appear in the time domain as intermittent spike-
like deflections. They can be seen in the unexpanded display but are usually seen more readily in
the expanded mode as shown in the figure. Considerable evidence has been presented in the
support of the hypothesis that crackles are caused by the sudden opening of airways. It is likely
that they are also caused by fluid in the airways. Crackles are divided into two types, fine and
coarse by the acoustic properties. In auscultation fine crackles are in general higher pitched, less
intense and of shorter duration than coarse crackles. Crackle wave form features such as initial
deflection width, largest cycle deflection, number of zero crossings, etc. have been used to
separate fine and coarse crackles objectively. These characteristics can be measured and utilize
in computer algorithms allowing automatic detection, counting and classification at the bedside.
Note that the crackling sound generated by the same event can be recorded and identified by
multiple microphones. When crackles are counted one has to pay special attention to avoid
counting the same event at multiple microphones. The term “unrelated” crackle rate is used to
signify that only crackles representing unrelated events are counted. While fine crackles can be
heard in normal particularly after special maneuver such as after breath holding at low lung
volumes, they are usually a sign of disease

Coarse Crackles

 These are intermittent “bubbling” sounds.

 Laenner compared these sounds to the sound of water being poured from a bottle.

 They are caused by airway opening and secretions in airways.

As noted, previous display course crackles are in general lower pitched, less intense and of
longer duration than fine crackles. The most common conditions associated with coarse crackles
are congestive heart failure and pneumonia

Fine Crackles Vs. Coarse Crackles

 Fine – high pitched, “explosive” sounds.

 Coarse – lower pitched, “bubbling” sounds.

Wheezes

 These are high pitched, whistling or sibilant sounds.

 They are caused by airway narrowing and/or secretions.

Wheezes are described as relatively “continuous sounds” as compared to crackles. They usually
last for more than 200 milliseconds and have a musical quality. On time expanded waveform
analysis, they can be seen to have a sinusoidal pattern. Wheezes are believed to be caused by
airway narrowing. While bronchospasm is a common cause of the narrowing that causes
wheezing, a variety of other conditions can also produce this adventitious sound including
airway edema, secretions, endobronchial tumors and extrinsic compression of an airway.
Wheezing in congestive heart failure is likely due to increased fluid in peribronchial lymphatics
causing airway compression.

Stridor

 Stridor sounds like a wheezing noise but is usually more prominent during inspiration.
  It is caused by airway obstruction.

Stridor has a characteristic feature of upper airway obstruction. Stridor is a continuous sound
heard on auscultation, with or without a stethoscope that is loudest over the mouth, neck, and
upper trachea. It sounds like a wheeze and acoustic analysis shows that stridor is quite similar to
wheezing. The major distinguishing feature is that stridor tends to have inspiratory
predominance. The use of accessory muscles of respiration and retraction of the supraclavicular
fossae with inspiration are often observed. Careful inspection of the mouth for evidence of
aspiration of food or a foreign body is important. Examination of the neck for masses, scars, and
tracheal deviation is also important. The skin should be surveyed for hives, as they may provide
a clue to the presence of angioneurotic edema of the glottis, an important cause of upper airway
obstruction.
Stridor heard immediately after extubation may indicate the need for reintubation.

Pleural Rub

 This sound has been described as sounding like two pieces of leather being rubbed
together.

 They are caused by inflamed pleural surfaces rubbing against each other.

These sounds have a leathery quality. This sound has been compared to the sound made when
two pieces of leather are rubbed together. The waveform has a complex pattern as seen in the
illustration. Rubs occur when the pleural surfaces are inflamed which can be caused by a variety
of disease processes. The most common cause is a pneumonic process that has spread to the
pleura.

Rhonchi

 These are low pitched, snore-like sounds.

 They are caused by airway secretions and airway narrowing.

 They usually clear after coughing.

Rhonchi are also described as “continuous” sounds as they usually last more than 1/4 of a
second. They are lower in pitch than wheezes and have a snoring quality. They also have a
sinusoidal pattern on waveform, but the number of deflections per unit of time is less than that of
wheezes as they are of lower frequency. Although rhonchi are almost always due to airway
secretions and usually clear with cough, they may be present in other conditions that cause
airway narrowing.
Wheezes Vs. Rhonchi

 Wheezes are higher pitched and have more deflections per unit time than rhonchi.

 Rhonchi are low pitched, snore-like sound.

Wheezes and rhonchi have both been described as “continuous” sounds. “Continuous” in this
sense means that their duration is longer than the intermittent or discontinuous sound of crackles.
Wheezes are approximately 200 milliseconds or longer, while crackles are about 20
milliseconds’ long. Note: sounds with a sinusoidal pattern and a duration between 25 and 200
milliseconds are called squawks or short wheezes. Wheezes and rhonchi have sinusoidal
waveforms. They are presented in this illustration. Although exact frequency that divides
wheezes and rhonchi is not known, the frequency of rhonchi is usually 100 to 120 Hz, wheezes
have frequencies of 300 Hz or more.

Squawks

 These sounds are short inspiratory wheezes.

 They have been described in diffuse interstitial diseases, including hypersensitivity

pneumonia.

 They also occur in pneumonia.

Squawks or short wheezes are brief “squeaky” sounds that are also referred to as squawks. Their
waveforms show a sinusoidal pattern of brief duration. Squawks have been described as bird
fancier’s disease and other forms hypersensitivity pneumonia. They are also heard in a variety of
conditions in which alveolitis is present. In one study they were found in 10% of patients with
pneumonia.