January/February 2007 Nursing made Incredibly Easy! 7

ELAINE HARBISON, 20, has a history ofasthma. She’s now in the emergency de-partment (ED) complaining of shortness ofbreath that has been getting progressivelyworse after a cold. She says that a chroniccough has been keeping her up at night,and you notice that she’s only able to speakin short phrases. She hasn’t gotten any relieffrom her rescue inhaler.

During your initial assessment, you findthat her oxygen saturation is 94% and thatshe’s leaning forward in a tripod position.She’s becoming increasingly nervous andhyperventilating. You immediately take hervital signs and conduct a general survey ofher physical appearance, body structure,mobility, and behavior. When you auscultateher lungs, you don’t hear much.

What’s going on with your patient?The answer isn’t too hard to figure out—if

you understand the basics of interpretingbreath sounds. In this article, I’ll walk youthrough how to listen to breath sounds andwhat kinds of sounds you may hear. Butfirst, let’s quickly review what’s normal andwhat isn’t.

Is that normal?Normal breath sounds include the follow-ing: n Tracheal breath sounds. These soundsaren’t usually auscultated during a rou-tine exam. They’re very loud and high-pitched, hollow, or harsh sounds. Theycan be heard over the extra thoracic por-tion of the trachea. The inspiration phaseis equal to or slightly shorter than the ex-piratory phase. n Bronchial breath sounds. Loud and high-pitched, they sound like air blowingthrough a tube. These sounds can be heard

over the manubrium (upper part of the ster-num). The inspiratory phase is quieter andshorter than the expiratory phase. n Bronchovesicular breath sounds. Thesesounds are a mixture of bronchial andvesicular sounds. They’re medium in loud-ness and pitch, and they can be heard ante-riorly near the main stem bronchi, at thefirst and second intercostals spaces, andposteriorly between the scapulae. The inspi-ratory and expiratory phases are equal inlength. n Vesicular breath sounds. Relatively softand low-pitched, these sounds are likesighing or a gentle rustling of leaves.They can be heard over most of the pe-ripheral parts of the lung. The inspira-tory phase is two and a half to threetimes longer than the expiratory phase,and there’s no pause between thephases.

See Qualities of normal breath soundsfor a quick and visual overview.

This can’t be rightAbnormal breath sounds include theabsence of breath sounds or the pres-ence of normal sounds in areas wherethey aren’t normally heard. For example,bronchial or tubular breath sounds are ab-normal if they’re heard in the peripheral ar-eas where only vesicular sounds are gener-ally heard. Bronchial sounds heard in areasthat are distant from their normal locationgenerally indicate that the patient may havea consolidation, such as in pneumonia. Re-member, dense tissue transmits soundsfrom the lung more efficiently.

Adventitious breath sounds (extra soundsthat can be heard on top of normal sounds)are also abnormal. Examples include crack-

Every breath you take: Makingsense of breath soundsMARGARET MCCORMICK, RNDirector of Nursing Skills Lab • Towson University • Towson, Md.

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breathsounds.

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January/February 2007 Nursing made Incredibly Easy! 9

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les, wheezes, pleural friction rub, and stri-dor. Let’s take a closer look.

Crackles, formerly known as rales, arecaused by fluid in the small airways. They’rediscontinuous sounds—intermittent, non-musical, and short. Usually heard on inspira-tion, crackles create popping sounds becauseair is being forced through respiratory pas-sages that are narrowed by fluid, mucus, orpus. This may indicate inflammation orinfection. Crackles that don’t clear withcoughing mean the patient has heart failureor acute respiratory distress syndrome. Finecrackles are soft, high-pitched, and short. Tosimulate the sound, try rolling a strand ofhair between your fingers near your ear.Coarse crackles are louder, lower-pitched, andlonger than fine crackles. They sound likeyou’re ripping open a nylon hook-and-loopfastener.

Wheezes are continuous sounds heardduring inspiration or expiration. Wheezesmay be high-pitched with a squeaking ormusical quality (formerly called sibilantrhonchi), caused by air moving through con-stricted bronchial airways such as in asthma,or they may be low-pitched with a snoringor moaning quality (formerly called sonorous

rhonchi), caused by excess secretions such asin bronchitis.

A pleural friction rub is a low-pitchedgrating or creaking sound that occursbecause of inflamed pleural surfaces rubbingtogether during respiration. It’s usuallyheard during inspiration but can also beheard during expiration. A pleural frictionrub can best be heard over the lower lateralanterior surface of the thorax. To determineif the rub is pleural or pericardial, have yourpatient hold her breath. If you still hear therub, it’s a pericardial rub.

Stridor is a high-pitched harsh soundheard during inspiration. It’s caused by anobstruction of the upper airway from a for-eign body or epiglottitis. Stridor is a sign ofrespiratory distress and requires immediateattention.

Train your earNow, let’s get back to Elaine, your patientin the ED. You need to perform a completerespiratory assessment to determine what’sgoing on. Here’s what to do. n Listen to the breath sounds in a quiet en-vironment. n Have your patient sit upright and take

Qualities of normal breath sounds

Breath sound

Tracheal

Bronchial

Bronchovesicular

Vesicular

Quality

Harsh, high-pitched

Loud, high-pitched

Medium in loudnessand pitch

Soft, low-pitched

I:E ratio

I = E

I < E

I = E

I > E

Location

Above supraclavicularnotch, over the trachea

Just above clavicleson each side of thesternum, over themanubrium

Next to the sternum, between scapulae

Remainder of lungs

10 Nursing made Incredibly Easy! January/February 2007

Chest auscultation sequenceFollow this sequence when listening for breath sounds.

1 1

2 2

3 3

4 4

5 5

1 1

2 2

3 3

4 4

5 5

6 6

7 7

8 8

Anterior Posterior

deep breaths through her mouth. n Use the diaphragm of your stethoscopeto listen to a full inspiration and a full expi-ration at each point, starting at the apex ofthe lung (C7) and progressing to the base(T10). Remember to listen anteriorly, poste-riorly, and laterally under the axilla to the

seventh or eighth rib (see Chest auscul-tation sequence). Don’t listen over a

gown, chest hair, or bone.n Compare similar lung segments

with one another; don’t just goup and down one side. First

concentrate on inspiration.What’s the length of in-spiration? Compare itwith expiration. What’s

the length of expiration?Do you hear air moving? Are

the sounds correct for that loca-tion? Do you hear any abnormal sounds?

Normal findings include: n relaxed posture n regular respiratory rate of 10 to 18breaths/min

n absence of cyanosis or pallor n ratio of the anterior and posterior chestdiameter to the transverse diameter of 1:2 n symmetrical chest expansion during in-spiration and expirationn tactile fremitus that’s equal bilaterallywhen the chest is palpated. To test this,have the patient say 99. Decreased or absentfremitus is caused by a decrease in vibra-tion transmission, such as in emphysema.An increase in fremitus occurs if vibrationsare enhanced, such as in lung consolidation.n absence of palpable lumps or masses andno tenderness of the lungs n resonant sound on percussion n diaphragmatic excursion of 3 to 5 cmthat’s equal bilaterallyn vesicular sounds heard over the periph-eral lung fields on auscultationn bronchovesicular sounds heard paraster-nally and between the scapulaen absence of adventitious sounds.

When you physically examine Elaine, younotice that her heart rate and respiratory rateare elevated. Her worsening shortness of

Normal breathsounds are

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January/February 2007 Nursing made Incredibly Easy! 11

breath is causing her to use accessory mus-cles in her neck and retract her intercostalmuscles. When you auscultate her lungs,you now hear wheezing. The expiratoryphase of her breathing is labored and pro-longed. Remember, even if you don’t detectcrackles or wheezing, your patient isn’t nec-essarily OK. Diminished or absent breathsounds require prompt and immediate med-ical attention.

Breathing easy againYou suspect that Elaine is having anasthma attack, which is confirmed by theED physician. He orders a nebulizer treat-ment with levalbuterol (Xopenex), a fast-acting bronchodilator, and prednisone, 40mg by mouth. After her treatment, Elainebegins to breathe easier. She’ll continue tak-ing prednisone for 10 days. She’s also sent

home with instructions to use a cortico-steroid inhaler twice a day and levalbuterolas needed for wheezing.

Sound adviceBy carefully listening to breath sounds andrecognizing the difference between what’snormal and what’s abnormal, you’ll be betterable to accurately assess your patient’s con-dition and provide the best care possible. n

Learn more about itSmeltzer SC, Bare BG. Brunner & Suddarth’s Textbook ofMedical-Surgical Nursing, 10th edition. Philadelphia, Pa.,Lippincott Williams & Wilkins, 2004.

Surgical Care Made Incredibly Visual! Philadelphia, Pa., Lip-pincott Williams & Wilkins, 2007.

Weber JR, Kelley J. Health Assessment in Nursing, 2nd edi-tion. Philadelphia, Pa., Lippincott Williams & Wilkins,2003.

Weber JR. Nurses’ Handbook of Health Assessment, 5th edition.Philadelphia, Pa., Lippincott Williams & Wilkins, 2005.