Auscultation of lung sounds and

murmurs
R. Beňačka, MD, PhD
 
Aim: To gain basic practical experiences and
theoretical knowledge in auscultation of lung
sounds and murmurs in preclinical training.
 
Methods: 1) For training of auscultations
skills the model simulator is used  (The Life /
Form Auscultation Trainer and
Smartscope simulator. The system is
equipped with a the torso of the chest of an
adult man figurine, wireless programmable
unite containing with a set of pre-
programmable respiratory and cardiac sound
phenomena and special stethoscope with
sound generator producing sounds in
a stethoscope bell. When the bell is being
moved over the particular auscultatory points,
the place – specific sounds are heard. A map
showing these typical auscultatory sites for
both respiratory and cardiac sounds is also
available with the simulator and is of
beneficial use. The points are also noted by
colors spots on the surface of figurine in order
to help in navigation. If the stethoscope bell is
placed outside the usual auscultation points
no sound can be heard. 2) Students perform
listening in within groups one after another. In
the beginning the auscultation for one or more
sounds is demonstrated by the teacher. After
setting of the sound in program unite teacher
uses stethoscope to hear the sounds  when
mover over specific points on figurine while
students can hear the sounds through the
speaker. After then, each trial being
separated by sufficient disinfection of the
olives in the stethoscope, students can train
listening of selected phenomena themselves,
----------------------------------------------------
Life/Form Auscultation Trainer and
Smartscope. (adult) (adult) Nasco (Fort
Atkinson, Wisconsin): Lung: 5, anterior, 10
posterior, and 2 midaxillary locations. Heart: 6
anterior sites. Remote controller selects heart
and lung sounds. Smartscope plays sounds
through in-stelhoscope transceiver.
Placement of stethoscope on chest activates
transponder playback of audio files. Dual
headsets and
remote speaker playback options.
 
Lung auscultation simulator    
     
A) Basic breathing sounds  (B) A
1 Normal breathing - sample Adventitios d
2 Vesicular breathing lung d
3 Bronchovesicular breathing sounds i
4 Bronchial breathing 6 Wheezes t
5 Tracheal breathing (polyphasic) i
  7 Wheezes o
  (monophonic n
8 Rhonchi a
9 Crackes l
(rales) fine s
10 Cracles o
(rales) u
coarse n
11 Stridor d
12 Pleural
friction rig s
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Breath sounds are generated by the air-flow
passing through the different parts of the
lower airways during inspiratory - expiratory
cycle and the effect of these structures on an
moving air. The pattern of normal breath
sounds is a result of a given physical
properties of lung matter the sound is
conducted though from the place it is created
towards the auscultation point. The same
phenomena  can be heard a bid differently
from different places. Sound phenomena
related to breathing can subdivided into 2
broad categories: normal lung
sounds and abnormal lung
sounds (murmurs).
 
Normal breathing sounds refer to how the
normal typical eupnoeic breathing cycle
composed of inspiration and expiration can be
heard from different locations over the chest,
provided the breathing is performed in a
normal rate and appropriate intensity (deeper
than quiet rest breathing). Sounds
are physiologically classified  as vesicular,
bronchial,  bronchovesicular  and
tracheal sounds. According to their location,
breath sounds are described by:
•      duration  (how long the sound lasts),
•      intensity (how loud the sound is),
•      pitch (how high or low the sound is),
•      timing (when the sound occurs in the
respiratory cycle).
 
Normal findings on auscultation include:
1) Soft, breezy, low-pitched vesicular breath
sounds over most of the peripheral lung
fields
2) Loud, high-pitched bronchial breath
sounds over the trachea
3) Medium pitched bronchovesicular
sounds over the mainstream bronchi,
between the scapulae, and below the clavicl
 
Normal breathing sounds    

Vesicular sounds are soft, blowing or

rustling sounds normally heard throughout
most of the lung fields. Vesicular sounds are
normally heard throughout inspiration,
continue without pause through expiration,
and then fade away about one third of the
way through expiration
 
Bronchial sounds are present over the large
airways in the anterior chest near the 2nd
and 3rd intercostal spaces, Bronchial
sounds are high in pitch, louder and
more tubular and hollow-sounding than
vesicular sounds, but not as harsh as tracheal
breath sounds. Expiratory sounds last longer
than inspiratory sounds or duration  is the
same. Intensity of inspiration and expiration is
the same. There is a short gap between
inspiration and expiration.
 
Bronchovesicular sounds are heard in the
posterior chest between the scapulae and in
the center part of the anterior chest.
Bronchovesicular sounds are softer than
bronchial sounds, but have a tubular quality.
Bronchovesicular sounds are about equal
during inspiration and expiration; differences
in pitch and intensity are often more easily
detected during expiration.
 
Tracheal breath sounds are heard over the
trachea. These sounds are harsh and sound
like air is being blown through a pipe.
In a normal air-filled lung, vesicular sounds
are heard over most of the lung fields,
bronchovesicular sounds are heard between
the 1st and 2nd interspaces on the anterior
chest, bronchial sounds are heard over the
body of the sternum, and tracheal sounds are
heard over the trachea.
 
 
   

Weezing This is the sound of wheezing when

auscultating breath or lung sounds. It can be
heard when there is an airway obstruction such
as when you listen to a patient with mild to
moderate asthma during an
exacerbation. Wheeze is mainly expiratory and
occurs during both phases..
 
Fine Crackles (aka Rales) are high pitched
sounds mostly heard in the lower lung bases.
This can be abnormal findings on physical exam
suggestive of things like congestive heart
failure, pneumonia or atelectasis.
 
Coarse Crackles are low pitched lungs sounds
heard in pathologies such as chronic bronchitis,
bronchiectasis, pneumonia, and severe
pulmonary edema. Compared to fine crackles,
they are often louder, longer in duration and
lower in pitch.
 
Squawks short inspiratory wheezes (200 ms;
200 - 300 Hz) in late inspiration often preceded
by late inspiratory crackles. Squawks are found
in: pulmonary fibrosis, pneumonitis, pneumonia,
allergic alveolitis and bronchiolitis oblite-rans.
They are produced by the oscillations of
peripheral airways in deflated lung zones
opened in late inspiration.
 
Pleural rub is nonmusical, short,. biphasic
(inspiro-expiratory)  explosive sound (grating,
rubbing, creaky, or leathery). It occurs due to
inflamed pleural surface rubbing each other
during breathing.
 
Stridor is loud, high-pitched, mainly
inspiratory,.musical sound produced by upper
respiratory tract obstruction. It is different from
wheezing:  It is louder over the neck than chest
wall. In expiration, it is biphasic. Stridor is
caused by the turbulent flow passing through a
narrowed segment of the upper respiratory
tract.
 
   
     
Note:  There are myriads of available text or
audio-visual  internet resources to increase
the knowledge output.
Below is a recommened samples of useful
sources.
 
Recommended audiovisual internet
resources – Respiration
 
1.Breathing (simple illustrated edition)
Armando Hasudungan
Mechanism of
Breathing https://youtu.be/GD-HPx_ZG8I
Control Of
Respiration https://www.youtube.com/watch?
v=9j6BpanhpKY
Respiratory gas
exchange: https://www.youtube.com/watch?
v=qDrV33rZlyA
Understanding
spirometry: https://www.youtube.com/watch?
v=YwcNbVnHNAo
Lung Function - Lung Volumes and
Capacities: https://www.youtube.com/watch?
v=9VdHhD1vcDU
Oxygen - Haemoglobin Dissociation
Curve: https://www.youtube.com/watch?
v=BYGPkRFvzOc
Respiratory System Physiology -
Ventilation and Perfusion (V:Q
Ratio)  https://www.youtube.com/watch?v=-
mL_NQ3pKnA
 
2. Auscultation if lungs

 Lung Sounds
Collection –
EMTprep   https://www.youtube.com/watch?
v=KRtAqeEGq2Q
 
Respiratory
sounds: https://en.wikipedia.org/wiki/Respirat
ory_sounds
 
A) Basic breathing souds
Vesicular Breath
Sounds:   https://youtu.be/VtnMRG0ORLs
Bronchovesicular Breath
sounds https://www.youtube.com/watch?
v=E9iNwFF6R1Y
Bronchial Breath
Sounds  https://www.youtube.com/watch?
v=WfkWMfE9VTY
 
B) Additional sounds
Wheezing
(expiratory): https://youtu.be/T4qNgi4Vrvo
Rhonchi: https://youtu.be/YgDiMpCZo0w
Fine Crackles
(Rales) : https://youtu.be/LHqqvrm2j6g
Coarse Crackles
(Rales): https://youtu.be/LHqqvrm2j6g
Stridor: https://youtu.be/YgDiMpCZo0w
Sounds of Croup
(Laryngotracheitis): https://youtu.be/C1q6A
TkMtm0