Lung sounds nomenclature

Lung sounds nomenclature: 

Lung sounds nomenclature South Coast Region G. Garcia, MBA, RRT, RRT-NPS, RRT-SDS, RPFT, AE-C, RCP Regional Director, Prime Health Care Garden Grove Hospital and Medical Center Huntington Beach Hospital February 8, 2012

Objectives: 

Objectives Identify the four basic parts of a stethoscope and their uses. Describe the proper technique for auscultation of the lungs. Identify the four characteristics of breath sounds that should be evaluated during auscultation Define the following terms used to describe lung sounds and the mechanisms responsible for producing the sounds: Tracheal Bronchovesicular Vesicular (normal) Diminished /absent

Objectives: 

Objectives Define the following terms used to describe abnormal (adventitious) lung sounds and the mechanisms responsible for producing the sounds: Crackles (rales) Wheezes Rhonchi Stridor Pleural friction rub Use qualifying adjectives to describe lung sounds and explain the importance of using these qualifying adjectives.

Objectives: 

Objectives Describe the significance of the following auscultatory findings: Monophonic wheeze Polyphonic wheezes Stridor Late inspiratory crackles Inspiratory and expiratory crackles Pleural friction rub Define bronchophony and its cause.

Inventor of the Stethoscope: 

Inventor of the Stethoscope René Laënnec (17 February 1781 – 13 August 1826

Inventor of the Stethoscope: 

Inventor of the Stethoscope

Modern Day Acoustic Stethoscope: 

Modern Day Acoustic Stethoscope Earpieces Binaurals Tubing Chestpiece Bell Diaphragm

PowerPoint Presentation: 

* Eli Finkelstein (2008-07-01). "The Ultimate Acoustic Stethoscope Review" . http://www.forusdocs.com/reviews/Acoustic_Stethoscope_Review.htm . .

ds32a Digital Electronic Stethoscope: 

ds32a Digital Electronic Stethoscope Thinklabs . thinklabsmedical.com

Technique: 

Technique

Four Characteristics of breath sounds: 

Four Characteristics of breath sounds Pitch (vibration frequency) Amplitude or intensity (loudness) Distinctive characteristics Duration of inspiratory sound is compared with that of expiration

Normal Breath Sounds: 

Normal Breath Sounds Created by turbulent air flow Inspiration Air moves to smaller airways hitting walls More turbulence, Increased sound Expiration Air moves toward larger airways Less turbulence, Decreased sound Normal breath sounds Loudest during inspiration, softest during expiration

Normal Breath Sounds: 

Normal Breath Sounds Tracheal Very loud, high pitched sound Expiratory sound duration = > Inspiratory Heard over trachea Bronchovesicular Intermediate intensity, intermediate pitch Inspiratory = Expiratory sound duration Upper half of sternum on the anteriorly, and between scapulae posteriorly It is not evaluated in most situations

Normal Breath Sounds: 

Normal Breath Sounds Vesicular Soft, low pitched sound Lower in pitch and intensity (loudness) than tracheal breath sounds Heard primarily on Inspiratory > Expiratory sounds Major normal BS, heard over most of lungs

Laennec’s Original Description of Adventitious sounds: 

Laennec’s Original Description of Adventitious sounds 1. Râle humide ou créptiation 2. Râle muqueux ou garguouillment 3. Râle sec sonore ou ronflement 4. Râle sibilant sec ou sifflement 5. Râle crépitant sec á grosses bulles ou craquement

Sir John Forbes: 

Sir John Forbes In the year 1831, a knighted Scotsman named Sir John Forbes, editor of The British and Foreign Medical Review, incorrectly translated Laennec’s terms rales and rhonchus as having different meanings rather than the same meaning as was originally intended. * * Robertson, AJ, Coope R. Rales, rhonchi , and Laennec. Lancet 1957; 2:417-23

Robertson and Coope negotiated a brief classification of breath sounds.: 

Robertson and Coope negotiated a brief classification of breath sounds. Continuous sounds (a) High-pitched wheezes (b) Low-pitched wheezes Interrupted sounds (a) Coarse crackling sounds (b) Medium crackling sounds (c) Fine crackling sounds ( crepitations ) Robertson, AJ, Coope R. Rales, rhonchi , and Laennec. Lancet 1957; 2:417-23

PowerPoint Presentation: 

ACOUSTIC CHARACTERISTICS AMERICAN THORACIC SOCIETY NOMENCLATURE COMMON SYNONYMS LAENNEC’S ORIGINAL TERMS Discontinuous, interrupted explosive sounds Loud, low in pitch; Average values; IDW = 1.25, 2CD = 9.32 Coarse crackle Coarse rale Râle muqueux ou garguouillment Discontinuous, interrupted explosive sounds Less loud than above and of shorter duration; higher in pitch than coarse crackles or rales; average values, IDW =0.92, 2CD = 6.02 Fine crackle Fine rale , crepitation Râle humide ou créptiation Continuous sounds longer than 250 ms high pitched; dominant frequency of 400 Hz or more, a hissing sound Wheeze Sibilant rhonchus Râle sibilant sec ou sifflement Continuous sounds longer than 250 ms, low pitched; dominant frequency about 200 Hz or less, a snoring sound Rhonchus Sonorous rhonchus Râle sec sonore ou ronflement American Thoracic Society. Report of the ATS-ACCP Ad Hoc Subcommittee on Pulmonary Nomenclature. ATS News 1977;3:5-6.

Adventitious Breath Sounds: 

Adventitious Breath Sounds Crackles (Rales) Discontinuous, intermittent, nonmusical, brief sounds Heard more commonly with inspiration Classified as fine or coarse Normal at anterior lung bases Maximal expiration Prolonged recumbency Crackles caused by air moving through secretions and collapsed alveoli

Adventitious Breath Sounds: 

Adventitious Breath Sounds Crackles Possible Mechanism Characteristics Causes Inspiratory and expiratory Excess airway secretions moving with the airflow Coarse and often clear with cough Bronchitis, respiratory infections Early inspiratory Sudden opening of proximal bronchi Scanty , transmitted to mouth; not affected by cough Bronchitis, emphysema, asthma Late inspiratory Sudden opening of peripheral airways Diffuse, fine; occur initially in the dependent regions Atelectasis, pneumonia, pulmonary edema, fibrosis

Adventitious Breath Sounds: 

Adventitious Breath Sounds Wheeze Continuous, high pitched, musical sound, longer than crackles Hissing quality, heard > with expiration, however, can be heard on inspiration Produced when air flows through narrowed airways Associated conditions asthma, congestive heart failure, bronchitis

Adventitious Breath Sounds: 

Adventitious Breath Sounds Wheeze Polyphonic wheeze – many different musical notes begin and end simultaneously. They indicate that multiple airways are obstructed as in asthma Monophonic wheezes may be single or multiple, with each one indicating obstruction of a bronchus.

Adventitious Breath Sounds : 

Adventitious Breath Sounds Rhonchi Similar to wheezes Low pitched, snoring quality, continuous, musical sounds Implies obstruction of larger airways by secretions Associated condition acute bronchitis

Adventitious Breath Sounds: 

Adventitious Breath Sounds Stridor Inspiratory musical wheeze Loudest over trachea Suggests obstructed or inflammed trachea or larynx Medical emergency requiring immediate attention Associated conditions inhaled foreign body Croup Epligottitis postextubation

Adventitious Breath Sounds: 

Adventitious Breath Sounds Pleural Rub Discontinuous or continuous brushing sounds Heard during both inspiratory and expiratory phases Occurs when pleural surfaces are inflamed and rub against each other Associated conditions Pleural effusion, Pulmonary fibrosis

Diminished/Absent breath sounds : 

Diminished/Absent breath sounds Associated conditions Asthma COPD Endotracheal tube advancement R lung Pneumothorax ARDS Atelectasis Breath sounds are described as diminished when the intensity decreases and absent in extreme cases

Transmitted Voice Sounds: 

Transmitted Voice Sounds If abnormally located bronchial or bronchovesicular breath sounds assess transmitted voice sounds with stethoscope Ask the patient to say “Ninety-nine”, should normally be muffled, if heard louder and clearer this is bronchophony Ask the patient to say “ ee ”, should normally hear muffled long E sound, if E to A change this is egophony Ask the patient to whisper “Ninety-nine”, should normally hear faint muffled sound, if louder and clearer sounds are heard this is whispered pectoriloquy Increased transmission of voice sounds suggests that air filled lung has become airless

Conclusion: 

Conclusion