1. Lung Sounds An Assessment of the Patient in Respiratory Distress Michael Ciccarelli, DO December 12, 2006

2. Introduction Lungs major function –Provide continuous gas exchange between inspired air and blood in the pulmonary circulation

3. Anatomy of Respiratory System Nasopharynx Larynx Trachea Bronchi Bronchioles Alveoli

4. Anatomy Respiratory tract extends from mouth/nose to alveoli Upper airway filters airborne particles, humidifies and warms inspired gases Lower airway serves for gas exchange

5. Anatomy

6. Blood Supply Lungs have a double blood supply –Pulmonary circulation for gas exchange with the alveoli (pulmonary artery with subdivisions) –Bronchial arteries arising from descending aorta supplies lung parenchyma

7. Contributors of Respiration Controlled in the brainstem Mediated by muscles of respiration –Diaphragm primary muscle of inspiration –Accessory muscles of inspiration SCM Scalenes Intercostals Expiration is a passive process from elastic recoil of lung and chest wall, with passive diaphragm relaxation

8. Mechanism for Breathing Pressure gradient required to generate air flow –Diaphragm contracts, descends and enlarges thoracic cavity –Intra-thoracic pressure decreases –Air flows through tracheobronchial tree into the alveoli expanding lungs

10. Technique for Respiratory Exam NEED ORDERLY PROCESS Before beginning, if possible: –Quiet environment –Proper positioning (patient sitting for posterior thorax exam, supine for anterior thorax exam) –Bare skin for auscultation –Patient comfort, warm hands and diaphragm of stethoscope, be considerate of women (drape sheet to cover chest) Inspect Palpate Percuss Auscultate

11. Initial Respiratory Survey Observe the patient’s breathing pattern –Rate (normal vs. increased/decreased) –Depth (shallow vs. deep) –Effort (any sign of accessory muscle use, inspect neck) Assess the patient’s color –cyanosis

12. Normal Respiratory Rates –Infant 30-60 –Toddler 24-40 –Preschooler 22-34 –School-age child 18-30 –Adolescent 12-16 –Adult 10-20

13. Pertinent History –Any chronic conditions Asthma, COPD, CHF, DM –Exposure to new medication ACE-Inhibitor, Abx –Recent change in diet Peanuts, Strawberries –Substance abuse/Overdose Opioid abuse, ASA toxicity –Prior DVT, PE –Recent trauma to chest

14. Inspection Note the shape of the chest and the way it moves –Deformities or asymmetry Increased AP diameter in COPD –Abnormal retractions of interspaces during respiration Lower interspaces, supraclavicular in acute asthma exacerbation –Impaired respiratory movement Flail Chest and paradoxical movement with rib fx’s

15. Palpation Identify tender areas –Bruising with rib fx Observe for appropriate chest wall expansion Feel for tactile fremitus symmetrically –palpable vibrations transmitted to chest wall –use ulnar surface of hand, say “ninety-nine” –decreased with COPD, pleural effusions, PTX

16. Percussion Helps to identify if underlying tissues are air-filled, fluid-filled, or solid –Hyperextend middle finger of either hand and press against chest wall –Strike with flexed middle finger of opposite hand Always percuss symmetrically on chest wall

17. Percussion Notes Flatness –Thigh Dullness –Liver Resonance –Lung Hyperresonance –None Tympany –Stomach, puffed cheek

18. Percussion Dullness replaces resonance when fluid or solid tissue replaces air containing lung –PNA –Pleural Effusions –Hemothorax –Tumor Unilateral Hyperresonance –Pneumothorax Generalized Hyperresonance –COPD

19. Auscultation 12 anterior locations 14 posterior locations Auscultate symmetrically Should listen to at least 6 locations anteriorly and posteriorly

20. Breath Sounds Normal –Tracheal –Bronchial –Bronchovesicular –Vesicular Abnormal –Absent/Decreased –Bronchial Adventitious –Crackles (Rales) –Wheeze –Rhonchi –Stridor –Pleural Rub

21. 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

22. Normal Breath Sounds Tracheal –Very loud, high pitched sound –Inspiratory = Expiratory sound duration –Heard over trachea Bronchial –Loud, high pitched sound –Expiratory sounds > Inspiratory sounds –Heard over manubrium of sternum –If heard in any other location suggestive of consolidation

23. Normal Breath Sounds Bronchovesicular –Intermediate intensity, intermediate pitch –Inspiratory = Expiratory sound duration –Heard best 1 st and 2 nd ICS anteriorly, and between scapula posteriorly –If heard in any other location suggestive of consolidation Vesicular –Soft, low pitched sound –Inspiratory > Expiratory sounds –Major normal BS, heard over most of lungs

24. 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

25. 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 –Associated conditions pulmonary edema, early CHF, PNA

26. 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, COPD

27. 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

28. Adventitious Breath Sounds Stridor –Inspiratory musical wheeze –Loudest over trachea –Suggests obstructed trachea or larynx –Medical emergency requiring immediate attention –Associated condition inhaled foreign body

29. 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, PTX

30. Causes of decreased or absent breath sounds Asthma COPD Pleural Effusion Pneumothorax ARDS Atelectasis

31. Case #1 Dispatch Information –62 yo female with progressive SOB over past 48 hours PMH –40 pack year smoking history –On home O2 –Some type of lung problem VS –O2 sat 78% on 2L O2 NC, RR 26, T 98.1 Physical Exam –Barrel shaped chest –Decreased BS B/L –Diffuse expiratory wheezing B/L lung fields –Digital cyanosis and clubbing noted

32. What is this patient’s condition and appropriate treatment prior to ED arrival?

33. Case #2 Dispatch Information –18 yo male with confusion and multiple episodes of vomiting PMH –No past medical history –Denies recent drug use or overdose VS –T 98.3, RR 32, HR 116, O2 sat 98% RA Physical Exam –Appears Lethargic –Dry Mucous Membranes –Deep, rapid breathing –Lungs CTA B/L Additional Findings –FS 450

34. What is this patient’s condition and appropriate treatment prior to ED arrival?

35. Case #3 Dispatch Information –74 yo male with progressive SOB over past week PMH –Poor historian, no family available for information –Difficult time sleeping on 4 pillows –States sees a heart doctor, however, not taking pills –At house full bottles of Coreg, Lisinopril, and Lasix VS –RR 30, O2 sat 82% RA, T 98.4 Physical Exam –Rapid, shallow breathing –Accessory muscles of respiration use –Crackles are auscultated at B/L bases –B/L LE pitting edema to knees

36. What is this patient’s condition and appropriate treatment prior to ED arrival?

37. Case #4 Dispatch Information –MVA rollover on Rt. 4 in East Greenbush 25 yo male unrestrained driver significant intrusion into driver door + LOC, GCS 13 at present PMH –EtOH abuse VS –RR 28, O2 sat 76% RA Physical Exam –multiple bruises on B/L chest wall –paradoxical movement of L chest wall –absent breath sounds on L side

38. What is this patient’s condition and appropriate treatment prior to ED arrival?

39. Case #5 Dispatch Information –42 yo female with difficulty breathing and facial swelling over past hour PMH –HTN –NKDA or food allergies –Started Lisinopril for BP 1 month ago VS –HR 108, RR 28, O2 sat 86% RA, T 98.4 Physical Exam –Perioral facial and lip swelling –Inspiratory stridor on auscultation

40. What is this patient’s condition and appropriate treatment prior to ED arrival?