The Breath Sounds: Intensity (Or Loudness)

The breath sounds
Breath sounds have intensity and quality

The intensity (or loudness) of the sounds may be normal, reduced or
increased.
The quality of normal breath sounds is described as vesicular
Breath sounds will be normal in intensity when the lung is inflating

normally,
may be reduced if there is localized airway narrowing, if the lung is
extensively damaged by a process such as emphysema, or if there is
intervening pleural thickening or pleural fluid
Breath sounds may be of increased intensity in very thin subjects.
Breath sounds probably originate from turbulent airflow in the larger
airways. When you place your stethoscope upon the chest, you are
listening to how those sounds have been changed on their journey from
their site of origin to the position of your stethoscope diaphragm.
Normal lung tissue makes the sound quieter, and selectively filters
out some of the higher frequencies. The resulting sound that you
hear is called a vesicular breath sound. There is usually no distinct
pause between the end of inspiration and the beginning of
expiration.
Box 6.7 Points to note on auscultation of the chest
 Vesicular breath sounds
 Bronchial breath sounds
 Vocal fremitus and resonance
o whispering pectoriloquy
o aegophony
 Added sounds
o pleural rub
o wheezes
o crackles
When the area underlying the stethoscope is airless, as in

consolidation, the sounds generated in the large airways are transmitted
more efficiently, so they are louder and there is less filtering of the
high frequencies. The resulting sounds heard by the stethoscope are
termed bronchial breathing, classically heard over an area of
consolidated lung in cases of pneumonia. The sound resembles that
obtained by listening over the trachea, although the noise there is
much louder. The quality of the sound is rather harsh, the higher
frequencies being heard more clearly. The expiratory sound has a
more sibilant (hissing) character than the inspiratory one, and lasts
for most of the expiratory phase.
The intensity and quality of all breath sounds is so variable from patient
to patient and in different situations that it is only by repeated
auscultation of the chests of many patients that one becomes familiar
with the normal variations and learns to recognize the abnormalities.
Added sounds
Added sounds are abnormal sounds that arise in the lung itself or in the
pleura. The added sounds most commonly arising in the lung are best
referred to as wheezes and crackles. Older terms such as râles to
describe coarse crackles, crepitations to describe fine crackles, and
rhonchi to describe wheezes are poorly defined, have led to confusion
and are best avoided.
Wheezes are musical sounds associated with airway narrowing.
Widespread polyphonic wheezes, particularly heard in expiration, are the
most common and are characteristic of diffuse airflow obstruction,
especially in asthma and COPD. These wheezes are probably related to
dynamic compression of the bronchi, which is accentuated in expiration
when airway narrowing is present. A fixed monophonic wheeze can be
generated by localized narrowing of a single bronchus, as may occur in
the presence of a tumour or foreign body. It may be inspiratory or
expiratory, or both, and may change its intensity in different positions.
Wheezing generated in smaller airways should not be mistaken for
stridor associated with laryngeal disease or localized narrowing of the
trachea or the large airways. Stridor almost always indicates a serious
condition requiring urgent investigation and management. The noise is
often both inspiratory and expiratory. It may be heard at the open mouth
without the aid of the stethoscope. On auscultation of the chest, stridor is
usually loudest over the trachea.
Crackles are short, explosive sounds often described as bubbling or
clicking. When the large airways are full of sputum, a coarse rattling
sound may be heard even without the stethoscope. However, crackles
are not usually produced by moistness in the lungs. It is more likely that
they are produced by sudden changes in gas pressure related to the
sudden opening of previously closed small airways. Crackles at the
beginning of inspiration are common in patients with chronic obstructive
pulmonary disease. Localized loud and coarse crackles may indicate an
area of bronchiectasis. Crackles are also heard in pulmonary oedema. In
diffuse interstitial fibrosis, crackles are characteristically fine in
character and late inspiratory in timing.
The pleural rub is characteristic of pleural inflammation and usually
occurs in association with pleuritic pain. It has a creaking or rubbing
character and in some instances can be felt with the palpating hand as
well as being audible with the stethoscope.
Take care to exclude false added sounds. Sounds resembling pleural rubs
may be produced by movement of the stethoscope on the patient's skin
or of clothes against the stethoscope tubing. Sounds arising in the
patient's muscles may resemble added sounds: in particular, the
shivering of a cold patient makes any attempt at auscultation almost
useless. The stethoscope rubbing over hairy skin may produce sounds
that resemble fine crackles.
Vocal resonance
You will note from the above that when listening to the breath sounds
you are detecting - with your stethoscope - vibrations that have been
made in the large airways. Vocal resonance is the resonance in the chest
of sounds made by the voice. When testing vocal resonance, you are
detecting vibrations transmitted to the chest from the vocal cords as the
patient repeats a phrase, usually the words 'ninety-nine'. The ear
perceives not the distinct syllables but a resonant sound, the intensity of
which depends on the loudness and depth of the patient's voice and the
conductivity of the lungs. As always in examining the chest, each point
examined on one side should be compared at once with the
corresponding point on the other side.
Not surprisingly, conditions that increase or reduce conduction of the
breath sounds to the stethoscope have similar effects on the vocal
resonance. Consolidated lung conducts sounds better than air-containing
lung, so in consolidation the vocal resonance is increased and the sounds
are louder and often clearer. In such circumstances, even when the
patient whispers a phrase (e.g. 'one, two, three') the sounds may be heard
clearly; this is known as whispering pectoriloquy. Above the level of a
pleural effusion, or in some cases over an area of consolidation, the
voice may sound nasal or bleating; this is known as aegophony, but is an
unusual physical finding.
Vocal fremitus
Vocal fremitus is detected with the hand on the chest wall. It should
therefore perhaps be regarded as part of palpation, but it is usually
carried out after auscultation (see below). As with vocal resonance, the
patient is asked to repeat a phrase such as 'ninety-nine'. The examining
hand feels distinct vibrations when this is done. Some examiners use the
ulnar border of the hand, but there is no good reason for this: the flat of
the hand, including the fingertips, is far more sensitive.
From the above, it should be clear that listening to the breath sounds,
listening to the vocal resonance and eliciting vocal fremitus are all doing
essentially the same thing: they are investigating how vibrations
generated in the larynx or large airways are transmitted to the examining
instrument - the stethoscope in the first two cases and the fingers in the
third. It follows that in the various pathological situations, all three
physical signs should behave in similar ways. Where there is
consolidation, the breath sounds are better transmitted to the
stethoscope, so they are louder and there is less attenuation of the higher
frequencies - 'bronchial breathing' is heard. Similarly, the vocal
resonance and the vocal fremitus are increased. Where there is a pleural
effusion, the breath sounds are quieter or absent and the vocal resonance
and vocal fremitus are reduced.
The intelligent student should now ask: 'Why try and elicit all three
signs?'. The experienced physician will answer: 'Because it is often
difficult to interpret the signs that have been elicited'.
Breath Sounds (Lung Sounds). Learn to identify patterns of breath sounds

by their intensity, their pitch, and the relative duration of their inspiratory
and expiratory phases. Normal breath sounds are:
●◗ Vesicular, or soft and low pitched. They are heard through inspiration,
continue without pause through expiration, and then fade away about , p. 328.
●◗Bronchovesicular, with inspiratory and expiratory sounds

about equal in
length, at times separated by a silent interval. Detecting
differences in
pitch and intensity is often easier during expiration.
●◗ Bronchial, or louder, harsher and higher in pitch, with a
short silence
between inspiratory and expiratory sounds. Expiratory
sounds last longer
than inspiratory sounds.
The characteristics of these three kinds of breath sounds are
summarized
below. Also shown are the tracheal breath sounds—very
loud, harsh sounds
that are heard by listening over the trachea in the neck.

The Breath Sounds: Intensity (Or Loudness)

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The breath sounds

Breath sounds have intensity and quality

Breath sounds will be normal in intensity when the lung is inflating

When the area underlying the stethoscope is airless, as in

Breath Sounds (Lung Sounds). Learn to identify patterns of breath sounds

●◗Bronchovesicular, with inspiratory and expiratory sounds

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