Which finding would the nurse document as normal after Auscultating a toddlers chest for breath sounds?

Breath sounds are the noises produced by the structures of the lungs during breathing.

The lung sounds are best heard with a stethoscope. This is called auscultation.

Normal lung sounds occur in all parts of the chest area, including above the collarbones and at the bottom of the rib cage.

Using a stethoscope, the health care provider may hear normal breathing sounds, decreased or absent breath sounds, and abnormal breath sounds.

Absent or decreased sounds can mean:

• Air or fluid in or around the lungs (such as pneumonia, heart failure, and pleural effusion)
• Increased thickness of the chest wall
• Over-inflation of a part of the lungs (emphysema can cause this)
• Reduced airflow to part of the lungs

There are several types of abnormal breath sounds. The four most common are:

• Rales. Small clicking, bubbling, or rattling sounds in the lungs. They are heard when a person breathes in (inhales). They are believed to occur when air opens closed air spaces. Rales can be further described as moist, dry, fine, and course.
• Rhonchi. Sounds that resemble snoring. They occur when air is blocked or air flow becomes rough through the large airways.
• Stridor. Wheeze-like sound heard when a person breathes. Usually it is due to a blockage of airflow in the windpipe (trachea) or in the back of the throat.
• Wheezing. High-pitched sounds produced by narrowed airways. They are most often heard when a person breathes out (exhales). Wheezing and other abnormal sounds can sometimes be heard without a stethoscope.

Seek immediate medical care if you have:

• Cyanosis (bluish discoloration of the skin)
• Nasal flaring
• Severe trouble breathing or shortness of breath

Contact your provider if you have wheezing or other abnormal breathing sounds.

Your provider will do a physical exam and ask you questions about your medical history and your breathing.

Questions may include:

• When did the breath sound start?
• How long did it last?
• How would you describe your breathing?
• What makes it better or worse?
• What other symptoms do you have?

The provider usually discovers abnormal breath sounds. You may not even notice them.

The following tests may be done:

• Analysis of a sputum sample (sputum culture, sputum Gram stain)
• Blood tests (including an arterial blood gas)
• Chest x-ray
• CT scan of the chest
• Pulmonary function tests
• Pulse oximetry

Lung sounds; Breathing sounds

Ball JW, Dains JE, Flynn JA, Solomon BS, Stewart RW. Chest and lungs. In: Ball JW, Dains JE, Flynn JA, Solomon BS, Stewart RW, eds. Siedel's Guide to Physical Examination. 9th ed. St Louis, MO: Elsevier; 2019:chap 14.

Kraft M. Approach to the patient with respiratory disease. In: Goldman L, Schafer AI, eds. Goldman-Cecil Medicine. 26th ed. Philadelphia, PA: Elsevier ; 2020:chap 77.

Updated by: David C. Dugdale, III, MD, Professor of Medicine, Division of General Medicine, Department of Medicine, University of Washington School of Medicine, Seattle, WA. Also reviewed by David Zieve, MD, MHA, Medical Director, Brenda Conaway, Editorial Director, and the A.D.A.M. Editorial team.

Introduction

The clinical examination of the lungs is part of almost any physical examination. Due to the close relationship with nearby structures such as the heart, great vessels, esophagus, and diaphragm, a careful examination of the lungs can provide clues towards a diagnosis.

The airway is derived from the embryonic foregut and is divided into the trachea, bronchi, bronchioles, and lungs. Although humans have two lungs they are not symmetrical: the right lung is bigger than the left. The right lung is composed of three lobes, and ten segments and the left lung consists of two lobes and nine segments. The segmental division of the lungs is based on their airway supply.[1][2][3]

The physical examination of the chest is composed of inspection, palpation, percussion, and auscultation. Although it is not unheard of clinicians skipping the first three steps of the chest auscultation important information can be derived from a complete lung examination.

Issues of Concern

Inspection

During the inspection, the examiner should pay attention to the pattern of breathing: thoracic breathing, thoracoabdominal breathing, costal markings, and use of accessory breathing muscles. The use of accessory breathing muscles (i.e., scalenes, sternocleidomastoid muscle, intercostal muscles) could point to excessive breathing effort caused by pathologies. The body habitus of the patient could provide information regarding chest compliance, especially in the case of severely obese patients were chest mobility, and compliance are reduced due to added weight from adipose tissue.

The position of the patient should also be noted, patients with extreme pulmonary dysfunction will often sit up-right, and in distress, they assume the tripod position (leaning forward, resting their hands on their knees).

Breathing through pursed lips, often seen in cases of emphysema.

Ability to speak: patients that are unable to speak or become short of breath during the interview are likely to have a worse pulmonary function or reserve. 

Skeletal chest abnormalities should also be noted during the inspection. The most common chest osseous abnormality is pectus excavatum where the sternum is depressed in to the chest cavity. Pectus carinatum is the exact opposite of pectus excavatum: in this anatomical abnormality, the sternum is protruding from the chest wall. Barrel chest could also be present which consists in increased anterior-posterior diameter of the chest wall and is a normal finding in children, but it is suggestive of hyperinflation with chronic obstructive pulmonary disease (COPD) in adults. Thoracic spine abnormalities such as kyphosis and scoliosis could also be noted during physical examination of the chest.

Palpation

Palpation should focus on detecting abnormalities like masses or bony crepitus. During palpation the examiner can evaluate tactile fremitus: the examiner will place both of his hands on the patient's back, medial to the shoulder blades, and ask the patient to say "ninety-nine." An increase in the tactile fremitus points towards an increased intraparenchymal density and a decreased fremitus hints towards a pleural process that separates the pleura from the parenchyma (pleural effusion, pneumothorax). Of note, the fremitus can also be auscultated and can be referred to as vocal fremitus.

Auscultation

Auscultation of the lungs should be systematic and follow a stepwise approach in which the examiner surveys all the lung zones. For practical purposes, the lung can be divided into apical, middle and basilar regions during auscultation. The description of abnormal breathing sounds should be tagged with the location in which it was heard.

The movement of air generates normal breath sounds through the large and small airways. Normal breath sounds have a frequency of approximately 100 Hz. The absence of breath sounds should prompt the health care provider to consider shallow breath, abnormal anatomy or pathologic entities such as airway obstruction, bulla, hyperinflation, pneumothorax, pleural effusion or thickening, and obesity.

Tubular breath sounds are high pitched, bronchial breath sounds, seen in the following conditions: consolidation, pleural effusion, pulmonary fibrosis, distal collapse, and mediastinal tumor over a large patent bronchus.

• Vesicular breath sounds/normal breath sounds: While Laënnec considered normal lung sounds to originate from the flow of air in and out of alveoli, later investigations of the origin of respiratory sounds have not shown lung “vesicles” to participate in sound generation. Therefore, vesicular breath sounds is a misnomer for normal breath sounds.

• Wheezes: High-pitched continuous sounds with a dominant frequency of 400 Hz or more. (ATS) Suggestive of asthma, COPD, airway obstruction, or mucus plug.

• Ronchi: Low-pitched continuous musical sounds with a dominant frequency of about 200 Hz or less (ATS).

• Crackles: A "popping" sound generated by the passage of air through the accumulated secretions within the large and medium-size airways, creating the bubbling sounds (brief, non-musical, “discontinuous” sounds). Seen in COPD, Pneumonia and Heart Failure.

• Pleural Rub: Occurs due to inflamed pleural surface rubbing each other during breathing. It is difficult to differentiate from fine crackles, but the sound is similar to rubbing your stethoscope against cotton.

• Stridor: A loud, high-pitched, musical sound produced by upper respiratory tract obstruction. It indicates an extrathoracic upper airway obstruction (supraglottic lesions like laryngomalacia, vocal cord lesion) when heard on inspiration. It occurs in expiration if associated with intrathoracic tracheobronchial lesions (tracheomalacia, bronchomalacia, and extrinsic compression). It occurs in both phases if a lesion is fixed, for example, stenosis.

Special Maneuvers

• Pectoriloquy - Ask the patient to whisper a word such as “one-two-three” or “ninety-nine” and listen with a stethoscope. Typically, words are heard faintly. In cases of consolidation, the whispered sounds will be heard clearly and distinctly.

• Egophony is elicited by asking the patient to say  "Ee," and it will sound like an "A." Suggestive of consolidation or pleural effusion. 

Clinical Significance

While an array of more elaborate and expensive technologies for the diagnosis of chest diseases has emerged over time, auscultation of the lung still provides valuable, immediate and low-cost information to the experienced clinician. Lung sounds can be divided primarily into continuous sounds "wheezes," and interrupted (discontinuous) sounds  "crackles." Wheezes are musical, and crackles are not. No lung sound is pathognomonic for any specific disease or anatomical site.[4][5]

A good mnemonic to aid in the memorization of the lung exam steps is PIPPA:

• Positioning of the patient

• Inspection

• Palpation

• Percussion

• Auscultation

References

Zimmerman B, Williams D. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Aug 30, 2021. Lung Sounds. [PubMed: 30725938]

Owen KN, Goldstein S. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Sep 20, 2021. EMS Clinical Diagnosis Without The Use Of A Thermometer. [PubMed: 29262152]

Bornemann P, Jayasekera N, Bergman K, Ramos M, Gerhart J. Point-of-care ultrasound: Coming soon to primary care? J Fam Pract. 2018 Feb;67(2):70-80. [PubMed: 29400896]

Gillman LM, Kirkpatrick AW. Portable bedside ultrasound: the visual stethoscope of the 21st century. Scand J Trauma Resusc Emerg Med. 2012 Mar 09;20:18. [PMC free article: PMC3352312] [PubMed: 22400903]

Makoul G, Altman M. Early assessment of medical students' clinical skills. Acad Med. 2002 Nov;77(11):1156. [PubMed: 12431933]

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