THE CHEST: FOCUS ON LUNG

SOUNDS

RICARDO M. SALONGA, MD, FCCP, FPCP, FPCC

Pulmonary Consultant, Manila Doctors’ Hospital,
Medical Center Manila and UPHDMC
Professor, Pulmonary Section, Dept. of Medicine,
College of Medicine-PGH
AND PHYSICAL EXAMINATION
in CLINICAL DIAGNOSIS
A good history and physical
examination by an astute clinician ca
already lead to a correct diagnosis in
approximately 80% of cases, and
almost 100% with additional diagnost
tools(i.e. Chest x-ray, CT Scan, PFT,
etc.)
 SYSTEM

. CONDUCTING SYSTEM:
from nasal cavity and
pharynx(upper airways) down to
the larynx, trachea, main bronchi,
down to distal bronchioles(lower
airways).

. GAS-EXCHANGING
SYSTEM: terminal bronchioles,
alveolar ducts and alveoli.
 ANATOMY(Cont’d)
he terminal bronchioles divide into 2-
5 alveolar ducts, each of which
consists of 10-16 alveoli. Alveoli has 3
cell types: Type I, the lining cell
accounts for 95% of the alveolar
surface area. Type II cell produces
surfactant, a mixture of
phospholipids, which maintains
alveolar stability. The macrophage
acts as phagocytic defense vs
infection.
he adult respiratory system contains
approx. 300 million alveoli.The
surface area of the alveolo-capillary
membrane available for 02-C02
 I. PHYSIOLOGY OF RESPIRATION

During inspiration, as these muscles

contract, the thorax expands.
Intrathoracic pressure decreases, drawing
air into the tracheobronchial tree into
the alveoli and expanding the lungs. Gas
exchange takes place in the alveoli.

After inspiratory effort stops, the

expiratory phase begins.The chest wall
and the lungs recoil, the diaphragm
relaxes and rises passively, air flows
outward and the chest and abdomen
return to their resting positions.
 II. PHYSIOLOGY OF RESPIRATION

During inspiration, air enters the upper

airway, travels through the lower airways
until it reaches the alveoli. Each alveolus
is surrounded by multiple capillaries.

During systole, deoxygenated blood

returning from the body’s cells is pumped
from the right ventricle through the
arterial pulmonary circulation to the
alveolar capillaries. CO2 diffuses from the
capillary blood across alveolo-capillary
membrane and enters the alveolar air.
Simultaneously, O2 from inspired atm. air
in the alveolus crosses the alv.cap.
membrane and enters the pulmonary
capillary blood.
 III. PHYSIOLOGY OF RESPIRATION
During expiration, CO2 is exhaled from the lungs.
Oxygenated blood travels to the left side of the heart
and is pumped from the ventricle into the arterial
circulation to the cells of the body, where cellular
respiration occurs.
CHEST & LUNGS

 INSPECTION

 PALPATION

 PERCUSSION

 AUSCULTATION
 INSPECTION
xamine skin over the chest for lesions that
estrict respiratory excursion and structural
eformities.(e.g. barrel chest, pigeon breast)
Note cough and noisy breathing
Observe respiratory movements: rate,
mplitude and rhythm.
Observe retraction of interspaces and other
igns of labored breathing(i.e. use of
ternocleidomastoids)
PALPATION
 Palpate to test respiratory excursion,
esp. posteriorly.
 Palpate for tracheal position.
 Palpate for any soft tissue masses/tenderness.
 Palpate for rib/costochondral tenderness
 Palpate for tactile fremitus, using base of finger
or edge of your hand, comparing the two side
of the chest.
RESPIRATORY EXCURSION
Tactile Fremitus

 Palpable vibration of the

chest wall from sounds
transmitted from the
phonating larynx.
 “Ninety-nine.”
 Compare symmetry.
 Abnormality MAY be ‘ed or
‘ed.
PERCUSSION
 With a quick, sharp but relaxed wrist motion,
strike the pleximeter finger with the right
middle finger or plexor finger. Aim at your dista
interphalangeal joint. Strike using the tip of the
plexor finger, not the finger pad.Your finger
should be almost at right angles to the
pleximeter. Withdraw your striking finger quick
to avoid dampening the vibrations you have
created.
 In summary, the movement is at the wrist. It is
directed, brisk yet relaxed and a bit bouncy!
ercussion

 Defines density of underlyi

structures by differences in
sound wave conduction.
 “Dull” – over thigh.
 “Flat” – over forehead.
 “Resonant” – over right
pectoralis.
 Examination Points

 = sites for percussion

 AUSCULTATION
Stethoscope: ideal length = 10-12
inches. Earpieces must fit tightly and
placed into the ears in an anterior
direction.
Auscultatory technique: always
compare both sides of the chest.
Include tracheal area using the bell.
There are auscultatory sites on the
posterior chest wall and on the
anterior chest wall. (See diagrams
with corresponding landmarks)
 Examination Points

 = sites for auscultation

 NORMAL BREATH SOUNDS
Tracheal and Bronchial Breath Sounds:
- are loud, high-pitched sounds heard
over the trachea and mainstem bronchi.
- produced by turbulent airflow patterns.
- IE ratio= 1:2 to 1:3.
- sound frequency= 200 to 2,000Hz.
- heard over chest wall on either side of the
sternum from 2nd to 4th ICS anteriorly
and along vertebral column from 3rd to
6th ICS posteriorly.
 NORMAL BREATH SOUNDS(Cont’d
Normal Breath Sounds Heard Over
Other Chest Wall Areas:
1.Vesicular breath sounds – produced by
changes in airflow patterns, quieter than
bronchial/tracheal BS. Inspiration is heard
clearly, immediately followed by expiration
which quickly fades as airflow rates rapidly
decline and turbulent airflow is directed
towards the central airways. IE ratio=3:1 to
4:1. Sound frequency = 200-600Hz.
NORMAL BREATH SOUNDS(Cont’d

2. Bronchovesicular breath sounds:

heard anteriorly and posteriorly
over large central airways. Pitch &
duration- between vesicular and
bronchial breath sounds, with IE
ratio=1:1.
Breath Sound Characteristics
Intensity of Pitch of
Duration “Normal”
Expiratory Expiratory
of sounds Location
Sounds Sounds
Inspiration Relatively Both lung
Vescicular Softer
> Expiration low fields
1st & 2nd
interspaces
Broncho- Inspiration
Intermediate Intermediate anteriorly;
vescicular = Expiration between
scapulae
Over
Inspiration Relatively
Bronchial Loud manubrium
< Expiration high
(?)
BRONCHIAL BREATH SOUNDS
 Occurs when lung tissue between centra
airways and chest wall becomes airless
because of conditions that increase lung
density, thus enhancing transmission of
breath sounds which become louder,
more tubular with IE ratio=1:1 or 1:2.
 Seen in consolidation, atelectasis and
fibrosis(which increase lung tissue densit
by fluid accumulation, lung collapse or
fibrotic scarring).
 ABNORMAL VOICE SOUND
Voice sounds are produced by vibrations of the
vocal cords as air from the lungs passes over
them.

Normally, vowel tones which contain high

frequency sounds are filtered and
diminished. However, over consolidated or
atelectatic lung tissue, less filtering takes
place, thus, enhancing transmission.
BNORMAL VOICE SOUNDS(Cont’d
The three types of abnormal voice sounds:
 Bronchophony- clear, distinct & intelligible voice
sound heard over airless lung tissue.
 Whispered Pectoriloquy – clear, distinct, intelligible
whispered voice sound heard over airless,
consolidated/atelectatic lung tissue.
 Egophony – voice sound with a nasal or bleating
quality heard over the chest wall over
consolidated/atelectatic lung tissue, also seen in
upper border of a large pleural effusion.
1977)
A. CRACKLES: discontinuous sounds
1. Loud & low pitched = coarse crackles.
2. Less intense, higher pitch & short duration =
fine crackles.
B. WHEEZES: continuous sounds that are high-
pitched with hissing sound.
C. “RHONCHI” or LOW-PITCHED WHEEZES:
low pitched, continuous sounds heard primar
during expiration and caused by
fluids/secretions partially blocking large
airways.
D. PLEURAL FRICTION RUB: due to inflammatio
1997)
STRIDOR
 Loud musical sound that is heard at a
distance without a stethoscope.
 It is caused by laryngeal spasm and
mucosal swelling.
 Typically heard during inspiration, but
maybe heard throughout the respiratory
cycle.
the Clinical Course of Pneumonia (Piir
CHEST, 102:1, 176-183, July, 1992)

 Early Stages: coarse crackles, mid-

inspiratory(due to edema, inflammation
alveolar infiltrates)

 Later Stages: fine crackles, late

inspiratory(due to improvement in
inflammation, consolidation with lowere
compliance)
THANK YOU!