MED: TEAM-BASED LEARNING THIRD SHIFT

TBL: LUNG SOUNDS

Dr. Isaias Lanzona
LEC # 8
FEB 17TH 2021

OUTLINE
I. Lung Auscultation (Marcial) V. Conclusion
A. Auscultatory Areas VI. Individual/Team Readiness Assessment Test (iRAT/tRAT)
B. Auscultatory Technique, Sequence and Procedure A. Discussion
II. Breath Sounds (Marcial & Journal) B. Test Rationale
A. Normal Breath Sounds VII. Team Application (tAPP) Case Studies
B. Abnormal/Adventitious Lung Sounds A. Case 1: Emphysema
C. Tracheal/Mediastinal Deviation B. Case 2: Upper Airway Obstruction
D. Percussion Notes C. Case 3: Tension Pneumothorax
E. Voice Sound Transmission D. Case 4: Pulmonary Embolism
F. Lung Auscultogram Forms E. Case 5: Asthma
III. Other Pulmonary Procedures (Marcial) F. Case 6: Pneumonia
IV. Case Examples in Marcial VIII. References
IX. Appendix

I. LUNG AUSCULTATION (Marcial)

A. AUSCULTATORY AREAS

Figure 1. Lung Auscultatory Areas (L: Anterior, R: Posterior)

Breath sounds are auscultated over the anterior, posterior, and lateral chest wall surfaces

B. AUSCULTATORY TECHNIQUE, SEQUENCE, AND PROCEDURE

AUSCULTATORY TECHNIQUE AUSCULTATORY SEQUENCE AND PROCEDURE

● Room must be quiet in order to hear the lung sound clearly and
distinctly Anterior Chest Wall
● Patient must not talk or make any noise ● Downward from the lung apices to the bases and covers the entire
● Press the diaphragm of the stethoscope on the patient’s chest anterior chest wall area including the lateral chest wall surfaces
wall over the intercostal spaces and not directly over the bone ● Compare sounds heard over the same auscultatory site over both
● There must be no clothing between chest wall and diaphragm right and left lungs
● Lightly dampen the chest if the person has a hairy chest and hold Posterior Chest Wall
the stethoscope firmly against the skin to minimize the crackling ● Starts above the left scapula over the lung apex
noises produced by the hair ● Progresses downward to the bases covering the entire posterior
chest wall area including the lateral chest wall surfaces
● Compare sounds heard over the same auscultatory site over both
right and left lungs

D-TWG3: Sangalang, D., Teamchai, I., Uy, N., Ventura, K., Roque, J. D- TEG4: Sosa, K., Sto. Domingo, M., Uaje, B., Yumul, R., Rosales, J.
TWG EIC: Rubiano, M. TEG EIC: See, K.
 AUSCULTATORY SEQUENCE AND PROCEDURE (cont.)
If patient is alert and healthy
1. Begin auscultation with the patient sitting upright and leaning slightly
forward
2. Position yourself behind the patient
3. Ask the patient to cross his arms in front to spread out the scapula behind
and widen the posterior auscultatory area between the left and the right
scapula
4. Ask the patient to breathe through an open mouth, slightly deeper than
usual, through several respiratory cycles
5. Place the diaphragm over the left lung apex and listen for at least one
complete respiratory cycle
6. Move the diaphragm to the same site over the right lung
7. Compare the breath sounds heard over these same locations
8. Continue in this manner, making contralateral comparisons at each
auscultatory site.
9. After auscultating the entire posterior chest wall and some parts of the
lateral chest wall, move to the frontof the patient
10. The patient should place his arms at his sides and breathe through an open
mouth slightly deeper than usual and listen to breath sounds over the entire
anterior chest wall

If the patient is dyspneic

● There is no need for taking a deeper breath

If the patient is comatose, critically ill, or bedridden

● Roll the patient from one side to the other to auscultate dependent lung regions
● Listen initially over dependent lung regions because gravity-dependent secretions
or fluids may produce abnormal sounds that sometimes disappear when the
patient is turned, breathes deeply, or coughs Figure 2. Auscultatory Sequence (Anterior and Posterior)

Table 1. Lung Auscultation Summary Table based on the concept map in Marcial

Anterior Thorax and Posterior Thorax

Normal Breath sounds
Tracheal, Bronchial, Bronchovesicular, Vesicular
(must be heard in specific areas of the lungs, otherwise it becomes abnormal)
Breath sound and Intensity
Normal, Increased, Decreased
Adventitious lung sounds
Continuous: Wheezes, rhonchi
Discontinuous: Coarse, fine crackles
Pleural friction rub
Stridor
Squawk
Transmission of Spoken words/Vocal Fremiti
Egophony, Bronchophony, Whispered pectoriloquy

II. BREATH SOUNDS

● Produced by turbulent flow of air as it moves through the large airways
● Frequency from 75 to 3000 Hz
● René Laënnec - invented the stethoscope in 1816
● Rale - term replaced by "crackle"
→ Adjectives used to qualify rales can be misleading
→ Crackles can be defined acoustically.

FYI: Representation of Sounds in Lung Auscultogram

● Breath sound represented by a slanting bar that can be heard during
inspiration (/) and expiration (\)
● An interruption of the bars depicts the pause that may be heard normally
● Thickness: qualitative indication of the loudness of the sounds
● Angle of the slant: represents the pitch
● Y-axis: qualitatively indicates the pitch
● X-axis: timing in respiration
● Abnormal locations: represented by pointing the line where the
abnormal sound was heard.
→ Ex: Bronchial breath sounds heard on the left infra-scapular area as
can occur in consolidation

MED.3.08 TBL: Lung Sounds 2 of 26

 A. NORMAL BREATH SOUNDS

TRACHEAL SOUNDS
MARCIAL JOURNAL
● High pitched, loud with a harsh and hollow (tubular) quality ● Hollow and nonmusical
● Heard best in the suprasternal notch ● Clearly heard in both phases of respiratory cycle
● Range from <100 Hz to >3000 Hz with a mark drop of energy ● Frequency ranges from 100 Hz to almost 5000 Hz with a sharp drop in
above 800 Hz power at a frequency of approximately 800 Hz and little energy beyond
● Heard in both respiratory and inspiratory 1500 Hz
● Pause is often heard between phases ● Produced by turbulent airflow in the pharynx, glottis, and
● I:E ratio = 1:1 subglottic region
AUSCULTOGRAM ● Similar in quality to other bronchial breathing heard in patients with
lung consolidation
● Noninvasive means to monitor sleep apnea syndrome
● May be used in identifying stridor in adults which may be caused by
bronchial, tracheal stenosis or by a tumor in the central airway
→ Can otherwise be missed when only the lungs are examined
● Can become frankly musical, characterized as either a typical stridor
or a localized, intense wheeze
● Tracheal wheeze: clinically important because it is often mistaken for
the wheeze of asthma
● Clinical correlations:
→ Represents/transports intrapulmonary sounds
→ Indicates upper airway patency
Figure 3. Lung Auscultogram of Tracheal Breath Sounds → Can be distributed (e.g. become noisier or even musical) if airway
patency is altered
→ Serves as good example of bronchial breathing

BRONCHIAL SOUNDS
MARCIAL JOURNAL
● Similarly produced as turbulent flow passes through mainstem ● Soft, nonmusical
bronchi ● Strong expiratory component
● Retain tubular or hollow quality of the tracheal breath sounds ● An intermediate between tracheal and normal breathing
● Heard best over the upper manubrium ● Heard on both phases of respiration (mimics tracheal sound)
● Generally loud and high-pitched ● Clinical correlations:
● Expiratory phase is usually longer than the inspiratory phase → Indicates patent airway surrounded by consolidated lung tissue
→ I:E ratio = 1:2 to 1:3 (e.g. pneumonia) or fibrosis
● Pause is also appreciated between phases → Corresponds to the air bronchogram on chest radiographs
→ Because the trachea and bronchial breath sounds are
produced in the same manner and would indicate the
turbulent flow as the air rushes through the trachea and large
airways
→ Distinction is not made between the 2 terms so they are
lumped together as tracheal sounds
AUSCULTOGRAM

Figure 4. Lung Auscultogram of Bronchial Breath sounds (Anterior and Posterior views)

MED.3.08 TBL: Lung Sounds 3 of 26

 A. NORMAL BREATH SOUNDS (cont.)

LUNG (VESICULAR) SOUNDS

MARCIAL JOURNAL
● Audible over peripheral lung fields ● Soft and nonmusical; Heard only on inspiration and on early expiration
● Soft and low pitched ● Heard over the surface of the chest
● Frequency range: 100-600 Hz but can still be detected with a → Markedly influenced by the anatomical structures between the site
sensitive microphone at 1000 Hz of sound generation and the site of auscultation
● Stethoscope is needed before lung sounds are appreciated ● Frequency range is narrower than tracheal sounds
● Resembles "rustling of the leaves" as the wind blows over → Extending from below 100 Hz to 1000 Hz, with a sharp drop at
trees approximately 100 to 200 Hz
● Longer inspiratory phase than expiratory phase ● Inspiratory Component: generated within lobar & segmental airways
→ I:E ratio = 3:1 or 4:1 ● Expiratory Component: generated from more central sources
● No pause appreciated between phases ● If there is a decrease in sound intensity:
● Inspiratory component generated primarily in the lobar and → Most common abnormality
segmental airways → Can be due to the following:
● Expiratory component come from the more proximal airways ▪ Decrease in the amount of sound energy at the site of generation
AUSCULTOGRAM ▪ Impaired transmission
▪ Both decrease in energy and impairment
● Sound Generation - can be decreased when there is a drop in
inspiratory airflow which can result from several conditions:
→ Poor cooperation (e.g. patient unwilling to take a deep breath)
→ Depression of central nervous system (e.g. drug overdose)
→ Airway conditions
▪ Blockage (e.g. by a foreign body or tumor)
▪ Narrowing in obstructive airway diseases (e.g. asthma, COPD)
− Decrease in breath sounds may be permanent as in cases of
pure emphysema or reversible, as in asthma
● Sound Transmission - can be impaired by the following:
→ Intrapulmonary Factors
▪ Harder to recognize
▪ Disruption of the mechanical properties of the lung parenchyma
(e.g. combination of hyperdistention and parenchymal
destruction in emphysema)
▪ Interposition of a medium between the source of generation and
the stethoscope that has a different acoustic impedance from
that of the normal parenchyma (e.g. pneumothorax, hemothorax
and intrapulmonary masses)
→ Extrapulmonary Factors
▪ Obesity
▪ Chest deformities (e.g. Kyphoscoliosis)
● Abdominal distention due to ascites
Figure 5. Lung Auscultogram of Normal Lung Sounds ● Rules out clinically significant airway obstruction
(Anterior and Posterior views)

BRONCHOVESICULAR SOUNDS
MARCIAL
● Best heard at the 1st and 2nd intercostal spaces anteriorly and posteriorly between the scapula
● Characteristic similar to bronchial breath sounds and normal (vesicular) lung sounds, thus explaining the name (I:E ratio = 1:1)
● Generated by turbulent flow from the large airways like the tracheal breath sounds and carries no special clinical meaning dissimilar to
tracheal sounds
AUSCULTOGRAM

Figure 6. Lung Auscultogram of Bronchovesicular Breath Sounds (Anterior and Posterior views)

MED.3.08 TBL: Lung Sounds 4 of 26

 B. ABNORMAL (ADVENTITOUS) BREATH SOUNDS

Abnormal Breath Sounds

● Divided into: (Marcial)
→ Continuous Sounds (CALS)
▪ Lasting longer than 250 milliseconds
− Wheezes
− Ronchi
▪ Caused by vibrations of air flowing rapidly through a narrowed airway
▪ Pitch of Sound:
− Related to the extent of the airway narrowing
− HIGHER pitch = TIGHTER airway obstruction (narrower)
− Depends on frequency of the vibrations determined by the airflow rate and the mechanical properties of the affected bronchus
→ Discontinuous Sounds (DALS)
▪ 250 milliseconds or less in duration
− Coarse Crackles
− Fine Crackles
▪ Explosive, sharp, discrete bursts of interrupted sounds
▪ Can be distinguished by the human ear

● Divided into: (Journal)

→ Musical – stridor, wheeze, rhonchus
→ Non-musical – crackles, pleural friction rub, squawk

WHEEZE
MARCIAL JOURNAL
● Higher pitch and greater intensity than rhonchi ● Most easily recognized adventitious sound
● Frequency ranges from 100-1000 Hz ● High-pitched musical sound
● Wave form consists of many sine waves superimposed upon ● Long duration (more than 100 msec): Can be discerned by human ear
one another ● Can be inspiratory, expiratory or biphasic
→ Each of these individual waves represents a fundamental ● Sound Analysis: Sinusoidal oscillations with sound energy in the
note and its harmonically related overtones range of 100 to 1000 Hz and with harmonics that exceed 1000 Hz on
→ Gives it a musical or whistling quality occasion
● Representation in Lung Auscultogram: ● Formed in the branches between the 2nd and 7th generations of the
→ Sine wave with smooth edges airway tree by the coupled oscillation of gas and airway walls that have
▪ Thickness emphasizes louder sounds been narrowed to the point of apposition by a variety of mechanical
▪ Pitch is approximated by the angles forces
AUSCULTOGRAM ● 2 Principles:
→ Although wheezes are always associated with airflow limitation,
airflow can be limited in the absence of wheezes
→ Pitch of an individual wheeze is determined by:
▪ Thickness of the airway wall
▪ Bending Stiffness
▪ Longitudinal Tension
● NOT pathognomonic of any particular disease
→ Can be heard in obstructive airway diseases (COPD and asthma)
wherein wheezes can be heard all over the chest
● Localized Wheeze: Related to a local phenomenon
→ Can be due to:
▪ Obstruction by a foreign body
Figure 7. Lung Auscultogram of a Wheeze ▪ Mucous plug
▪ Tumor
→ Patients with this type of wheeze often receive a misdiagnosis of
Degree of airflow limitation proportional to number of airways “difficult-to-treat asthma”
generating the wheezes ● Wheezes may be absent in patients with severe airway obstruction
→ Model cited above predicts that the more severe the obstruction, the
lower the likelihood of wheeze (absent if airflow is too low).
→ Example is a severe asthma attack
▪ Condition in which the lower respiratory flows cannot provide the
energy necessary to generate wheezes (or any sounds)
▪ Normal breath sound is also severely reduced or even absent
▪ Creating a clinical picture known as “silent lung”
▪ As the obstruction is relieved and airflow increases, both the
wheeze and normal breath sounds reappear

MED.3.08 TBL: Lung Sounds 5 of 26

 RHONCHUS
MARCIAL JOURNAL
● Lower in pitch <300 Hz ● Variant of the wheeze
● "Snoring" or "moaning" quality ● May be heard on inspiration, expiration, or both
● Representation in Lung Auscultogram: ● Lower pitch compared to wheeze (typically near 150 Hz)
→ Wave with sharp pointed edges ● Resembles snoring on auscultation
▪ Thickness emphasizes louder sounds ● Share the same mechanism of generation with wheeze
▪ Pitch is approximated by the angles → Unlike the wheeze, it may disappear after coughing
AUSCULTOGRAM ▪ Suggests that secretions play a role
● Associated with rupture of fluid films and abnormal airway
collapsibility
● Often occurs with airway narrowing caused by mucous thickening
or edema or by bronchospasm (e.g. bronchitis, COPD)

Figure 8. Lung Auscultogram of a Rhonchi

STRIDOR
MARCIAL JOURNAL
● Continuous, high intensity frequency sound that may be heard ● High-pitched
through respiration ● Produced as turbulent flow passes through a narrowed segment of the
→ Usually distinctly loud and prominent during inspiration upper respiratory tract
● Indicates upper airway obstruction ● Often intense and clearly heard without the aid of a stethoscope
● Very similar quality to a wheeze, but high pitched ● Sound Analysis: Regular, sinusoidal oscillations with a frequency of
→ Representation in Lung Auscultogram: approximately 500 Hz, often accompanied by several harmonics
▪ Smooth wave (similar to a wheeze), but with the distinct ● Difference from wheeze:
difference of pointing the arrow to the upper → More clearly heard on inspiration than on expiration
airway/trachea
▪ It is usually inspiratory, but it can also be expiratory or biphasic
AUSCULTOGRAM → More prominent over the neck than over the chest
● Can be heard due to:
→ Acute Epiglottitis
→ Airway Edema after device removal
→ Anaphylaxis
→ Vocal Cord Dysfunction
▪ Often confused with asthma
▪ Also called paradoxical vocal-cord motion
− Respiratory condition characterized by inappropriate
adduction of the vocal cord with resultant airflow limitation at
the level of the larynx, accompanied by stridorous breathing
→ Inhalation of a foreign body
→ Laryngeal tumors
Figure 9. Lung Auscultogram of a Stridor → Thyroiditis
→ Tracheal carcinoma
● Clinical Correlations:
NTK: Vocal Cord Dysfunction → Indicates upper airway obstruction
● In a review of 95 patients with vocal-cord dysfunction → When heard on inspiration: associated with extrathoracic lesions
treated at the National Jewish Center, more than half (e.g. laryngomalacia, vocal cord lesion, postextubation)
carried an incorrect diagnosis of asthma for years and had
been treated with glucocorticoids. ▪ In patients who have undergone extubation, its appearance can
● Several reports have documented the costs of be a sign of extrathoracic airway obstruction
misdiagnoses vocal cord dysfunction to the medical care → When heard in expiration: associated with intrathoracic lesions
system. (e.g. tracheomalacia, bronchomalacia, extrinsic compression)
→ When biphasic: associated with fixed lesions (e.g. croup, paralysis
of both vocal cords, laryngeal mass or web)

MED.3.08 TBL: Lung Sounds 6 of 26

 CRACKLES
MARCIAL JOURNAL
● FINE CRACKLES ● Short, explosive, nonmusical sounds usually on inspiration
→ Higher in pitch ● Among patients with similar levels of scarring on chest films, those with
→ Initial deflection width (IDW) averages 0.92 ms few crackles are more likely to have sarcoidosis while those who have
→ 2 cycle duration (2CD) <10 ms^12,19 many crackles are more likely to have idiopathic pulmonary fibrosis
→ Like velcro materials are pulled apart or lock of hair is ● Can be heard in healthy persons but tend to disappear after a few
rubbed between fingers deep breaths
→ Occur during late inspiration ● Persistence in both lungs in older persons with dyspnea should
→ Produced by sudden opening of partly or completely collapsed
prompt investigation for interstitial lung disease
small airways or alveoli as one gasps for air during inspiration
→ Representation in Lung Auscultogram: Small solid dots ● Two categories:
→ FINE CRACKLES (most helpful in diagnosing diseases)
● COARSE CRACKLES ▪ Distinct “velcro” sound or rales
→ Usually louder ▪ Usually heard during mid-to-late inspiration
→ Lower in pitch and gurgling quality compared to fine crackles. ▪ Well perceived in dependent lung regions
→ IDW: 1.25 ms ▪ Not transmitted to the mouth
→ 2CD: >10 ms ▪ Uninfluenced by cough
→ Longer than fine crackles helping the clinical ear distinguish
▪ Altered by gravity; changes or disappears with changing body
from the 2 sounds
position
→ Can occur at any phase of the respiratory cycle
▪ In sound analysis, they have a shorter duration and higher
→ Gurgling sound most often caused by air bubbling through
airway secretion as air flows during respiration frequency compared with coarse crackles
→ Representation in Lung Auscultogram: Open circles like ▪ Mechanism for generation: sudden inspiratory opening of
bubbles small airways held closed by surface forces during the previous
▪ Signify the bubbling or gurgling sound produced expiration
AUSCULTOGRAM ▪ Typically prominent in idiopathic pulmonary fibrosis but not
pathognomonic
▪ Appear first in the basal areas of the lungs and progress to the
upper zone
▪ Also found in other interstitial disease (e.g. asbestosis,
nonspecific interstitial pneumonitis, and interstitial fibrosis
associated with connective- tissue disorders)
▪ Considered to be an early sign of pulmonary impairment as it
is detected before radiologic abnormalities in idiopathic
pulmonary fibrosis and asbestosis
▪ Tend to be minimal or absent in sarcoidosis because the disease
primarily affects the central lung zones not abutting to the pleura

→ COARSE CRACKLES
▪ “Popping” quality
▪ Tend to appear early during inspiration and throughout
expiration
▪ Can be heard over any lung region
Figure 10. Lung Auscultogram of Fine Crackles ▪ Usually transmitted to the mouth
▪ Changes or disappears with coughing
▪ Uninfluenced by body position
▪ In sound analysis, they appear as rapidly dampened wave
deflections with a repetitive pattern
▪ Mechanism: boluses of gas passing through airways as they
open and close intermittently.
▪ Probably not produced by secretions (exceptions: crackling
sounds in moribund patients or patients with abundant
secretions)
▪ Common in obstructive lung diseases (e.g. COPD,
bronchiectasis, and asthma)
▪ usually in association with wheezes
▪ often heard in pneumonia and congestive heart failure

● In Pneumonia, coarse and mid-inspiratory crackles are heard in the

early phase while shorter, fine, and end- inspiratory crackles in the
recovery phase.
Figure 11. Lung Auscultogram of Coarse Crackles

MED.3.08 TBL: Lung Sounds 7 of 26

 PLEURAL FRICTION RUB
MARCIAL JOURNAL
● Is a creaking, leathery, or grating sound produced when the two ● Nonmusical and explosive
layers of an inflamed and/or thickened pleura rubs together during ● Normally, the parietal and visceral pleura slide over each other
breathing silently
● Usually heard during inspiration and expiration ● In lung diseases, the visceral pleura becomes rough enough that it
● Rub is often well-localized and audible throughout the respiratory produces crackling sounds heard as a friction rub
cycle ● More prominent on auscultation of the basal and axillary regions
● Sometimes mistaken for crackles than the upper regions
● Gritty leathery quality of the sound and the consistency of this ● Upper regions lie on the flat portion of the static pressure-volume
quality help in differentiating pleural friction rub from crackles curve
● Coughing and deep breathing may also help in distinguish pleural ● Basal regions lie on the steep portion of the curve and undergoes
friction rub from crackles greater expansion in changing transpulmonary pressure
● Presence of symptoms of pleurisy should also be sought to help ● Typically biphasic with the expiratory sequence of sounds mirroring
distinguish the 2 kinds of sounds the inspiratory sequence
● Pleural friction rub is also sometimes mistaken for pericardial friction ● Sound Analysis: Waveform is similar to crackles except for its
rub. longer duration and lower frequency
● Mechanism: Probably produced by the sudden release of
Table 1. Pleural Friction Rub VS Pericardial Rub tangential energy from a lung surface that is temporarily prevented
Pleural Friction Rub Pericardial Rub from sliding because of friction between the two pleural layers
Leather quality ● Typically heard in inflammatory diseases (e.g. pleuritis) or
May be found anywhere Localized in the left parasternal malignant pleural diseases (e.g. mesothelioma)
where there is pleura region, in the 2nd or 3rd ICS
Disappears during breath- Persists during breath-holding AUSCULTOGRAM
holding
Has 3 intermittent scratching
components that coincide with
systole and diastole
→ Atrial systole
→ Ventricular systole
→ Ventricular diastole
● Representation in Lung Auscultogram:
→ Open circle with a cross to represent the gritty scratchy quality
of the sound
→ Arrow to where the sound was heard connects the illustration
with the chest Figure 12. Lung Auscultogram of a Pleural Friction Rub

MIXED SOUND (SQUAWK)

MARCIAL JOURNAL
● Rarely described and appreciated sound ● Also called “short wheeze” or “squeak”
● Described in patients with interstitial fibrosis and allergic alveolitis ● Mixed = contains short musical and nonmusical components
● The sound is made up of a short inspiratory wheeze that is usually accompanied/preceded by crackles
preceded by crackling sounds. ● Sound Analysis in Hypersensitivity Pneumonitis: Appears as
● Representation in Lung Auscultogram: sinusoidal oscillations that are less than 200 msec with a
→ Short wavy line (as in wheeze) fundamental frequency between 200-300 Hz
▪ Preceded by small solid dots (as in fine crackles) ● Mechanism: Not entirely known
AUSCULTOGRAM → According to one theory, produced by oscillation of the peripheral
airways (in deflated lung zones) whose walls remain in
apposition long enough to oscillate under the action of the
inspiratory airflow
● Typically heard from the middle to the end of inspiration in
interstitial diseases, especially hypersensitivity pneumonitis
but NOT pathognomonic
● Also documented in bronchiectasis and pneumonia
● Pneumonia is most likely the next cause if there is no evidence of
interstitial disease

Figure 13. Lung Auscultogram of a Squawk

MED.3.08 TBL: Lung Sounds 8 of 26

 C. TRACHEAL / MEDIASTINAL DEVIATION (Marcial)

● Position of the trachea above the suprasternal notch and the location of
the apex beat
→ Indicate the position of the mediastinum and the lungs
● Shifting caused by imbalance of forces between 2 sides of the lungs
● Caused by various intrathoracic pathologic processes on one side of the
lungs
→ Pneumothorax
→ Pleural effusion
● Will push the mediastinum and trachea to opposite side of thorax
● Representation for deviation:
→ Arrow is drawn at the tracheal area to represent the deviation
→ Also used when apex beat is displaced
● Causes:
→ Atelectasis or collapse: trachea deviates ipsilaterally (same side)
Figure 14. Tracheal and Mediastinal Deviation to the left and to the right
→ Air or fluid: trachea deviates contralaterally (opposite)

D. PERCUSSION NOTES (Marcial)

● Important clues in physical diagnosis

● Has four qualities:
→ TYMPANIC
▪ Normal percussion note heard when the abdomen is percussed
▪ e.g. Gas-filled stomach bubble
→ RESONANT
▪ Normal percussion note heard when the normal chest is percussed
▪ e.g. Solid tissue (chest wall) overlying an air-filled lung tissue
− Best appreciated throughout the periphery of the lungs
− During a pathology, for example in pneumothorax and
emphysema (more air inside the chest cavity), the percussion
note becomes more hollow or drum-like = Hyperresonance
→ DULL
▪ Thud-like quality
▪ See additional description under "Flat" percussion note
→ FLAT
▪ As the acoustic mismatching of the chest cavity (with its contents)
and the chest wall diminishes, the percussion note changes to a Figure 15. Lung Auscultogram of Dull Percussion.
thud-like quality which we term as “dull” to almost no acoustic The area of interest or change in the percussion note is drawn with a cross
hatching or crisscrossing lines and is labeled with an arrow as
contrast which we term “flat” either hyperresonant, resonant, dull or flat.

E. VOICE SOUND TRANSMISSION (Marcial)

● Tactile fremitus refers to vibrations felt by the examining hands over the OTHER TYPES OF VOCAL RESONANCE
chest by asking the patient to say “tres, tres, tres..” or “ninety-nine, ninety- ● Bronchophony
nine..” → Increase in intensity and clarity of vocal resonance
→ Vibrations felt are the transmitted sounds originating from the vocal → Indicates an increased lung tissue density therefore increased
cords and traveling to the airways, lung tissue, and the chest wall transmission of sound through the chest
● VOCAL FREMITUS ● Whisper Pectoriloquy
→ Term used when a stethoscope is used to listen to the sound over the → Elicited by asking the patient to whisper (rather than say with a
chest instead of feeling for the vibrations with a hand normal voice tone) “tres, tres, tres” or “ninety-nine..”
● Fundamental notes produced by voice sounds ● Egophony
→ 130 Hz in males → Increased intensity of voice sounds that has a nasal or bleating
→ 230 Hz in females (goat-like) character
→ Overtones of 400-3500 Hz → Elicited by asking the patient to say “eee…” while you listen using
● Normal voice sounds heard through the normal chest are attenuated and a stethoscope
filtered ▪ When present, the “eee..” sounds like “aay…”
● Sound transmission from vocal cords is dependent on the acoustic
properties of the airways, lungs, and chest wall
FYI: To simplify the lung auscultogram, the proposal made by the
→ Frequency of <200 Hz is usually well transmitted ACCP-ATS is used in which it is to use plainly the words "increased" or
→ Frequency of >200 Hz is attenuated "decreased" transmission of the voice sounds
▪ Leads to filtration of most of the vowel formants
− Reason for incomprehensible low-pitched mumble sound heard
through a stethoscope from normal speech
● Various pathologies in the chest that can asymmetrically alter these
acoustic properties are best appreciated as uneven transmission of
vibrations or sounds ● e.g. In Figure 9, the area of the chest with decreased or increased
→ e.g. Pneumonia that causes a lobar consolidation facilitates the sound transmission is drawn with cross-hatchings and labeled
transmission of sounds due to the increased density of the lung tissue. accordingly
▪ Can be appreciated as an increased tactile/vocal fremitus

MED.3.08 TBL: Lung Sounds 9 of 26

 G. LUNG AUSCULTOGRAM FORMS (Marcial)

● Use a “Skeleton” illustration of the anterior and posterior

views of the chest as seen in Figure 14.
● These figures can be incorporated and printed on basic
physical examination (PE) forms of the official medical records
form used in the hospital
● The word “normal” is included in the figures to facilitate filling-
in of information when the patient shows no abnormalities on
lung auscultogram
→ The box preceding the word "normal" is just simply checked
and no other elaborate drawings need to be included
● For percussion notes and voice sound transmission
→ Findings can appropriately be entered by simply checking
the corresponding boxes
● Abnormal area of the chest can be cross-hatched and an
arrow connecting this area with the percussion note and voice Figure 16A. Anterior View of a Lung Auscultogram
sound findings is drawn to associate with the abnormal area
involved
● For breath sounds and adventitious sounds, 2 rectangular
forms on the right side are provided for each anterior and
posterior view figures
→ To facilitate and accommodate illustrations of possibly
several abnormalities in the lung auscultogram
→ Examiner may fill up one or both of these rectangular forms
based on his/her preference
→ An arrow connecting the rectangular forms with the drawing
of the anterior or posterior chest should be made to
represent the area where the PE finding was appreciated

Figure 16B. Posterior View of a Lung Auscultogram

III. OTHER PULMONARY PROCEDURES (Marcial)

1. CAMPBELL’S SIGN
● Elicited to predict severity of airflow obstruction ● Procedure:
● If inspiratory descent of trachea > 2.5 inches = chronic airflow 1. Patient sits up, close mouth, head and chin forward without
obstruction or ARD extending it to make neck muscles remain relaxed
→ Excessive inspiratory pull of trachea during strong diaphragmatic 2. Place tip of finger over thyroid cartilage
contraction 3. Look for inspiratory descent of trachea

2. CARDELL’S SIGN
● Detected in patients with aneurysm of aortic arch
● Transverse pulsation of trachea once trachea is shifted to left as
contact between left main bronchus and aortic arch is increased
● Procedure:
1. Patient sits up, closes mouth with head and chin forward without
extending it to make neck muscles remain relaxed
2. Palpate for thyroid cartilage
3. Press on thyroid cartilage, gently displacing it towards patient’s left.
4. Feel for transverse pulsation.
5. Examine whether it is synchronous with each systole or aortic
pulsation

*Yes same figure for Campbell’s and Cardell’s accdg to Marcial

MED.3.08 TBL: Lung Sounds 10 of 26

3. LARYNGEAL HEIGHT
● Done in patients suspected to have COPD
→ only significant if value obtained is combined with other parameters
● Determined by measuring the distance between top of thyroid cartilage
and suprasternal notch
● Value of < 4cm, specially found with other clinical factors (smoking, age
45 or more, self-reported history of COD) = correlated with presence of
hyperinflation in patients with emphysema.
● Procedure
1. Patient sits up, close mouth, head and chin forward without extending
it to make neck muscles remain relaxed
2. Stand in front of patient
3. Palpate for thyroid cartilage using index and middle finger. Identify
suprasternal notch
4. Measure distance between top of thyroid cartilage and suprasternal
notch at end of expiration (max. laryngeal height)
5. Measure distance at end of inspiration (min. laryngeal height)
6. Determine the difference (laryngeal descent)
7. Report in centimeters
4. BREATH SOUNDS’ INTENSITY (BSI) BEDSIDE PERFORMANCE
● Objective recording of reduction in breath sound intensity ● Procedure
→ helps in evaluation of obstructive pulmonary syndrome 1. Patient sits up. Ask to inhale, fast and deep, while at the
● Rating scale has 5 specifically defined stages (0 to 4) same time breathing through mouth.
→ grades in 6 areas of chest are added to give a total score with 2. Auscultate bilaterally over upper anterior zones, mid-axillae,
possible values ranging from 0 to 24. posterior bases.
● Grading of loudness of breath sounds = Poor screening test for mild 3. Quantify intensity of inspiratory component of vesicular
ventilator abnormality breath sounds:
● Normal breath sounds nearly excludes severe reduction in FEV ● 0: Absent
● Reduced breath sound intensity = strong evidence for presence of ● 1: Barely audible
obstructive pulmonary disease ● 2: Faint but definitely audible
● Interobserver reliability for BSI determination: Very good ● 3: Normal
● BSI: Accurate indicator of airflow obstruction ● 4: Louder than normal
→ BSI <9 strongly favours obstruction 4. Disregard superimposed adventitious sounds.
→ BSI >15 argues against it 5. Compute for BSI score
5. FORCED EXPIRATORY TIME (FET)
● Best bedside predictor for severity of airflow obstruction ● Procedure
● Possible results: 1. Evaluated by asking patient to sit upright, maximally inhale
→ Person with no airflow obstruction: (FEV1/FVC <70%) FET <5 and exhale through open mouth as forcefully as possible
seconds 2. Use bell of stethoscope over trachea in suprasternal notch,
→ Patients with airway obstruction: FET >6 seconds (50%) duration of audible exhalation is timed to nearest second.
▪ More prolonged FET, greater airflow obstruction
→ FET >9 seconds: patient with history of COPD and wheezing -
important variable in diagnosis of COPD
6. POSTURALLY INDUCED CRACKLES (PICs) 7. AUSCULTATORY PERCUSSION
● Noninvasive, simple and valuable bedside test for patients with ● Detection of elicited sounds through stethoscope
congestive heart failure 1. Place on back 3 cm below 12th rib of patient.
● Highly correlated with: 2. Chest is percussed downward and posteriorly from apex to
→ higher pulmonary capillary wedge base
→ lower pulmonary venous compliance 3. Change in percussion note from dull to loud that is
→ higher mortality after acute MI. localized over 12 rib indicating pleural fluid
● Higher score, greater severity of pulmonary congestion 4. Taps lightly over manubrium at the same time listening
● Procedure with stethoscope over symmetric locations of posterior
1. Patient sit upright for 3 minutes chestwall.
2. Instruct to breathe through mouth deeper than usual 5. Sound so generated travels unimpeded through the lungs,
3. Listen over the 8, 9, 10 ICS along posterior axillary line on both reaching the opposite chest wall in symmetric fashion
sides. 6. Any asymmetry in sound intensity is considered sign of
4. Listen for late inspiratory crackles during at least 5 consecutive lung disease
breaths
5. Assume supine for 3 minutes.
6. Listen again.
7. Elevate both legs at angle of 30 degrees for 3 minutes.
8. Listen again.
9. Give score and interpret results. (0-2)
▪ 0: none
▪ 1: Only audible in supine or leg-elevated
▪ 2: Present in all

MED.3.08 TBL: Lung Sounds 11 of 26

 IV. CASE EXAMPLES (Marcial)

As an exercise, readers are encouraged to look first at the lung auscultogram NTK: Looking at the lung auscultogram may break the monotony of
→ Determine the various abnormalities conveyed by the illustrations reading through paragraphs of long sentences which may be needed to
→ Try to figure out the diagnosis before reading the chest findings and the diagnosis in the paragraphs that follow describe most (if not all) of the PE findings of a case.

● Case 1: A 58-year-old male smoker complaining of

chronic cough and dyspnea. CR –100 beats/min, RR
– 30 beaths/min, BP – 140/90. His lung auscultogram
reveals hyperresonance on both anterior and posterior
chest with impaired transmission of voice resonance.
Expiratory wheezes can be appreciated all over the
anterior and posterior chest which appears to be
louder near large airways. Mid-inspiratory coarse
crackles can also be heard on the left parasternal area.
● Diagnosis: COPD in exacerbation

● Case 2: An 18-year-old male, tall, and lean individual,

suddenly developed dyspnea and right sided chest
heaviness. CR – 102 beats/min, RR – 28 breaths/min,
BP – 120/70. His lung auscultogram reveals shifting of
trachea and apex beat to the left. There is
hyperresonance on the right hemithorax with impaired
transmission of voice sounds. Bronchial breath sounds
are heard anteriorly and suspiciously more lateral in
the right infraclavicular area than is normally expected.
Normal breath sounds are not heard (as drawn with
dashed line) in the right infrascapular area.
● Diagnosis: Right-sided spontaneous pneumothorax
→ Note: Pneumothorax must have caused an almost,
if not complete, collapse of the right lung due the
hyperresonant percussion note
→ Impaired transmission of voice sounds appreciated
even more at the inframammary or infrascapular
areas.

● Case 3: A 25-year-old female developed high grade

fever and chills of 3 days duration. She also
complained of a cough with yellow viscid sputum. CR
– 100 beats/min, RR – 26 breaths/min, BP – 120/80, T
– 38.8 °C. Her lung auscultogram showed a dull
percussion note with increased transmission of voice
sounds on the right inframammary and infrascapular
areas. In the same area, there is absence of normal
breath sounds and some fine crackles can be heard.
● Diagnosis: Lobar pneumonia, right

MED.3.08 TBL: Lung Sounds 12 of 26

 V. CONCLUSION VI. INDIVIDUAL/TEAM READINESS ASSESSMENT TEST
● Lung auscultation is an essential part of the physical (iRAT/tRAT)
examination A. DISCUSSION
→ No other clinical procedure matches auscultation for the
provision of relevant clinical information about the respiratory ● Sound
system quickly, easily, and by nearly universally available → Vibrational energy that is sufficient to be heard
means ● Lung Sounds
→ Minimal cooperation on the part of the patient → Audible vibrations produced within the lungs or its airways
→ Cost-effective which can be auscultated with a stethoscope
→ Can be repeated as often as necessary ● Adventitious Sounds
● Portable objective means to record, analyze, and store lung → Referenced as crackles, wheezes, rhonchi, and stridor
sounds → As well as voice sounds
→ Development of robust acoustic devices for use at the ▪ Egophony, bronchophony, whispered pectoriloquy
bedside (electronic stethoscopes paired with small recorders) ● Why Chest Auscultation?
→ This can make sound tracking possible, further enhancing → Remains undiminished even after the development of modern
usefulness of auscultation\ imaging technologies
● Finally, it must be kept in mind that auscultation is NOT a ▪ Very common procedure
laboratory test but a COMPONENT of the physical ▪ Can be done anytime
examination whose usefulness depends on its proper ▪ Non-invasive
correlation with the available clinical information ▪ Easy to do
→ Acoustic findings correlated with pathology are noted on
autopsy for over more than 200 years and in almost all
conceivable circumstances
▪ Since the stethoscope was invented in 1818
→ Careful diagnostician is rewarded with confirmation of his
diagnostic impression gained by the use of the stethoscope
● First Stethoscope
→ René Laennec’s observations were very meticulous and
detailed that his conclusions have lasted until now with very
little modification
● The Stethoscope
→ Remains simply as conduits
→ Critical components
▪ Length: 12”
▪ Tubing: Not soft, like medical tubing
▪ Air Seal: Tight
→ Amplification seems to occur below 112 Hz (lower)
→ Attenuates at higher frequencies
● How to Listen to the Sounds
→ 11 recommended sites
→ For patients with disease: Auscultate more areas
→ Always compare one side with the other

MED.3.08 TBL: Lung Sounds 13 of 26

 B. TEST RATIONALE
QUESTION AND ANSWER RATIONALE
1. Auscultation of normal breath sounds of the chest ● Choice A: Bronchial breath sounds over the interscapular area
demonstrates: → Bronchial breath sounds are best heard over the upper
manubrium
A. Bronchial breath sounds over the interscapular area ● Choice B: Vesicular breath sounds at the bases (CORRECT
B. Vesicular breath sounds at the bases ANSWER)
C. Bronchovesicular breath sounds over the. trachea → Vesicular breath sounds are heard over the lesser bronchi,
D. Bronchial breath sounds that are lowest in intensity bronchioles, and lobes
are at the bases ● Choice C: Bronchovesicular breath sounds over the trachea
→ Bronchovesicular breath sounds are best heard
▪ Anteriorly: At the 1st and 2nd intercostal spaces
▪ Posteriorly: Interscapular area
→ Tracheal breath sounds are best heard over the neck (tracheal
area) and above the suprasternal notch
● Choice D: Bronchial breath sounds that are lowest in intensity are
at the bases
→ Only vesicular breath sounds are heard at the base. Figure 17. Areas of Auscultation
2. Characteristics of vesicular breath sounds: ● Choice A: Expiratory phase is longer than inspiratory phase
→ In vesicular breath sounds, inspiratory phase is longer than expiratory phase
A. Expiratory phase is longer than inspiratory phase ● Choice B: Intensity of sound is secondary to turbulent airflow
B. Intensity of sound is secondary to turbulent airflow ● Choice C: Hollow, non-musical sound heard during inspiration and expiration
C. Hollow, non-musical sound heard during inspiration → Describes tracheal breath sounds
and expiration → Vesicular
D. Inspiratory component of the sounds come from ▪ Soft, nonmusical sound heard only during inspiration and early expiration
lobar and segmental airways ▪ Heard at the bases
▪ Shorter expiratory phase
● Choice D: Inspiratory component of the sounds come from lobar and segmental airways (CORRECT ANSWER)
→ Origin of Vesicular Sounds: Central airways (expiration) and lobar to segmental airways (inspiration)
→ Origin of Tracheal Sounds: Pharynx, larynx, trachea, and large airways

Figure 18. Normal Tracheal Sound , Normal Vesicular Sound and Normal Bronchovesciular Sound from PPT

MED.3.08 TBL: Lung Sounds 14 of 26

3. As a low-pass filter to sound transmission, the normal ● Choice A: Amplifies voice sounds (e.g., egophony)
lungs: → Does not amplify voice sounds
● Choice B: Attenuates adventitious sounds
A. Amplifies voice sounds (e.g. egophony) → Does not attenuates adventitious sounds
B. Attenuates adventitious sounds ● Choice C: Amplifies bronchovesicular sounds
C. Amplifies bronchovesicular sounds → Does not amplify bronchovesicular sounds
D. Attenuates tracheobronchial sounds ● Choice D: Attenuates tracheobronchial sounds (CORRECT ANSWER)
→ Human ear
▪ Most sensitive to sounds 500 and 4,000 Hz
→ Perception of loudness is increased if higher:
▪ Frequency/Pitch
▪ Intensity
→ Most normal and abnormal lung sounds
▪ Found between 1,000 and 1,200 Hz
▪ Normal: < 400 Hz
→ Lung tissue functions as a low-pass filter
▪ Poor medium for sound transmission since it contains air
▪ Acoustic filter
▪ Cannot amplify bronchovesicular sounds
▪ Attenuates tracheobronchial sounds
− Vesicular sounds are attenuated tracheobronchial sounds
− Breath sounds > Tracheobronchial breath sounds > Lower airways > Sounds are attenuated (since flow becomes
laminar)
− Air is still located in the tracheobronchial tract
− Air passes from trachea and bronchus
o Trachea and bronchial sound
− Becomes vesicular as it reaches the lungs
● Additional Information (discussed by Dr. Lanzona):
Figure 19. Types of Airflow from PPT → Disease processes may change transmission properties of lung tissue
→ Auscultate patient in a quiet room since vesicular breath sounds are soft
→ Generation of lung sounds
▪ Normal: Turbulence of air flow from larynx to segmental bronchi
▪ Abnormal:
− Crackles: Rapid opening of airways
− Wheezing: Vibration of airways
▪ Filtering effect of lung tissue and chest wall
→ Sound Transmission
▪ Flow rate in the fine tubes
− Low
− Airflow is divided among thousands of tubes
▪ Laminar
− Sum total of diameters of each generation increases exponentially
→ Phonopneumograph
▪ Sound intensity VS flow
▪ Inspiration and expiration in normal tracheal and peripheral lung sound, the intensity for tracheal sound has been dampened
4. A patient consulted with cough and fever. The chest x- ● Choice A: Closed airways
ray showed consolidation of the right lower lobe with air → If airways are closed, no breath sounds will be heard
bronchogram. On auscultation, bronchial breath sounds ● Choice B: Patent airways (CORRECT ANSWER)
mimicking tracheal sounds were appreciated. This would → There are less air in consolidations
indicate: → Bronchial breath sounds are heard over the periphery of the lung
▪ Where vesicular sounds should be heard
A. Closed airways ▪ Indicates airlessness of underlying lung
B. Patent airways ▪ May be due to atelectasis or consolidation
C. Upper airway obstruction ▪ Consolidation produces bronchial breath sounds, assuming that airways are patent
D. Over-distended airway alveoli ● Choice C: Upper airway obstruction
● Choice D: Over-distended airway alveoli

MED.3.08 TBL: Lung Sounds 15 of 26

5. The most likely mechanism of fine (velcro-like) crackles ● Choice B: Re-opening of small airways that was previously closed (CORRECT ANSWER)
is due to: → Crackles: Explosive, nonmusical sounds
Fine Crackles Coarse Crackles
A. Passage of boluses of gas in the airways
Exclusively inspiratory events Seen in early inspiration and occasionally in expiration
B. Re-opening of small airways that was
Quality similar to velcro Popping quality and less reproducible
previously closed
Explosive re-opening of small airways that have closed Arise from fluids in the small airways
C. Secretions in central airways producing during previous expiration
bubbly Abnormal airway closure from increased lung stiffness d/t Change in pattern after coughing
D. Airway inflammation and transient narrowing • Congestive heart failure
and widening • Pulmonary fibrosis
Often audible in the mouth in expiration
Higher pitch Lower pitch
Not transmitted to mouth Transmitted to mouth
Answer: B Not affected by cough Affected by cough
Drawn as closed circles
Alveoli are closed & will be opened
Rapidly dispersed wave deflection Drawn as open circles (Open due to secretions)
Typical frequency: about 650 Hz
Typical Duration: About 5 msec

● Choice A: Passage of boluses of gas in the airways

→ Describes coarse crackles
● Choice C: Secretions in central airways producing bubbly sounds
→ Describes rhonchus
● Choice D: Airway inflammation and transient narrowing and widening
→ Describes wheezing
6. A 23-year-old female with recurrent bouts of dyspnea. ● Choice B: An expiratory wheeze (CORRECT ANSWER)
The auscultogram points to: → Wheeze - musical sounds that occur mainly in expiration
▪ Severe Obstruction: Appreciated during expiration
− Number of wheezes and distribution corresponds to pathology
o Single/Monophonic
= Heard over a particular area
= Suggests presence of a single obstructed airway

o Multiple/Polyphonic
= Varying in intensity, starting and stopping at different times and heard diffusely
= Acoustic hallmark of asthma and COPD
▪ Smooth (sine) wave
▪ High pitched
▪ Suggests airway narrowing or blockade when localized (e.g., foreign body, tumor)
▪ Associated with generalized airway narrowing or airflow limitation when widespread (e.g., asthma or COPD)
▪ Degree of airflow limitation proportional to the number of airways generating wheezes
▪ May be absent if airflow is too low (e.g., severe asthma, destructive emphysema)
A. An inspiratory wheeze
B. An expiratory wheeze
C. An expiratory rhonchus
D. An expiratory stridor

MED.3.08 TBL: Lung Sounds 16 of 26

7. What adventitious sound is most helpful in the ● Choice A: Crackle (CORRECT ANSWER)
diagnosis of diseases? → Can sometimes precede x-ray findings
→ Can be the earliest sign of disease (e.g., idiopathic pulmonary fibrosis, asbestosis)
A. Crackle
B. Wheeze
C. Squawk
D. Rhonchus
8. The following statement regarding adventitious ● Choice A: Coarse crackles, just like fine crackles, are unaffected by coughing
sounds is TRUE: → Fine Crackles: Not affected by coughing
→ Coarse Crackles: Affected
A. Coarse crackles, just like fine crackles, are unaffected by ● Choice B: A stridor can be best evaluated by placing the stethoscope at the lung bases
coughing → Stridor: Best appreciated at trachea
B. A stridor can be best evaluated by placing the stethoscope ● Choice C: Appreciation of end-inspiratory fine crackles can be the earliest sign of pulmonary fibrosis (CORRECT
at the lung bases ANSWER)
C. Appreciation of end-inspiratory fine crackles can be the → Can sometimes precede x-ray findings
earliest sign of pulmonary fibrosis → Can be the earliest sign of disease (e.g., idiopathic pulmonary fibrosis, asbestosis)
D. In the evaluation of severe asthma in the ER, the absence ● Choice D: In the evaluation of severe asthma in the ER, the absence of wheezing on auscultation is a good prognostic sign
of wheezing on auscultation is a good prognostic sign → Wheezing may be absent in very severe airway obstruction
▪ Not necessarily a good prognostic sign
▪ May progress to respiratory failure
9. A squawk is described as: ● Choice A: Leathering, grating sound unaffected by cough
→ Describes pleural friction rub
A. Leathering, grating sound unaffected by cough ● Choice B: Musical, low-pitch sound similar to snoring
B. Musical, low-pitch sound similar to snoring → Describes rhoncus
C. Coarse crackles appreciated at the mouth of a dying patient ● Choice C: Coarse crackles appreciated at the mouth of a dying patient
D. Mixed sounds consisting of a short inspiratory wheeze → Describes death rattle
followed by crackles ● Choice D: Mixed sounds consisting of a short inspiratory wheeze followed by crackles (CORRECT ANSWER)
→ Squawk
▪ Short, inspiratory wheezes often heard with fine crackles
▪ Wheeze is caused by an unstable airway (opening & fluttering)
▪ Described in interstitial lung disease
▪ Can occur in pneumonia
10. A 16-year-old tall and lanky basketball player presents ● Choice C: Pneumothorax (CORRECT ANSWER)
with sudden dyspnea. Here are the PE findings: → Trachea deviated contralaterally
→ Heart also deviated
▪ Apex beat displaced
▪ Mediastinal shift
→ Auscultogram shows dotted lines: Decreased breath
sounds
● Additional Information (discussed by Dr. Lanzona):
→ Consolidation, Atelectasis, Semi-Airless Lung
▪ Acoustic filter diminishes
▪ Higher frequencies speech components may
pass through
▪ Speech becomes more intelligible
− Egophony
− Whisper Pectoriloquy
− Bronchophony
What is your diagnosis? − Vesicular sound to bronchial or
bronchovesicular
A. Lobar consolidation → Transmitted Voice Sounds
B. Pulmonary embolism ▪ Normal: Sounds are muffled or gargled
C. Pneumothorax ▪ Consolidated: Clearer
D. Emphysema ▪ Padded Airways: For sound transmission
▪ Pathologies: Depend on less (consolidated) or more air

MED.3.08 TBL: Lung Sounds 17 of 26

 VII. TEAM APPLICATION (tAPP) CASE STUDIES

A. CASE 1
● History of Present Illness
→ A 65-year-old female with exertional dyspnea that has ● Questions
gradually worsened over the last several years is seen in the → Describe the breath sounds.
outpatient clinic. Several years earlier, the patient had stopped ▪ Reduced lung sounds on both lungs
jogging because of dyspnea. She now finds that her exercise ▪ Hyperresonant
tolerance is limited to walking one block or a half flight of stairs. ▪ Other groups heard fine crackles
She also complains of cough and sputum production. She − Auscultation is prone to observer variability
denies chest pain, orthopnea or allergies. She has 50-pack − Findings in auscultation is transient and not permanent
years of smoking history o Daily monitoring is important
− What is important here is that there is a diminished
● Past Medical History breath sound
→ Illnesses: unknown
→ Familial Histories: Father died of emphysema at 75 years old,
a brother has obstructive airway disease, mother has → Draw the auscultogram.
tuberculosis
→ Occupational History: saleswoman in a car factory
→ Travel: Zamboanga a month ago
→ TB History: Exposed to mother
→ Smoking History: 1-pack of cigarette for 50 years, stopped a
year ago

● Pertinent PE Findings
→ General: not in acute distress
→ Vital Signs: within normal limits
→ Neck: The trachea is midline and mobile. There is no stridor
on tidal volume or forced vital capacity maneuvers. Carotid
pulses are +2 and symmetrical. There are no Figure 21A. Auscultogram (Anterior View) of Patient in Case 1
lymphadenopathy. Accessory muscles are used for breathing
with minimal exertion.
→ Chest: There is substantially increased AP diameter and there
is decreased expansion with respiration. Increased resonance
is noted upon percussion.
→ Heart: Cardiac sounds are mildly diminished. There is no right
ventricular heave. The cardiac sounds are regular in rhythm
without murmurs and gallops.
→ Lungs: Listen to the lung sounds for case 1.
→ Abdomen: Soft and non-tender. Bowel sounds are present.
The liver is percussed 2 cm below the costal margin, however,
the total width is only 10 cm at the midclavicular line.
→ Extremities: There is no cyanosis, clubbing, or edema. Pulses Figure 21B. Auscultogram (Posterior View) of Patient in Case 1
are +2 and symmetrical in all areas.
→ Pulmonary Function Test: FVC is 84% predicted, FEV1 is 45%
predicted and DLCO is 48% predicted, no significant change → What is the most likely diagnosis?
after bronchodilator inhalation ▪ Emphysema
→ Chest Radiograph:
→ What physiologic principles explain the auscultatory
findings in this case?
▪ This patient has emphysema secondary to alveolar
destruction.
▪ The elastic recoil in her lungs is lost, therefore, distant
bronchioles collapse during early expiration, trapping air in
the lungs. As a result, the lungs become hyperexpanded.
▪ The airways obstruction severely limits airflow throughout
the bronchial tree, preventing the development of
turbulence and reducing sound production.
▪ In addition, hyperexpanded lung fields transmit sounds
poorly. The result is diminished lung and heat sounds.
▪ Hyperresonance results from increased air in the alveoli

→ What abnormalities are present in the chest radiograph?

Figure 20. Chest Radiograph of Patient in Case 1
▪ The chest radiograph shows severe pulmonary
hyperinflation.
▪ The lateral view shows an increased retrosternal airspace
typical for emphysema.
▪ The vascular markings are absent in the lower lung fields.

MED.3.08 TBL: Lung Sounds 18 of 26

 B. CASE 2 → What pulmonary disorders can cause the patient’s
● History of Present Illness problems?
→ The patient is a 40-year-old female with a 10-month history of ▪ Upper airway obstruction like laryngitis, epiglottitis, foreign
wheezing, cough, and gradually increasing dyspnea on body aspiration, tracheal stenosis and partial airways
exertion. She was given different medications: short-acting β2 obstruction
agonist, levocetirizine, esomeprazole, erdosteine, oral and
inhaled steroids and antibiotics. Other symptoms and signs → What is the most likely diagnosis?
include severe morning cough and daily sputum production of ▪ Upper airway obstruction
yellowish sputum. Her cough has changed substantially over
the past 4 months becoming more brassy in nature. Exercise → What physiologic principles underlie the auscultatory
tolerance is currently 2 blocks at normal pace. She has also findings in the case?
lost 5-lb weight loss since the onset of her symptoms. ▪ Stridor is a sign of upper airway obstruction
Pertinent negative symptoms include the absence of chest ▪ Stridor is produced by the rapid, turbulent flow of air
pain, fever, night sweats, orthopnea, and pedal edema. through a narrowed or partially obstructed segment of the
● Past Medical History extra-thoracic upper airway. Involved areas include the
→ Illnesses: childhood illness including measles and whooping pharynx, epiglottis, larynx, and the extrat-horacic trachea.
cough ▪ May be heard throughout respiration but distinctly loud and
→ Familial Histories: (+) exposure to TB - father prominent during inspiration
→ Occupational History: computer programmer
→ Travel: None C. CASE 3
→ Hobbies: cooking ● History of Present Illness
→ Marital status: married → You are asked to evaluate a 25-year-old male who has been
→ Medications: metered-dose inhalers (salbutamol, budesonide, have treated for an upper respiratory viral infection for the past
formoterol-beclometasone), theophylline, oral prednisone, 2 weeks. He was without physical complains until the
methylprednisolone, levocetirizine, montelukast, azithromycin afternoon when he noticed a sharp pain in his right chest and
without evidence of improvement slight dyspnea while playing tennis. The pain was of sudden
→ Smoking History: 30 pack years (started at age 15) onset, became worst with breathing, and improved when he
→ Allergies: flowers, perfumes held his breath. It radiated through his back but not to his
● Pertinent PE Findings shoulder or jaw. It did not change with exercise or change in
→ General: She is alert, oriented and not in acute respiratory position. He has no other complaints and specifically denies a
distress history of asthma and allergies
→ Vital Signs: Within normal limits ● Past Medical History
→ HEENT: throat congested, no oral lesions → Illnesses: childhood illness including measles
→ Neck: The trachea is midline and mobile to palpation. There is → Familial Histories: Noncontributory
no swelling of the lymph nodes, no jugular venous distention, → Occupational History: messenger in a food chain company
and no bruit heard over the carotid arteries. → Travel: None
→ Chest: The chest is symmetrical with breathing. → Hobbies: pool, tennis
→ Heart: Regular rate and rhythm without murmurs, gallops. No → Marital status: married
ventricular heaves noted. → Smoking History: 30 pack years (started at age 15)
→ Lungs: Refer to the PowerPoint presentation. Listen to the ● Pertinent PE Findings
breath sounds appreciated over the upper airway. Inspiratory → General: The patient is tall and thin male who appears
and expiratory monophonic wheezing is heard over the upper approximately his stated age at 25. He is alert, oriented, and
lung field. Faint monophonic wheezes heard over the lower in no respiratory distress while sitting up during the
lobes. examination.
→ Abdomen: Soft and non-tender. Bowel sounds are present. → Vital Signs: normal except a pulse rate of 100
The liver is percussed 2 cm below the costal margin, however, → Neck: The trachea is mildly deviated toward the left but is
the total width is only 10 cm at the midclavicular line. mobile to palpation. There is no lymphadenopathy, jugular
→ Extremities: There is no cyanosis, clubbing, or edema. Pulses venous distentions or carotid bruits. Carotid pulsations are +2.
are +2 and symmetrical in all areas. → Chest: The chest is asymmetrical, and there is more
● Questions movement on the left side with breathing. Percussion of the
→ Describe the breath sounds heard on auscultation over chest reveals increased resonance over the right chest.
the neck → Heart: Regular rate and rhythm without murmurs, gallops. No
▪ Breath sounds are loud and there is stridor upon both ventricular heaves noted.
inspiration and expiration. → Lungs: Refer to the PowerPoint presentation. Listen to the
→ Draw the auscultogram. lung sounds for case 3.
→ Abdomen: Soft and non-tender. Bowel sounds are present.
The liver is percussed 2 cm below the costal margin, however,
the total width is only 10 cm at the midclavicular line.
→ Extremities: There is no cyanosis, clubbing, or edema. Pulses
are +2 and symmetrical in all areas.

Figure 22. Auscultogram of Patient in Case 2

MED.3.08 TBL: Lung Sounds 19 of 26

 → Chest Radiograph:
D. CASE 4
● History of Present Illness
→ A 40-year-old man has been cared in the surgical unit for
approximately five days after a cholecystectomy. Forty-hours
previously, he had experienced a sudden onset of dyspnea
while in the bathroom. The dyspnea gradually decreased in
severity, however, he developed chest pain on the right side
approximately 24 hours later. He denies cough, fever, night
sweats, or sputum production. He denies leg tenderness or
swelling as well as any history of asthma and allergies
● Past Medical History
→ Illnesses: Mild hypertension
→ Familial Histories: Father died of cardiac arrest
→ Occupational History: mechanic exposed to brake dust and
fumes
→ Travel: None
Figure 23. Chest Radiograph of Patient in Case 3 → Hobbies: playing lotto
→ Surgeries: Appendectomy and recent cholecystectomy
● Questions
→ Marital status: Married
→ Describe the breath sounds
→ Smoking History: 20 pack years
▪ Only the right side is affected
● Pertinent PE Findings
− Left side is normal
→ General: The patient is obese, supraclavicular retractions
▪ Reduced breath sounds
noted while lying during the examination
▪ Chest PE (+) hyperresonance on the R
→ Vital Signs: Temperature: 38.5ºC, heart rate: 98/min,
▪ (-) adventitious breath sounds respiratory rate: 28/min, blood pressure 120/70 mmHg
→ Draw the auscultogram. → Neck: The trachea is midline and mobile to palpation. Carotid
pulsations +2. There are no carotid bruits. There is no jugular
venous distention noted.
→ Chest: Supraclavicular retractions noted. The chest has
normal AP diameter and decreased expansion with
respiration. Decreased resonance on both lungs.
→ Heart: Regular rate and rhythm without murmurs, gallops. No
ventricular heaves noted.
→ Lungs: Refer to the PowerPoint presentation. Listen to the
lung sounds for case 4.
→ Abdomen: Soft and non-tender. The recent surgical scar
Figure 24A. Auscultogram (Anterior View) of Patient in Case 3 appears to be healing well and is without evidence of
inflammation. Bowel sounds are present.
→ Extremities: There is no cyanosis, clubbing, or edema. Pulses
are +2 and symmetrical in all areas. There is no calf
tenderness or other evidence of vein inflammation (venous
thrombophlebitis).
→ ABG: pH 7.48, PaCO2 30 mm Hg, PaO2 55 mm Hg on room
air
→ Chest Radiograph:

Figure 24B. Auscultogram (Posterior View) of Patient in Case 3

→ What is the most likely diagnosis?

▪ Tension Pneumothorax
→ What physiologic principles underlie the auscultatory
findings in the case?
▪ Left side is resonant and has normal sound transmission
▪ Right side is hyperresonant and has decreased sound
transmission
− Higher air/fluid ratio higher amplitude and lower
frequency = very loud, very low, long
− Hyperresonance on percussion indicates the presence
of too much air within the lung tissue
− Since it is only noted unilaterally, this is a case of
pneumothorax
− Pneumothorax presents with a very small lung, distance
from the chest wall is greater resulting to reduced lung Figure 25. Chest Radiograph of Patient in Case 4
sounds ● Questions
o Second principle of sound transmission: anything → Describe the breath sounds
which increases the distance between the ▪ Right lung – vesicular sound with leathery grating sound
airways/lungs and the chest wall will decrease
− Leathery grating is suggestive of pleural rub
transmission of vibrations/sounds
▪ Left lung – normal

MED.3.08 TBL: Lung Sounds 20 of 26

 distress. She is using accessory muscles of respiration and is
→ Draw the auscultogram. diaphoretic.
→ Vital Signs: Temperature: 37⁰C, heart rate: 140/min,
respiratory rate: 28/min, blood pressure 120/70 mmHg. There
is paradoxical pulse of 18 mmHg
→ HEENT: Examination shows slight flaring of the nares and
cyanosis of the lips
→ Neck: The trachea is midline and mobile to palpation. There is
no stridor during tidal breathing or forced vital capacity
maneuvers. There is mild jugular venous distention with
respiration. Carotid pulsations +2. There are no carotid bruits.
→ Chest: There is increased AP diameter and decreased
Figure 26A. Auscultogram (Anterior View) of Patient in Case 4 expansion with respiration. The chest is hyperresonant in
percussion.
→ Heart: Regular rate and rhythm without murmurs, gallops. No
ventricular heaves noted.
→ Lungs: Refer to the PowerPoint presentation. Listen to the
lung sounds for case 5.
→ Abdomen: Soft and non-tender. The patient is not comfortable
lying down, so the abdominal exam was difficult to perform.
→ Extremities: Cyanosis of the nailbeds on both upper and lower
extremities
→ ABG: pH 7.35, PaCO2 40 mm Hg, PaO2 55 mm Hg on room
Figure 26B. Auscultogram (Posterior View) of Patient in Case 4 air
→ Chest Radiograph:
→ What is the most likely diagnosis?
▪ Pulmonary embolism secondary to deep vein thrombosis
→ What physiologic principles underlie the auscultatory
findings in the case?
▪ Post-op cholecystectomy blood stasis and body is in
hypercoagulative state which may cause pulmonary
embolism
▪ Pleural friction rub tends to occur if the blood clot that has
floated is fairly small and has lodge in a part of the lungs
near the pleura causing inflammation which roughens he
smooth surfaces of the parietal and visceral pleura
→ X-ray findings Figure 27. Chest Radiograph of Patient in Case 5
▪ Red circle Hampton’s hump
● Questions
− radiological sign consisting of a peripheral, wedge- → Describe the breath sounds
shaped opacification adjacent to the pleural surface, ▪ Both lungs are affected
which represents pulmonary infarction distal to a ▪ Reduced lung sounds
pulmonary embolus ▪ Inspiratory crackles with expiratory wheezes
→ Draw the auscultogram.
E. CASE 5
● History of Present Illness
→ The patient is a 25-year-old female teacher who presented to
the emergency room after a hard day working on finishing her
modules. She complains of severe dyspnea. She has been
treated for asthma since she was age 6 with an increasingly
complex medication regimen, currently consisting of a 24-hour
sustained action theophylline, a β 2-agonist metered-dose
inhaler and a steroid metered-dose inhaler. She has not
recently required oral prednisone. Her current complaints
include extreme dyspnea, severe nonproductive cough, a Figure 28A. Auscultogram (Anterior View) of Patient in Case 5
heavy sensation in her chest, and a feeling of impending
doom. She denies recent fever, night sweats, chills, change in
sputum or peripheral edema.
● Past Medical History
→ Illnesses: Nasal poly removed at age 20
→ Familial Histories: Mother is asthmatic
→ Occupational History: High school teacher
→ Pets: 3 cats
→ Hobbies: sewing
→ Surgeries: None
→ Marital status: Married
→ Smoking History: 20 pack years Figure 28B. Auscultogram (Posterior View) of Patient in Case 5
● Pertinent PE Findings
→ General: She is sitting on the edge of the bed with her hands → What is the most likely diagnosis?
propped on her knees and is complaining of respiratory ▪ Asthma

MED.3.08 TBL: Lung Sounds 21 of 26

 → Lungs: Refer to the PowerPoint presentation. Listen to the
→ What physiologic principles underlie the auscultatory lung sounds for case 6.
findings in the case? → Abdomen: Soft and non-tender. Bowel sounds are present.
▪ Hyperresonance may be attributed to hyperinflation. → Extremities: There is no cyanosis, clubbing, or edema
Expiatory wheezing is due to the minimal narrowing of the → CBC: WBC 24,000/mm3, Hgb 11 gms%, Hct 40%, Segs 80%,
airways (tight airway but still with air entry). With severe Bands 15%, Lympho 5%
narrowing (no air entry), there would be no more wheezing → Chest Radiograph:
heard; such becomes emergency

Figure 29. Chest radiograph of Patient in Case 6

● Questions
→ Describe the breath sounds
▪ Left: Normal vesicular lung sound. No egophony (spoken
words are muffled/
▪ Right: Bronchial lung sound with fine crackles upon
inspiration, louder and longer expiratory component.
(+) Egophony on the right side (spoken “ee” heard as “ay”
→ Draw the auscultogram.

Figure 28. Physiology of Patient's Auscultatory Findings in Case 5

● Patient is in respiratory failure: (+) cyanosis

F. CASE 6
● History of Present Illness
→ The patient is a 64-year-old alcoholic female who has been
admitted through the emergency room because of a two-day
history of cough, shaking chills, and sputum production. The Figure 30A. Auscultogram (Anterior View) of Patient in Case 6
sputum is yellow in color, thick, and tenacious. The patient’s
temperature has been 39 C several times during the two days
prior to admission. In addition to the fever, the patient
complains of mild dyspnea and severe right lower chest pain
during inspiration. She denies ankle edema, wheezing,
palpitations.
● Past Medical History
→ Illnesses: Hypertension, COPD
→ Familial Histories: None
→ Occupational History: secretary in a company
→ Pets: None
→ Travel: Wuhan, China Figure 30B. Auscultogram (Posterior View) of Patient in Case 6
→ Hobbies: watching Probinsiyano
→ Medications: amlodipine → What is the most likely diagnosis?
→ Marital status: Married ▪ Pneumonia
→ Smoking History: 40 pack years → What physiologic principles underlie the auscultatory
→ Allergies: None findings in the case?
● Pertinent PE Findings ▪ There is decreased expansion on the right lung. The
→ General: Touching and placing pressure on her right chest consolidation produces bronchial breath sounds.
with inspiration ▪ There is egophony because an airless lung makes spoken
→ Vital Signs: Temperature: 38.5 C, heart rate: 110/min, words loud and clear.
respiratory rate: 28/min, blood pressure 120/70 mmHg VIII. REFERENCES
→ Neck: The trachea is midline and mobile to palpation and there
Batch 2022 Trans.
is no stridor during tidal volume. There is mild jugular vein Bohadana A, Izcbiki G, and Kraman, SS. Fundamentals of Lung Auscultation. N Engl J Med
distention with respiration. Carotid pulsations +2. 2014; 370: 744-751
Bohadana A, Izcbiki G, and Kraman, SS. Fundamentals of Lung Auscultation. N Engl J Med
→ Chest: Normal AP diameter but slightly decreased expansion 2014; 370: 744-751. Interactive Graphic Fundamentals of Auscultation
with respiration particularly on the right side. There is normal Marcial, MR (2015) Pulmonary Examination. In A. Tan-Alora (Ed.), Comprehensive Guide to
resonance to percussion over most of the chest except the Physical Examination pp. 288-311. Manila, University of Santo Tomas Publishing House.
Wilkins, R.L., Hodgkin, J.E., & Lopez, BL. (1996). Lung Sounds: a Practical Guide. Mosby-Year
right lower chest which has decreased resonance and Book Inc.
decreased expansion with respiration.
→ Heart: Regular rate and rhythm without murmurs, gallops. No
ventricular heaves noted.

MED.3.08 TBL: Lung Sounds 22 of 26

 IX. APPENDIX

Table 3. Summary of Lung Sounds taken from Marcial and Fundamentals of Lung Auscultation by Bohadna et. al.
Lung Sound Characteristics Mechanism Conditions/Correlations Other Notes
Normal ● Non-musical ● Produced by turbulent airflow ● Clinical Conditions: ● Noninvasive means to monitor sleep apnea
● High pitched, loud with a harsh and hollow in the ff: → Sleep apnea syndrome
Tracheal
(tubular) quality → Pharynx → Tracheal wheeze ● Good model of bronchial breathing
Sound ● Heard best in the suprasternal notch → Glottis ▪ often mistaken for the wheeze of asthma ● May be used in identifying stridor in adults
● Clearly heard in both phases of respiratory → Subglottic region which may be caused by bronchial, tracheal
cycle ● Clinical Correlations: stenosis or by a tumor in the central airway
● Pause is often heard between phases → Represents intrapulmonary sounds → Can otherwise be missed when only the
● Range from <100 Hz to >3000 Hz with a mark (upper airway patency) lungs are examined
drop of energy above 800 Hz and little energy → Can be distributed (e.g. become noisier ● Can become frankly musical, characterized as
beyond 1500 Hz or even musical) if airway patency is either a typical stridor or a localized, intense
● Similar in quality to other bronchial breathing altered wheeze
heard in patients with lung consolidation → Serves as good example of bronchial → Tracheal wheeze
breathing ● Lung Auscultogram:

Normal ● Lung or "vesicular" sounds ● Inspiratory component ● Clinical Conditions: ● Markedly influenced by the anatomical
● Soft and non-musical generated primarily in the → Airway Blockage: Foreign body or tumor structures between the site of sound
Lung Sound
● Low pitched lobar and segmental airways → Narrowing in obstructive airway diseases generation and the site of auscultation
● Frequency range is narrower than tracheal ● Expiratory component come ▪ Asthma: Reversible decrease ● If there is a decrease in sound intensity:
sounds from the more proximal ▪ COPD → Most common abnormality
→ Extending from below 100 Hz to 1000 Hz, airways ▪ Pure Emphysema: Permanent decrease ● Assessed as an aggregate score with normal
with a sharp drop at approximately 100 to ● Diminished by factors affecting → Lung destruction breath sound
200 Hz the following: → Pleural Effusion ● Rules out clinically significant airway
→ Can still be detected with a sensitive → Sound Generation → Intrapulmonary Factors obstruction
microphone at 1000 Hz → Sound Transmission ▪ Harder to recognize ● Lung Auscultogram:
● Heard only on inspiration and early expiration ▪ Combination of hyperdistention and
→ Longer inspiratory phase than expiratory parenchymal destruction in emphysema
phase ▪ Pneumothorax
● Heard over the surface of the chest --> over ▪ Hemothorax
peripheral lung fields ▪ Intrapulmonary masses
● Compared to "rustling of the leaves" as the → Extrapulmonary Factors
wind blows over the trees. ▪ Obesity
● No pause appreciated between phases ▪ Chest deformities (Kyphoscoliosis)
▪ Abdominal distention (ascites)
Bronchial ● Soft and nonmusical ● Turbulent flow passes through ● Clinical Conditions: ● Retain tubular or hollow quality of the tracheal
● Generally loud and high-pitched main-stem bronchi → Lung Consolidation breath sounds
Breathing
● Intermediate between tracheal and normal ▪ Pneumonia ● Lung Auscultogram:
breathing → Lung Fibrosis
● Heard on both phases of respiratory cycle
→ Mimics tracheal sounds ● Clinical Correlations:
→ Expiratory phase is usually longer → Indicates patent airway surrounded by
(Strong expiratory component) consolidated lung tissue (e.g. pneumonia)
● Heard best over the upper manubrium or fibrosis
● Pause is also appreciated between phases → Corresponds to the air bronchogram on
chest radiographs

MED.3.08 TBL: Lung Sounds 23 of 26

Broncho- ● Similar to bronchial breath sounds and ● Generated by turbulent flow ● Lung Auscultogram:
normal (vesicular) lung sounds from the large airways like the
vesicular
● Best heard at the 1st and 2nd intercostal tracheal breath sounds and
Sound spaces carries no special clinical
→ Anteriorly and posteriorly between the meaning dissimilar to tracheal
scapulas sounds

Stridor ● Musical and high-pitched ● Produced as turbulent flow ● Clinical Conditions: ● When heard on the ff:
● May be heard: passes through a narrowed → Acute Epiglottitis → Inspiration: EXRA-thoracic Lesions
→ Over the upper airways or segment of the upper → Airway Edema after device removal → Expiration: INTRA-thoracic Lesions
● Often intense respiratory tract → Anaphylaxis → Biphasic: FIXED Lesions
→ Clearly heard without the aid of a → Inhalation of a foreign body ● Difference from wheeze:
stethoscope → Thyroiditis → More clearly heard on inspiration than on
● Sound Analysis: Regular, sinusoidal expiration
→ Tracheal carcinoma
oscillations with a frequency of ▪ It is usually inspiratory, but it can also be
● Clinical Correlations: Upper airway
approximately 500 Hz, often accompanied obstruction associated with the ff: expiratory or biphasic
by several harmonics → More prominent over the neck than over the
→ Extrathroacic Lesions
chest
▪ Laryngomalacia
▪ Vocal Cord Lesion
▪ Lesion after extubation
→ Intrathoracic Lesions
▪ Tracheomalacia
▪ Bronchomalacia
▪ Extrinsic Compression
→ Fixed Lesions
▪ Croup
▪ Paralysis of both vocal cords
▪ Laryngeal Mass or Web
Wheeze ● Most easily recognized adventitious sound ● Formed in the branches ● Clinical Conditions: ● Degree of airflow limitation is proportional to
● Musical and high-pitched between the 2nd and 7th → Localized Wheeze number of airway generating wheezes
→ Higher pitch and greater intensity than generations of the airway tree ▪ Obstruction by a foreign body ● May be absent if airway is too low
rhonchi → By the coupled oscillation ▪ Mucous plug ● Lung Auscultogram: Sine wave with smooth
● Heard on inspiration, expiration, or both of gas and airway walls that ▪ Tumor edges
● Frequency ranges from 100-1000 Hz have been narrowed to the ▪ Patients often receive a misdiagnosis of → Thickness emphasizes louder sounds
● Long duration (more than 100 msec) point of apposition by a → Pitch is approximated by the angles
“difficult-to-treat asthma”
→ Can be discerned by human ear variety of mechanical
● Clinical Correlations:
● Sound Analysis: Sinusoidal oscillations forces
→ May be absent in patients with severe
with sound energy in the range of 100 to ● 2 Principles:
airway obstruction
1000 Hz and with harmonics that exceed → Although wheezes are
→ Airway narrowing or blockage (when
1000 Hz on occasion always associated with
localized):
airflow limitation, airflow
can be limited in the ▪ Foreign Body
absence of wheezes ▪ Tumor
→ Pitch of an individual → Generalized airway narrowing & airflow
wheeze is determined by: limitation (when widespread):
▪ Thickness of the airway ▪ Asthma
wall ▪ COPD
▪ Bending Stiffness → Airflow is too low:
▪ Longitudinal Tension ▪ Severe Asthma
▪ Destructive Emphysema
▪ NOT pathognomonic of any particular
disease

MED.3.08 TBL: Lung Sounds 24 of 26

Rhoncus ● Variant of the wheeze ● Share the same mechanism of ● Clinical Conditions: ● Non-specific
● Musical and low-pitched generation with wheeze ● Airway narrowing caused by either of the ff: ● Lung Auscultogram: Wave with sharp
→ Lower in pitch than wheeze (typically → Unlike the wheeze, it may → Mucosal thickening pointed edges
near 150 Hz) disappear after coughing → Edema
● Similar to snoring or "moaning" quality on ▪ Suggests that secretions → Bronchospasm
auscultation play a role in larger ▪ Bronchitis
● Heard on inspiration, expiration, or both airways ▪ COPD
● Lower in pitch <300 Hz ● Clinical Correlations:
→ Associated with rupture of fluid films &
abnormal airway collapsibility

Fine Crackle ● Non-musical, short, and explosive ● Produced by sudden opening ● Associated with the ff: ● Unaffected by cough
● Higher in pitch of partly or completely → Interstitial Lung Fibrosis ● Gravity-dependent
● Heard on mid-to-late inspiration collapsed small airways or → Congestive Heart Failure ● Not transmitted to mouth
→ Occasionally on expiration alveoli as one gasps for air → Pneumonia ● Unrelated to secretions
● Like velcro materials are pulled apart or during inspiration ● Earliest sign of the ff: ● Lung Auscultogram: Small solid dots
lock of hair is rubbed between fingers → Idiopathic Pulmonary
● May ppear first in the basal areas of the ▪ Typically prominent but not
lungs and progress to the upper zone pathognomonic
→ Fibrosis
→ Asbestosis
● Clinical Correlations:
→ Early sign of pulmonary impairment
▪ Present before found in radiology
→ Minimal or absent in sarcoidosis
▪ Primarily affects the central lung zones
not abutting to the pleura
Coarse ● Non-musical, short, and explosive ● Gurgling sound most often ● Clinical Conditions: ● Affected by cough
● Usually louder caused by air bubbling through → Chronic Bronchitis ● Transmitted to mouth
Crackle
● Lower in pitch and gurgling quality airway secretion as air flows → Common in obstructive lung diseases ● Lung Auscultogram: Open circles like bubbles
compared to fine crackles during respiration ▪ COPD → Signify the bubbling or gurgling sound
● Heard on early inspiration and throughout → Indicates intermittent ▪ Bronchiectasis produced
expiration airway opening ▪ Asthma
● Heard over any lung region → Often heard in:
● Gurgling or "popping" quality ▪ Pneumonia
▪ Congestive Heart Failure
● Clinical Correlations:
→ Usually in association with wheezes

Pleural ● Non-musical and explosive ● Probably produced by the ● Clinical Conditions: ● Upper regions lie on the flat portion of the
Friction Rub ● Usually biphasic sounds sudden release of tangential → Inflammatory Diseases static pressure- volume curve
● More prominent on auscultation of the energy from a lung surface ▪ Pleuritis ● Basal regions lie on the steep portion of the
basal and axillary regions than the upper that is temporarily prevented → Malignant pleural Diseases curve and undergoes greater expansion in
regions from sliding because of friction ▪ Mesothelioma changing transpulmonary pressure
● Typically biphasic between the two pleural layers ● Lung Auscultogram: small open circles with
→ Expiratory sequence of sounds ● In lung diseases, the visceral cross markings
mirroring the inspiratory sequence pleura becomes rough
● Sound Analysis: Waveform is similar to enough that it produces
crackles except for its longer duration and crackling sounds heard as a
lower frequency friction rub
→ Normally, the parietal and
visceral pleura slide over
each other silently

MED.3.08 TBL: Lung Sounds 25 of 26

Squawk ● Mixed sound that contains: ● Not entirely known ● Clinical Conditions: ● Also called "short wheeze"
→ Short musical components → According to one theory, → Hypersensitivity Pneumonia (NOT ● Associated with conditions affecting distal
→ Nonmusical components produced by oscillation of pathognomonic) airways
▪ Accompanied/preceded by fine the peripheral airways (in → Other Types of Interstitial Lung Disease ● Lung Auscultogram: Thin smooth wavy line
crackles deflated lung zones) whose ▪ In patients who are not acutely ill proceeded by small dots
● Sound Analysis in Hypersensitivity walls remain in apposition → Bronchiectasis
Pneumonitis: Sinusoidal oscillations that long enough to oscillate → Pneumonia
are less than 200 msec with a fundamental under the action of the ▪ In patients who are acutely ill
frequency between 200-300 Hz inspiratory airflow ▪ Mostlikely the next cause if there is no
● Typically heard from the middle to the end evidence of interstitial disease
of inspiration
→ Interstitial diseases, especially
hypersensitivity pneumonitis

Table 4. Amplitude-Time Plot of Respiratory Sounds taken from Fundamentals of Lung Auscultation by Bohadna et. al.

Table 5. TWG3 and TEG4 Assignment

TWG Member Assignment TEG Member
Roque, Jannine I.A. Breath Sounds - I.C. Tracheal Deviation Rosales, Miguel
Sangalang, Darrell I.D. Percussion Notes - G. Case Samples Sosa, Kyron
Teamchai, Inah II. Fundamentals of Lung Auscultation Sto. Domingo, Margareth
Uy, Nicole III. Individual/Team Readiness Assessment Test Uaje, Bea
Ventura, Kristiane IV. Team Application (tAPP) Case Studies Yumul, Rica
Edited by:
Torres, CD
Umali, JF

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