Breath sounds

       
Breath sounds are the noises produced by the structures of the lungs during breathing.

Considerations
The lung sounds are best heard with a stethoscope. This is called auscultation.

Normal lung sounds occur in all parts of the chest area, including above the collarbones and at
the bottom of the rib cage.
 Using a stethoscope, the doctor may hear normal breathing sounds, decreased or absent breath
sounds, and abnormal breath sounds.

Absent or decreased sounds can mean:

 Air or fluid in or around the lungs (such as pneumonia, heart failure, and pleural effusion)
 Increased thickness of the chest wall

 Over-inflation of a part of the lungs (emphysema can cause this)

 Reduced airflow to part of the lungs

There are several types of abnormal breath sounds. The 4 most common are:

 Rales. Small clicking, bubbling, or rattling sounds in the lungs. They are heard when a
person breathes in (inhales). They are believed to occur when air opens closed air spaces. Rales
can be further described as moist, dry, fine, or coarse.

 Rhonchi. Sounds that resemble snoring. They occur when air is blocked or air flow
becomes rough through the large airways.

 Stridor. Wheeze-like sound heard when a person breathes. Usually it is due to a blockage
of airflow in the windpipe (trachea) or in the back of the throat.

 Wheezing. High-pitched sounds produced by narrowed airways. Wheezing and other

abnormal sounds can sometimes be heard without a stethoscope.

Causes
 Causes of abnormal breath sounds may include:

 Acute bronchitis
 Asthma
 Bronchiectasis
 Chronic bronchitis

 Congestive heart failure

 Emphysema
 Interstitial lung disease
 Foreign body obstruction of the airway

 Pneumonia
 Pulmonary edema
 Tracheobronchitis

When to Contact a Medical Professional

Seek immediate medical care if you have:

 Cyanosis (bluish discoloration of the skin)

 Nasal flaring
 Severe trouble breathing or shortness of breath

Contact your health care provider if you have wheezing or other abnormal breathing sounds.

Your provider will do a physical exam and ask you questions about your medical history and
your breathing.

Questions may include:

 When did the breath sound start?

 How long did it last?

 How would you describe your breathing?

 What makes it better or worse?

 What other symptoms do you have?

The provider discovers abnormal breath sounds in most cases. You may not even notice them.

The following tests may be done:

 Analysis of a sputum sample (sputum culture, sputum Gram stain)
 Blood tests (including an arterial blood gas)
 Chest x-ray
 CT scan of the chest
 Pulmonary function tests
 Pulse oximetry

Alternative Names
Lung sounds; Breathing sounds

Images

 Lungs

 Breath sounds


References
Ball JW, Dains JE, Flynn JA, Solomon BS, Stewart RW. Chest and lungs. In: Ball JW, Dains JE,
Flynn JA, Solomon BS, Stewart RW, eds. Siedel's Guide to Physical Examination. 9th ed. St.
Louis, MO: Elsevier; 2019:chap 14.
Kraft M. Approach to the patient with respiratory disease. In: Goldman L, Schafer AI,
eds. Goldman-Cecil Medicine. 25th ed. Philadelphia, PA: Elsevier Saunders; 2016:chap 83.

Lungs
     
Overview
The major features of the lungs include the bronchi, the bronchioles and the alveoli. The alveoli are
the microscopic blood vessel-lined sacks in which oxygen and carbon dioxide gas are exchanged.

Review Date 1/1/2021

Updated by: Jacob L. Heller, MD, MHA, Emergency Medicine, Emeritus, Virginia Mason Medical
Center, Seattle, WA. Also reviewed by David Zieve, MD, MHA, Medical Director, Brenda Conaway,
Editorial Director, and the A.D.A.M. Editorial team.

Breath sounds
     
Overview
Normal lung sounds occur in all parts of the chest area, including above the collarbones and as low
as the bottom of the rib cage.

Review Date 5/6/2019

Updated by: David C. Dugdale, III, MD, Professor of Medicine, Division of General Medicine,
Department of Medicine, University of Washington School of Medicine. Also reviewed by David
Zieve, MD, MHA, Medical Director, Brenda Conaway, Editorial Director, and the A.D.A.M. Editorial
team

Breath sounds: Test your

knowledge
Oct 11 2016by Lisa Bonsall, MSN, RN, CRNP

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Below are the results of a recent nursing quiz about lung auscultation posted
on our Twitter page. This revealed a need for clarification of common
adventitious lung sounds and the commonly associated clinical conditions. 

Answer: B. Crackles are heard when collapsed or stiff alveoli snap open, as in
pulmonary fibrosis. Wheezes are commonly associated with asthma and
diminished breath sounds with neuromuscular disease. Breath sounds will be
decreased or absent over the area of a pneumothorax.

 
First, let’s review the most common adventitious lung sounds.
A wheeze is high-pitched continuous musical sound, which may occur during
inspiration and/or expiration, due to an obstructive process. The classic
wheeze may be referred to as “sibilant wheeze.” This refers to the high-pitched
whistle-like sound heard during expiration, typically in the setting of asthma, as
air moves through a narrow or obstructed airway.
  

Alternately, what we often refer to as rhonchi is the “sonorous wheeze,” which

refers to a deep, low-pitched rumbling or coarse sound as air moves through
tracheal-bronchial passages in the presence of mucous or respiratory
secretions.

In stridor, you’ll hear high-pitched, monophonic inspiratory wheezing. It’s

typically loudest over the anterior neck, as air moves turbulently over a
partially-obstructed upper airway.

Crackles, or rales, are short, high pitched, discontinuous, intermittent, popping

sounds created by air being forced through an airway or alveoli narrowed by
fluid, pus, or mucous. These sounds may also be heard when there is delayed
opening of collapsed alveoli.
  

Crackles are typically heard during inspiration and can be further defined as
coarse or fine. Coarse crackles are heard during early inspiration and sound
harsh or moist. They are caused by mucous in larger bronchioles, as heard in
COPD. Fine crackles are heard during late inspiration and may sound like hair
rubbing together. These sounds originate in the small airways/alveoli and may
be heard in interstitial pneumonia or pulmonary fibrosis.

Now, let’s think about test-taking strategies. In this instance, it would be

helpful to go through each clinical condition separately and predict what
you may hear on auscultation.
 

The first choice was asthma. Asthma is a condition mediated by inflammation.

The resulting physiologic response in the airways is bronchoconstriction and
airway edema. This response is triggered by an irritant, allergen, or infection.
As air moves through these narrowed airways, the primary lung sound is high-
pitched wheeze. Initially the wheezes are expiratory but depending on
confounding factors or worsening clinical symptoms, there may be inspiratory
wheezes, rhonchi or crackles. For testing purposes, however, expiratory
wheezes are associated with asthma.
The second choice was pulmonary fibrosis. This is a form of interstitial lung
disease in which scarring (or fibrosis) is the hallmark clinical feature. This
scarring leads to thickness and stiffness in the lungs. The most common
adventitious sound associated with pulmonary fibrosis is fine bibasilar crackles.
This may be hard to distinguish from congestive heart failure. The crackles are
the result of the snapping open of collapsed, stiff alveoli.

Neuromuscular disease was the third choice. Neuromuscular disorders can

cause respiratory problems through several pathways as the muscles
responsible for breathing are affected. Diaphragmatic weakness can lead to
hypoventilation; chest wall muscle weakness can lead to ineffective cough;
and upper airway muscle weakness can lead to difficult swallowing and
ineffective clearing of upper airway secretions. In general, there are not
specific adventitious sounds associated with neuromuscular disorders.

Lastly, a pneumothorax is a collapsed lung. There would be loss of breath

sounds over the area of a pneumothorax as there is no air movement in the
area of auscultation.

So, this leads us to the correct answer. During lung auscultation, crackles are
heard in pulmonary fibrosis, which is choice B.  

Reviewing what you know and thinking about each response choice can help
you focus in on the correct answer. Do you have an easy acronym or pearl for
remembering breath sounds, or some test-taking strategies to share?
 
Reference:
Hinkle, J. & Cheever, K.  (2013). Brunner & Suddarth's Textbook of Medical-Surgical
Nursing. Philadelphia: Lippincott Williams & Wilkins.

 
Megan Doble, MSN, RN, CRNP