Clinicopathologic Correlations

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In addition to the normal breath sounds discussed, other lung sounds may be produced in abnormal clinical states. These abnormal sounds heard during auscultation are called adventitious sounds. Adventitious sounds include the following:

Crackles are short, discontinuous, nonmusical sounds heard mostly during inspiration. Also known as rales or crepitation, crackles are caused by the opening of collapsed distal airways and alveoli. A sudden equalization of pressure seems to result in a crackle. Coarser crackles are related to larger airways. Crackles are likened to the sound made by rubbing hair next to the ear or the sound made when Velcro patches are pulled apart. They may be described as early or late, depending on when they are heard during inspiration. The timing of common inspiratory crackles is summarized in Table 13-6. The most common causes of crackles are pulmonary edema, congestive heart failure, and pulmonary fibrosis.

Wheezes are continuous, musical, high-pitched sounds heard mostly during expiration. They are produced by airflow through narrowed bronchi. This narrowing may be caused by swelling, secretions, spasm, tumor, or foreign body. Wheezes are commonly associated with the bronchospasm of asthma.

Rhonchi are lower pitched, more sonorous lung sounds. They are believed to be more common with transient mucus plugging and poor movement of airway secretions.

A pleural rub is a grating sound produced by motion of the pleura, which is impeded by frictional resistance. It is best heard at the end of inspiration and at the beginning of expiration. The sound of a pleural rub is like the sound of creaking leather. Pleural rubs are heard when pleural surfaces are roughened or thickened by inflammatory or neoplastic cells or by fibrin deposits.

All the adventitious sounds should be described with regard to their location, timing, and intensity.

There is much confusion regarding the terminology of adventitious sounds. Table 13-7 summarizes the adventitious sounds.

On occasion, breath sounds are transmitted abnormally. This may result in auscultatory changes known by the following terms:

Whispered pectoriloquy Bronchophony

Egophony (egobronchophony) is said to be present when the spoken word heard through the lungs is increased in intensity and takes on a nasal or bleating quality. The patient is asked to say "eeee" while the examiner listens to an area in which consolidation is suspected. If egophony is present, the ''eeee'' will be heard as "aaaah" This ''e-to-a'' change is seen in consolidation of lung tissue. The area of compressed lung above a pleural effusion often produces egophony.

Whispered pectoriloquy is the term for the intensification of the whispered word heard in the presence of consolidation of the lung. The patient is instructed to whisper, ''one-two-three'' while the examiner listens to the area suspected of having consolidation. Normally, whispering produces high-pitched sounds that tend to be filtered out by the lungs. Little or nothing may be heard when the examiner listens to a normal chest. However, if consolidation is present, the transmission of the spoken words is increased, and the words are clearly heard.

Crackles Wheezes Rhonchi

Pleural rubs

Table 13-7 Adventitious Sounds

Recommended Term

Older Term

Mechanism

Causes

Crepitation

Excess airway secretions

Bronchitis, respiratory infections, pulmonary edema, atelectasis, fibrosis, congestive heart failure

Wheeze

Sibilant rale Musical rale Sonorous rale Low-pitched wheeze

Rapid airflow through obstructed airway

Asthma, pulmonary edema, bronchitis, congestive heart failure

Rhonchus

Transient airway plugging

Bronchitis

Pleural rub

Inflammation of the pleura Pneumonia, pulmonary infarction

Bronchophony is the increased transmission of spoken words heard in the presence of consolidation of the lungs. The patient is asked to say, ''ninety-nine'' while the examiner listens to the chest. If bronchophony is present, the words are transmitted more loudly than normally.

One of the most important principles concerning the examination of the chest is to correlate the findings of percussion, palpation, and auscultation. Dullness, crackles, increased breath sounds, and increased tactile fremitus are suggestive of consolidation. Dullness, decreased breath sounds, and decreased tactile fremitus are suggestive of a pleural effusion.

Many physical signs are associated with obstructive lung disease. These include impaired breath sounds, barrel chest, decreased chest expansion, impaired cardiac dullness, use of accessory muscles, absent cardiac impulse, cyanosis, and diminished diaphragmatic excursion. Although all these are important physical findings, the first three have the greatest intrinsic value as diagnostic tools.

Table 13-8 lists some of the common causes of dyspnea and their associated symptoms. Table 13-9 summarizes some important manifestations of common pulmonary conditions.

Table 13-8 Common Conditions Associated with Dyspnea

Condition Dyspnea Other Symptoms

Asthma

Pulmonary edema

Pulmonary fibrosis Pneumonia Pneumothorax Emphysema Chronic bronchitis

Episodic; symptom free between attacks

Abrupt

Progressive

Exertional, insidious onset

Sudden, moderate to severe

Insidious onset, severe

As disease progresses and with infection

Wheezing, chest pain, productive cough

Tachypnea, cough, orthopnea, and paroxysmal nocturnal dyspnea with chronic state

Tachypnea, dry cough

Productive cough, pleuritic pain

Sudden pleuritic pain

Cough as disease progresses

Chronic, productive cough

Obesity

Exertional

Table 13-9 Differentiation of Common Pulmonary Conditions

Condition

Asthma*

Emphysema

Vital Signs

Tachypnea; tachycardia

Stable

Chronic bronchitis Tachycardia

Pneumonia

Pulmonary embolism

Tachycardia; fever; tachypnea

Tachycardia; fever; tachypnea

Pulmonary edema Tachycardia;

tachypnea

Pneumothorax Tachypnea;

tachycardia

Pleural effusion

Atelectasis

Tachypnea; tachycardia

Tachypnea

Acute respiratory Tachycardia; distress tachypnea syndrome

Inspection

Dyspnea; use of accessory muscles; possible cyanosis; hyperinflation

Increased anteroposterior diameter; use of muscles; thin individual

Possible cyanosis; patients tend to be short and stocky

Possible cyanosis; possible splinting on affected side

Often normal

Possible signs of elevated right-sided heart

Palpation

Often normal; decreased fremitus

Findings

Percussion

Often normal; hyperresonant; low diaphragm pressures*

Often normal; lag on affected side

Often normal; lag on affected side

Often normal; lag on affected side

Use of accessory muscles; cyanosis

Decreased tactile fremitus

Often normal

Increased tactile fremitus

Usually normal

Often normal

Absent fremitus; trachea may be shifted to other side

Decreased fremitus; trachea shifted to other side

Decreased fremitus; trachea shifted to same side

Usually normal

Increased resonance; decreased excursion of diaphragm

Often normal

Dullness

Usually normal

Often normal

Hyperresonant

Dullness

Dullness

Often normal

Auscultation

Prolonged expiration; wheezes; decreased lung sounds

Decreased lung sounds;

decreased vocal fremitus

Early crackles; rhonchi

Late crackles; bronchial breath sounds{

Usually normal

Early crackles; wheezes

Absent breath sounds

Absent breath sounds

Absent breath sounds

Normal initially; cackles and decreased lung sounds, late

*The physical findings in asthma are often not reliable in predicting its severity. ^Bronchophony, whispered pectoriloquy, and egophony are also often present. {Elevated jugular venous distention, pedal edema, and hepatomegaly.

Useful Vocabulary

Listed here are the specific roots that are important for understanding the terminology related to diseases of the chest.

Root

Pertaining to

Example

Definition

bronch(o)-

bronchus

bronchitis

Inflammation of the bronchus

-capnia

carbon dioxide

hypercapnia

Excessive carbon dioxide in the blood

chondro-

cartilage

chrondroma

Hyperplastic growth of cartilage

costo-

ribs

costochondritis

Inflammation of the rib cartilage

muc(o)-

mucus

mucolytic

Agent that dissolves mucus

phren(o)-

diaphragm

phrenohepatic

Pertaining to the diaphragm and liver

pleur(o)-

pleura

pleuritic

Pertaining to inflammation of the pleura

-pne(o)-

breath

dyspnea

Difficulty in breathing; shortness of breath

pneumo-

lungs

pneumonectomy

Surgical removal of lung tissue

spiro-

to breathe

spirogram

A tracing of respiratory movements

-stern(o)-

sternum

costosternal

Pertaining to the ribs and sternum

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If you suffer with asthma, you will no doubt be familiar with the uncomfortable sensations as your bronchial tubes begin to narrow and your muscles around them start to tighten. A sticky mucus known as phlegm begins to produce and increase within your bronchial tubes and you begin to wheeze, cough and struggle to breathe.

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