PHYSICAL ASSESSMENT OF THE ⮚ It appears when there is at least 5g/dl of

RESPIRATORY SYSTEM (Part 2) unoxygenated hemoglobin

⮚ The general appearance gives clues to ⮚ Causes of cyanosis are anemia,
respiratory status. A thorough physical polycythemia vera, internal hemorrhage,
assessment includes IAPP. Problems with the lungs, Blood clot in
the arteries of the lungs
INSPECTION OF GENERAL ⮚ Assessment of cyanosis is affected by
APPEARANCE room lighting, patient’s skin color
⮚ The nurse inspect for normal and Types of Cyanosis
abnormal findings such as presence of ⮚ Central cyanosis- is observe on the
clubbing of the fingers and cyanosis tongue and lips. This indicates a
decrease in oxygen tension in the blood.
NORMAL FINDINGS
Skin ⮚ Peripheral cyanosis- results to decreased
⮚ Pink, no cyanosis or pallor present blood flow to the periphery (fingers, tip
Nails of the noes, toes, and earlobes) due to
⮚ no signs of clubbing, generally be vasoconstriction from exposure to cold
a pink color - with the healthy nail plate and does not indicate a systemic
being pink, and the nail being white in problem
color as it grows off the nail bed. 
PALLOR
CLUBBING OF FINGERS
▪ Pale looking
⮚ change in the normal nail bed.
▪ caused by reduced blood flow and
⮚ is a symptom of disease, often of the
oxygen or by a decreased number of red
heart or lungs which cause chronically
blood cells or hemoglobin. It can occur
low blood levels of oxygen
all over your skin or appear more
⮚ In clubbing, the distal phalanx of each
localized.
finger is rounded and bulbous. Nail plate
▪ Usually seen in lower palpebral
is more convex and the angle between
conjunctiva, tip and dorsum of the
the plate and the proximal nail fold
tongue, soft palate, nail beds, palmar or
increases to 180 degrees or more
plantar creases, general body skin.
⮚ Seen in patients with chronic hypoxia,
chronic lung infections, congenital heart
UPPER RESPIRATORY STRUCTURES
disease, endocarditis and inflammatory
⮚ Penlight and tongue blades, nasal
bowel disease.
speculum is necessary,
CYANOSIS
Nose and Sinuses
⮚ Bluish color of the skin and mucous
⮚ Inspect for the lesions, asymmetry or
membranes caused by low oxygen levels
inflammation
in the red blood cells or problems
⮚ Gently tilt the head backward and gently
getting oxygenated blood to your body
push the tip of the nose upward in order
⮚ A very late sign of hypoxia and often a
to examine the internal structures
threatening sign
⮚ Inspect for color, swelling, exudate or
⮚ The presence or absence of cyanosis is
bleeding
determined by the amount of
unoxygenated hemoglobin
 ⮚ Nasal mucosa is normally redder than
oral mucosa
⮚ Swollen and hyperemic if patient has
common cold
⮚ Pale and swollen due to allergic rhinitis
⮚ Inspect the septum for deviation,
perforation or bleeding
⮚ Inspect the inferior and middle
turbinates. In chronic rhinitis, nasal
polyps may develop
⮚ Palpate the frontal and maxillary sinuses
for tenderness
⮚ Gentle apply thumb pressure in an
upward fashion at the supraorbital ridge
(frontal sinuses) and in the check area
adjacent to the nose
⮚ Tenderness is a sign of inflammation
⮚ Frontal and maxillary can be inspected
by transillumination (passing a strong
light through a bony area to inspect the
cavity. If the light fails to penetrate, the
cavity is likely containing fluid or pus.
MOUTH AND PHARYNX
⮚ Instruct the client to open the mouth
wide and take a deep breath as this
flattens the posterior tongue and allows
a full view of the anterior view and
posterior tonsils, uvula and posterior
pharynx
⮚ Inspect for color, symmetry and
evidence of exudates, ulceration or
enlargement
⮚ If tongue blade is needed to depress the
tongue to visualize the pharynx ,it is
pressed firmly beyond the midpoint of
the tongue to avoid gag response.
TRACHEA
⮚ Direct palpation is used to assess the
position and mobility of the trachea.
This is performed by placing the thumb
and index finger of one hand on either
side of the trachea just above the sternal
notch
⮚ Trachea is highly sensitive and palpating
too firmly may trigger coughing or
gagging reflex
⮚ Trachea should be in the midline
normally and abnormal if it is deviated
into one side.
⮚ Pleural effusion, hemothorax,
Pneumothorax, or tension pneumothorax
can deviate the trachea away from the
affected side (toward the opposite side)
⮚ Trachea is pulled toward the affected
side to patients with atelectasis, fibrosis,
tumors on the neck.
ASSESSMENT OF THE
LOWERRESPIRATORY STRUCTURES
POSITIONING
⮚ Sitting position with arms crossed in
front of the chest and hands placed on
the opposite shoulders. This position
separates the scapulae widely and
exposes more lung area for assessment.
⮚ If the patient is unable to sit, with the
patient supine, roll the patient form side
to side to complete the posterior
examination.
⮚ To assess the anterior thorax and lungs,
patient should be supine or sitting, it
allows easier displacement of the
patient’s breast tissue and chest
examination.
CHEST INSPECTION
a. Observe the uses of diaphragm, intercostal
and accessory muscles with breathing.
⮚ Intercostal retractions (sucking in of the
muscles and skin between ribs during
inspiration) usually mean that the
patient is making a larger effort at
inspiration than normal
⮚ Frequent use of accessory muscles
indicates respiratory problem.
 ⮚ Observe for use of the abdominal
muscles during passive expiratory
phase. Labored breathing maybe
accompanied by interrupted speech
pattern as he or she gulps for air.
b. Look at the diameter of the chest, from
front to back (antero-posterior diameter) of
the chest.
⮚ Increased antero-posterior diameter of
the chest is due to overexpansion or
inflation of the lungs from COPD and
kyphosis (curvature of the spine)
c. Look for Chest deformities.
⮚ These are important in helping to
determine the reason for respiratory
distress. Khyposcoliosis or flail chest
from trauma may indicate a respiratory
distress.
CHEST WALL ABNORMALITIES
BARREL CHEST
⮚ Due to overinflation of the lungs which
increases the antero-posterior diameter
of the lungs
⮚ A barrel chest means a broad, deep
chest that resembles the shape of a
barrel. A man with a barrel chest have
a large rib cage, round torso and great
upper body strength. A barrel chest
usually relates to osteoarthritis as you
age which can stiffen the joints where
the ribs attach to the spine. The ribs
become fixed in their most expanded
position, causing the appearance of a
barrel chest
⮚ It occurs with aging and a hallmark sign
of emphysema and COPD
⮚ In patient with emphysema the ribs are
more widely spread and the intercostal
spaces tend to bulge on expiration
indicating that lungs have lost their
elasticity and the diaphragm is flattened
FUNNEL CHEST/PECTUS EXCAVATUM
⮚ A funnel shape depression on all or part
of the sternum. This may compress the
heart and great vessels resulting to
murmurs that may interfere with
respiratory and cardiac function
⮚ Funnel chest may occur with rickets and
Marfan syndrome
PIGEON CHEST/PECTUS CARINATUM
⮚ A pigeon chest occurs as a result of the
anterior displacement of the sternum,
which increases the anteroposterior
diameter/ Displaced sternum that
protrudes in front of the abdomen that
increases the front to back diameter of
the chest
⮚ the breastbone to push outward instead
of being flush against the chest. 
⮚ the tissue that connects the breastbone to
the ribs grows too much. Another cause
might be when parts of the bone itself
grow too much. Sometimes it happens
following open heart surgery. Pigeon
chest seems to run in families
⮚ Treatment options include chest-wall
bracing and/or surgery
⮚ This may occur with rickets, Marfan’s
syndrome and severe kyphoscoliosis
THORACIC KYPHOSCOLIOSIS
⮚ Characterized by elevation of the
scapula and a corresponding S-shaped
spine/ Characterized by spinal curvature
to one side and rotate vertebra
⮚ It causes difficulty in assessing
respiratory status because of the rotation
distorts the lung tissue
d. Look for Posture.
⮚ Patients with obstructive pulmonary
disease often sit and prop themselves up
on outstretched arms or lean forward
with their elbows on a table in an effort
to elevate their clavicles
e. Note for masses, scars that indicate trauma
or surgery.
⮚ A scar may signify old injuries to the
chest and provide clues to possible
sources of distress
f. The respiratory Rate and Depth of the
respiration
⮚ It should be counted over at least 15
seconds among healthy or stable patients
and a full minute over a critical ill
patients
⮚ Deep rapid, shallow respiration may
indicate compensation for acidosis.
Shallow respiration at 40breaths/min is
an indication of severe respiratory
distress
NORMAL BREATHING PATTERNS AND
RESPIRATORY RATES
General appearance
▪ Breathing is quiet and easy without
apparent effort
Respiratory rate
▪ <1 y/o=30-40
▪ 1-5yo=25-35
▪ 5-12=20-25
▪ 12-20/ minute- normal adult
Breathing Pattern
EUPNEA
⮚ Smooth and regular breathing, quiet
and passive with symmetric chest
expansion and Regular in depth and
rhythm
ALTERED BREATHING PATTERN AND
RESPIRATORY RATES
▪ Changes in RR and rhythm may be the
first sign of clinical deterioration in
patients who are acutely ill.
▪ Labored breathing is an important factor
of respiratory distress. As part of the
inspection, the nurse should determine if
the patients is using the accessory
muscles such as sternocleidomastoid,
scalene muscles, and trapezius muscles
during inspiration and the abdominal
and intercostal muscle during expiration.
▪ Bulging of the intercostal spaces
during expiration implies obstruction of
expiratory airflow as in Emphysema
▪ Mark retraction on inspiration (if
asymmetric) implies blockage of a
branch of bronchi tree.
▪ Asymmetric bulging of the intercostal
spaces is created by an increase in
pressure within the hemithorax as a
result of air trapping within the pleural
cavity where it is not normally present
(ex. Pneumothorax) or the fluids within
the pleural space (Pleural effusion)
▪ These muscles provide additional
support to assist the breathing effort
during times of exertion (Bickly, 2013)
BRADYPNEA
⮚ Decrease RR usually below 12
breath/min with normal depth and
regular rhythm
⮚ CNS depression caused by sedation,
tissue damage or Diabetic coma,
intracranial pressure, brain injury and
drug overdose such as narcotics
TACHYPNEA
⮚ Shallow breathing with a respiratory rate
greater than 20 breath/minute
⮚ Seen in patients with restrictive lung
disease, pain, fever, obesity or anxiety,
Pneumonia, Pulmonary edema,
metabolic acidosis, severe pain, rib
fracture and septicemia
HYPOVENTILATION
⮚ very slow, shallow respiration resulting
to increased PaCO2 level in the blood.
⮚ COPD. Neuromuscular disorders -
Amyotrophic lateral sclerosis, muscular
dystrophies (Duchenne and Becker
dystrophies), diaphragm paralysis,
Guillain-Barré syndrome, myasthenia
gravis, Chest wall deformities
Kyphoscoliosis,thoracoplasty

HYPERVENTILATION
⮚ increased rate and depth breathing that
results in decreased PaCO2 level
⮚ inspiration and expiration nearly equal
in duration
⮚ associated with exertion, anxiety and
metabolic acidosis
KUSSMAUL’S BREATHING
⮚ Deep rapid breathing. RR is greater than
20 and labored breath sounds
⮚ Metabolic acidosis or DKA
APNEA
⮚ Period of cessation of breathing/
Absence of breathing/temporary pauses
of breathing
⮚ Apnea may occurs briefly during other
breathing disorders such as sleep apnea
⮚ Life threathening is sustained
OBSTRUCTIVE SLEEP APNEA
⮚ Occurs repeatedly during sleep
secondary to transient upper airway
blockage
HYPERPNEA
⮚ Deep rapid breathing
⮚ Can occur during or after exercise or
result from pain, anxiety or metabolic
acidosis
⮚ Indicate hypoxia or hypocalcemia in a
coma patient
CHEYNE-STOKES BREATHING
⮚ Regular cycle where the rate and depth
of breathing increase, then decrease until
apnea (about 20 seconds occurs)
⮚ marked rhythmic, waxing and waning
(weakening or disappearing) respirations
from very deep and very shallow
breathing and temporary apnea.
⮚ Seen in heart failure, kidney failure or
CNS damage
BIOT’S BREATHING
⮚ Period of normal breathing (3-4 breaths)
followed by a varying period of apnea
(usually 10-60 seconds)
⮚ shallow breaths interrupted by apnea
⮚ associated with respiratory depression
due to drug overdose and brain injury
⮚ An ominous sign of severe CNS damage
APNEUSTIC BREATHING
⮚ prolonged, gasping inspiration followed
by a very short and inefficient expiration
⮚ is an abnormal pattern
of breathing characterized by deep,
gasping inspiration with a pause at full
inspiration followed by a brief,
insufficient release.
APNEUSTIC CENTER
▪ sends signals for inspiration for long and
deep breaths.
▪ It controls the intensity of breathing and
is inhibited by the stretch receptors of
the pulmonary muscles at maximum
depth of inspiration, or by signals from
the pnuemotaxic center.
▪ It increases tidal volume
h. Duration of inspiration and expiration
⮚ Helps to determine the presence of
obstructive lung disease. Expiration is
more than 1 ½ times long as inspiration
⮚ Expiration even though is
physiologically longer than inspiration,
on auscultation over lung fields it will
be shorter. The air moves away from
alveoli towards central airway
during expiration, hence you can hear
only early third of expiration
Inspiration Expiration Ratio
▪ refers to the ratio of inspiratory
time :expiratory time.
▪ In normal spontaneous breathing, the
expiratory time is about twice as long as
the inspiratory time.
▪ This ratio is typically changed in
asthmatics due to the prolonged time
 of expiration. They might have an ▪ Take measurements at the end of
I:E ratio of 1:3 or 1:4. deep inspiration and expiration.
▪ Take a tape and encircle chest around
▪ the level of nipple. Take measurements
i. Observation of thoracic expansion. at the end of deep inspiration and
⮚ Chest expansion is about 3 inches expiration.
occurs from maximal expiration to ▪ Normally, a 2-5" of chest
maximal inspiration. , expansion can be observed.
⮚ Compare the expansion with the upper ▪ For the upper expansion and
chest of that to the lower chest. Observe lower expansion, the values are 1.4 cm,
the movement of the diaphragm to 3.1 cm, 5.1 cm and 1.0 cm, 2.7 cm and
determine whether the patient has 4.3 cm respectively.
obstructive lung disease is concentrated ▪ It was concluded that chest
on expanding the lower chest and using expansion of both upper and
the diaphragm properly. lower thoracic increase with age
⮚ Expansion on side of the chest vs. the increases until the 3rd decade of life,
other side due to atelectasis due to and then steadily declines after this
mucus plugs may cause unilaterally ▪ Any lung or pleural disease can give rise
diminished chest expansion because to a decrease in overall chest expansion
the air is unable to move equally such chronic fibrotic disease,
through the pulmonary bed. consolidation, effusion, collapse or
⮚ Flail chest results from broken bone ribs pneumothorax
that are unable to maintain the integrity
of the chest wall during respiration. RESPIRATORY
Abnormal chest expansion may occur in EXCURSION/SYMMETRY OF CHEST
flail chest because the chest collapsed EXPANSION
instead of expanding during inspiration ▪ The nurse assesses the patient for range
⮚ Pulmonary embolus, pneumonia, pleural and symmetry of excursion.
effusion, pneumothorax, COPD or any ▪ Posterior assessment
problem associated with chest pain may ▪ Have patient seated erect or stand with
lead to diminished chest expansion arms on the side. Stand behind patient.
⮚ Endotracheal or nasotracheal tube
Place both hands posteriorly at the level
positioned beyond the trachea can
of T 9-T10, slide hands medially to pinch
diminished expansion on one side of the
a small amount of skin between your
chest
thumbs.
Normal Chest Size ▪ Have patient slowly take a deep breath
Men’s Size: S-34-36 (86-91cm), M-37-39 (94- and expire. Watch the symmetry of
99cm, L-40-42 (102-107cm), XL-43-46 (109- movement of the hemithorax.
117) Simultaneously, feel the chest
CHEST EXPANSION TEST expansion.
▪ Assessment of chest expansion with ▪ For anterior assessment- place the
deep inspiration helps identify the side thumbs along side the costal margin of
of abnormality the chest wall and instruct the patient to
inhale deeply. Place your hands
 over upper chest and apex and repeat
the process. Next, stand in front and lay
your hands over both apices of the lung
and anterior chest and assess chest
expansion
▪ The nurse observes movement of the
thumbs during inspiration and
expiration. This movement is normally
symmetric
▪ Normal- Chest expansion is symmetrical.
Both sides take off at the same time and to
the same extent.
▪ Abnormal- Asymmetrical chest expansion
is abnormal. The abnormal side expands less
and lags behind the normal side. Any form
of unilateral lung or pleural disease can
cause asymmetry of chest expansion.
▪ Asymmetric excursion may be due to
fractured ribs, splinting secondary to
pleurisy, trauma, or unilateral bronchial
obstruction.
DIAGPHRAGMATIC Excursion
▪ Is the movement of the thoracic
diaphragm during breathing
▪ to assess the position and motion of the
diaphragm, instruct the client to take a
deep breath and hold it while, the
maximal descent of the diaphragm is
percussed.
▪ Normal DE should be 3-5 cm but can
increase in healthy clients to 7-8 cm,
this measures the contraction of the
diaphragm. It is performed by asking the
patient to exhale and hold it.
▪ Maximal excursion of the diaphragm is
3-4 inches or 8-10cm or 5-7 cm (2-2.75
inches
▪ Decrease diaphragmatic excursion
indicates pleural effusion, Trauma or
cervical cord or phrenic nerve damage
due surgery (high C-spine injuries
involving C3-C5, phrenic nerve injury
during cardiac surgery)
▪ Increase diaphragmatic excursion
indicates Atelectasis or pregnancy
because the diaphragm is position high
in the thorax.
CHEST PALPATION
▪ Place the palm over the thorax. The
chest wall should be smooth, warm and
dry
▪ Palpate for tenderness, bulging,
retractions of the chest
▪ If there are reported pain in area if
lesions are apparent or superficial direct
palpation will be perform.
TACTILE FREMITUS
▪ The ability to feel the sound on the chest
wall. Tactile fremitus is more easily
palpated over the large bronchi
▪ Describes vibrations of the chest wall
that result from speech detected on
palpation/ the sensation of sound
vibrations produced when the patients
speaks.
▪ To assess the tactile fremitus, the
nurse ask the patient to say 99 or
“one, one, one” while moving his/her
hands over the posterior surfaces of
the chest wall. Tactile fremitus should
be symmetrical/ Place your open palms
on both sides of the client’s back
without touching his back with your
fingers.
▪ Diminished or absent tactile fremitus
due to an increase in air per unit volume
of lung, because air impedes the
transmission of sound (in Emphysema,
atelectasis
▪ Increase Fremitus- Increase in
vibration is felt due to consolidation of
the lung (Lung consolidation occurs
when the air that fills the small airways
in your lungs is replaced may be
replaced with: a fluid, such as pus,
blood, or water. a solid, such as stomach
contents or cell ) caused by fluid-filled
or solid structures
 ▪ due to Pneumonia and tumor of the
lungs
CHEST PERCUSSION TONES
▪ Chest Percussion is done if or when
lungs are filled with air, fluid or solid
material
▪ to percuss the chest, the HCP presses
one finger from the non-dominant hand
against the chest and uses a finger tip
from the dominant hand to strike the
knuckle pressed against the chest.
▪ Healthy lung tissue is resonant
▪ Percussion normally begins in
Posterior thorax. The nurse percusses
across each shoulder top locating the 5
cm width of resonance overlying the
lung apices.
▪ To perform percussion anterior chest,
begin in the supraclavicular area and
proceeds downward, form one ICS to
the next
▪ Dullness noted to the left sternum
between 3rd and 5th ICS is a normal
finding because of the location of the
heart
1. Resonant
▪ heard over normal lung tissue
▪ Long, loud, low pitch
▪ Simple chronic bronchitis
2. Hyper resonant
▪ abnormal sound heard during percussion
in adults
▪ Long, Very loud lower pitch sound
▪ Hyperinflated lung/air trapping such
emphysema and Pneumothorax
3. Flat
▪ heard over airless tissue/ a part of the
body that contains no air.
▪ Short, soft, high pitch, extremely dull
▪ Atelectasis, and extensive pleural
effusion
4. Dull
▪ Medium in intensity and pitch
▪ occurs over dense lung tissue such as
tumor and consolidation. Due to Lobar
pneumonia, pulmonary edema and
hemorrhage
4.Tympanic
▪ Loud, high pitch, moderate length,
musical drum like sound
▪ Gastric air bubble, air in the intestine
▪ indicates large tension pneumothorax
and asthma.
CHEST AUSCULTATION
▪ Auscultate the anterior, posterior and
lateral thorax. Auscultation helps to
assess the flow of air through the
bronchial tree and to evaluate the
presence of fluid or solid obstruction in
the lungs
▪ We auscultate normal breath sounds and
adventitious sounds
▪ Place the diaphragm of the stethoscope
firmly on the chest wall as the patient
breath slowly and deeply through the
mouth.
▪ Auscultate the chest started to the apices
to the base and along midaxillary lines.
The sequence of auscultation is similar
in doing percussion.
▪ Listen to two full inspiration and
expiration at each anatomic location for
valid interpretation of the sound heard.
▪ The location, quality, and intensity of
the breath sounds are determined by
auscultation.
Normal Breath Sounds
Vesicular
⮚ low pitch sound and heard all over the
chest and heard best in the bases of
 lungs except over the upper sternum and
between the scapulae
⮚ best heard on (prolong) inspiration and
shortened during expiration
Broncho vesicular
⮚ Moderate pitch with moderate amplitude
created by air moving through larger
airway
⮚ Heard when pt inhales or exhales
equally
⮚ heard between the scapulae and lateral
to the sternum at the first and second
ICS
Bronchial
⮚ High pitch and loud sounds created by
air moving through the trachea.
⮚ Heard loudest when patient exhales just
above the clavicles on each side of the
sternum, over the manubrium
Tracheal
⮚ Harsh, high pitch sound
⮚ Heard when patient inhale or exhales/
inspiratory and expiratory sounds are
about equal.
⮚ Above supraclavicular notch, over the
trachea
ADVENTITIOUS Breath Sounds
Crackles/rales in general
▪ Soft high pitch, discontinuous popping
sounds that occur during inspiration
(usually heard in inspiration and may
also be heard in expiration)
▪ Usually don’t clear with coughing
▪ caused by collapse or fluid filled alveoli
▪ Associated with heart failure and
pulmonary fibrosis
Classified by Fine or Coarse
Fine Crackles
▪ discontinuous popping sound heard in
late inspiration; sounds like hair rubbing
together, originates in the alveoli
▪ intermittent, non-musical, soft, high
pitch, short crackling popping sounds,
heard during inspiration
▪ Causes- associated with interstitial
pneumonia and restrictive pulmonary
disease (fibrosis)
Coarse Crackles
▪ Discontinuous popping sound heard
in early inspiration
▪ Intermittent, loud, low pitch, bubbling or
gurgling sounds heard during inspiration
at bases of lower lung lobes
⮚ Harsh moist sound originating in the
large bronchi
⮚ air passing through fluid or mucus in
any air passage.
⮚ Asthma, Bronchitis, or Obstructive
pulmonary disease
WHEEZE (Sibilant)
⮚ continuous, high pitched musical squeak
or whistling sound occurring on
EXPIRATION and inspiration when air
moves through a narrowed or partially
obstructed airway
⮚ May clear with coughing
⮚ Bilateral wheezes is an indication of
bronchoconstriction which can be
treated with short acting bronchodilator
like albuterol
⮚ Unilateral wheezes indicate a foreign
body obstruction which requires
bronchoscopy
⮚ Asthma, chronic bronchitis,
bronchiectasis and build-up of
secretions.
Sonorous Wheeze (Rhonchi)
▪ Deep, low pitch rumbling sounds heard
primarily during expiration
▪ Cause by air moving through narrowed
tracheobronchial passages
Pleural friction rub
 ⮚ Harsh, crackling sound like two pieces ▪ It transforms the sound into clearly A
of leather rubbing together (rubbing rather than E
thumb and finger together near the ear) Whispered Pectoriloquy
⮚ Heard during inspiration and expiration ▪ Describes the ability to clearly and
⮚ Best heard over the lower lateral anterior distinctly hear whispered sounds that
should not normally be heard.
surface of the thorax
⮚ May subside when patients hold their
breath; coughing will not clear the
sound
⮚ Cause by rubbing of inflamed pleural
surfaces, loss of lubrication pleural
fluid.
Gurgling/rhonchi
⮚ continues, low pitch, snoring quality
⮚ best heard on expiration, but could be
heard in both inspiration and expiration
⮚ Cause: air passes through a narrow
passages due to swelling and
secretion/blocks the large airways

VOICE SOUNDS
Voice Resonance
▪ The sound heard through the
stethoscope when the patient talks
▪ Assess voice sound when abnormal
breath sounds are auscultated
▪ The vibrations produced in the larynx
are transmitted to the chest wall as they
passes to the through the bronchi to the
alveolar tissue
▪ Voice are evaluated by having the
patient repeat “99” or “1, 1, 1” while the
nurse listens with the stethoscope in
corresponding areas of the chest from
the apices to the base
▪ Normal- faint and indistinct
▪ Abnormal- increase lung density such as
in Pneumonia and Pulmonary edema.

ABNORMAL VOICE RESONANCE

Bronchopony
▪ a voice resonance that is more intense
and clearer than normal
Egophony
▪ describes voice sounds that are
distorted. It is best appreciated by
having the patient repeat the letter E