Nova Zhang
Listening to breath sounds is a critical skill for EMTs, paramedics, and students, as it can help identify abnormal lung sounds. Auscultation, or listening with a stethoscope, is part of every patient assessment, especially in cases of respiratory illness. Normal breath sounds include bronchial, vesicular, or bronchovesicular sounds, while abnormal or adventitious sounds include crackles, rhonchi, wheezes, stridor, and rubs. Learning to differentiate these sounds can be challenging, especially in chaotic prehospital environments, but online resources, audio recordings, and practice can help EMTs and paramedics improve their listening skills and gain confidence in identifying abnormal lung sounds.
| Characteristics | Values |
|---|---|
| Breath sounds | Vesicular, bronchial, bronchovesicular, adventitious |
| Adventitious breath sounds | Crackles, rhonchi, wheezes, stridor, rubs |
| Vesicular sounds | Low to moderate sound intensity, low pitch (200-600 Hz), rustling quality |
| Bronchial breath sounds | Hollow, tubular, higher pitch than vesicular sounds |
| Wheezes | Continuous with a musical quality, high or low pitch |
| Wheezes caused by | Secretions, obstructions, tumors, airway compression |
| Auscultation | Use stethoscope diaphragm, place on bare skin |
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What You'll Learn
How to use a stethoscope
To listen to breath sounds, a healthcare professional will use a stethoscope, a medical instrument designed to listen to the internal sounds of the body. The stethoscope has two sides: the diaphragm, which is the larger, flat side, used to hear high-pitched sounds; and the bell, which is cone-shaped and used to hear low-pitched sounds.
Auscultation is the term for the technique of using a stethoscope to listen to the body's internal sounds. It is usually performed in a quiet, warm, and private environment. The patient will be asked to sit upright and take deep breaths through their mouth. The healthcare provider will place the stethoscope on the patient's chest, starting at the front, and listen to the breath sounds, moving the stethoscope down and comparing the sounds of each lung. The provider will then place the stethoscope on the patient's back and repeat the process, listening to one complete breath cycle at each site. They will compare the sounds between the front and back of the lungs.
When listening to breath sounds, the healthcare provider will assess the quality, volume, timing, and pitch of the sounds. They will also listen for any abnormal sounds, such as wheezing, which can indicate narrowed airways, or rales, which are small clicking or bubbling sounds believed to be caused by air opening closed air spaces.
Auscultation can also be used to listen to the sounds of the heart, arteries, and abdomen. To listen to the heart, the stethoscope is placed at different points corresponding to the heart valves. To listen to the abdomen, the patient lies down, and the provider places the stethoscope on the abdomen to listen to the sounds of the bowels.
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Normal breath sounds
Vesicular sounds are the most common auscultated sounds, usually heard over most of the chest wall. These sounds are low to moderate in intensity (volume) with a low pitch (200-600 Hz) and a rustling quality. During expiration, the sound intensity can diminish. The inspiration to expiration (I:E) ratio is typically 3 to 1. Vesicular sounds are soft, low-pitched, predominantly inspiratory, and are appreciated especially well at the posterior lung bases. They are normally heard over most of the peripheral lung fields and are well-appreciated over most of the lung fields.
Bronchial sounds (also called tubular sounds) normally arise from the tracheobronchial tree. They are loud, harsh, and high-pitched, and are typically heard over the trachea or at the right apex. They are predominantly heard during expiration. If heard in other areas of the lung, bronchial sounds are abnormal.
Bronchovesicular sounds are heard between the 1st and 2nd interspaces on the anterior chest. They are medium-pitched and are heard over the mainstream bronchi, between the scapulae, and below the clavicles.
Breath sound intensity can be graded on a 0-4 scale (zero being none, one being barely audible, two being diminished, three being normal, and four being louder than normal). The intensity of vesicular breath sounds can indicate pathology. Greater intensity of breath sounds correlates with more profound ventilation, while quieter breath sounds can indicate decreased ventilation and the worsening of a disease such as asthma.
In a normal air-filled lung, breath sounds are smooth and soft.
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Abnormal breath sounds
Rhonchi, or continuous, low-pitched sounds, are often heard when a person is breathing out, and the sound may move around the chest when the patient coughs. This sound is sometimes described as snoring or gurgling and can be caused by mucus in the airways. A pleural rub, on the other hand, is a rough, grating sound caused by the lining of the lungs rubbing against each other. This can be heard during inhalation and exhalation and may be caused by inflammation of the pleura.
Other causes of abnormal lung sounds include respiratory infections such as bronchitis or croup, especially in children, as well as chronic obstructive pulmonary disease (COPD), cystic fibrosis, anaphylaxis, pulmonary edema, and interstitial lung disease. It is important to note that a diagnosis cannot be made based solely on lung sounds, and a healthcare provider will consider other symptoms, health history, and additional tests to determine the underlying cause of abnormal breath sounds.
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Lung auscultation guides
Lung auscultation is a technique used by healthcare professionals to listen to the internal sounds of the body, such as the heart, lungs, and bowel sounds. It is performed by placing a stethoscope on the body at different locations corresponding to various organs. The diaphragm of the stethoscope is used for auscultating breath sounds.
To optimise the effectiveness of lung auscultation, the environment should be quiet, warm, and well-lit. The patient should ideally be sitting, and their upper body should be exposed. The examiner should listen to at least one ventilatory cycle at each position of the chest wall, beginning at the top and working towards the lung bases, comparing both sides.
Normal breath sounds include bronchial, bronchovesicular, and vesicular lung sounds. Vesicular sounds are the most common and are usually heard over most of the chest wall. They are low to moderate in sound intensity with a low pitch (200-600 Hz) and a rustling quality. During expiration, the sound intensity can diminish. Bronchial breath sounds, on the other hand, are hollow and tubular, higher-pitched than vesicular sounds, and can be auscultated over the trachea and along the sternum.
Adventitious or abnormal sounds include crackles, rhonchi, wheezes, stridor, and rubs. Crackles are caused by conditions such as bronchitis, asthma, heart failure, or pneumonia, and they indicate excessive fluid on the lungs. Wheezes are caused by forced airflow through collapsed or narrowed airways and are associated with secretions, obstructions, tumors, or airway compression. They are continuous sounds with a musical quality and are heard more frequently on expiration. Pleural rubs produce a creaking or brushing sound and indicate inflammation of the pleural surfaces.
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Tips for EMTs and paramedics
It is important to be able to identify lung sounds as they can give clues as to what is happening with the patient during a respiratory emergency. EMTs and paramedics are expected to auscultate a patient's blood pressure and listen to lung sounds as part of a respiratory illness physical exam.
When using a stethoscope, ensure that the ear tubes and ear tips are inserted correctly, with the tubes angled towards the user's nose. The diaphragm of the stethoscope should be placed on the patient's bare skin, held firmly enough that it doesn't slide around but not so firmly that it presses into the patient's tissue. Reduce any ambient noise and use verbal direction and body language to quieten those around you.
Start by listening to the patient's back, as this is where you will hear the best lung sounds. Listen in three locations: the apex of each lung (right above the clavicle), the mid lung (mid-sternal), and at the bases (roughly at the level of the xiphoid process).
Listen for normal breath sounds, such as bronchial, vesicular, or bronchovesicular sounds, and abnormal adventitious sounds, which can include crackles, rhonchi, wheezes, stridor, and rubs. Vesicular sounds are the most common and are usually heard over most of the chest wall. They are low to moderate in sound intensity with a low pitch and a rustling quality. Bronchial breath sounds, in contrast, are hollow and tubular, higher-pitched than vesicular sounds, and can be heard over the trachea and anteriorly along each side of the sternum. Wheezes are continuous sounds with a musical quality, and their pitch indicates the degree of airway obstruction. Rhonchi are low-pitched, coarse, and rattling, and can indicate airway obstruction or inflammation in the larger air passages of the lungs. Stridor is a high-pitched, harsh-sounding whistle that indicates upper airway obstruction.
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Frequently asked questions
Breath sounds refer to the noises produced by air moving through the lungs and airways. These sounds can be auscultated, or listened to, using a stethoscope.
Normal breath sounds include bronchial, vesicular, and bronchovesicular sounds. Vesicular sounds are the most common and are usually heard over most of the chest wall. They are low to moderate in volume with a low pitch and a rustling quality. Bronchial breath sounds, on the other hand, are hollow and tubular, with a higher pitch.
Listening to breath sounds is a skill that can be developed over time. Here are a few tips to improve your ability to listen to breath sounds:
- Practice on yourself, your family, and anyone else you can—learn what normal sounds like so you can identify abnormal sounds.
- Use a high-quality stethoscope and ensure it is placed correctly on the patient's bare skin.
- Visualize the anatomical locations of the lungs and focus on the correct areas.
- Quiet your mind and body, and try to tune out distractions.
- Listen to a variety of audio recordings and lessons on lung sounds to familiarize yourself with different types of breath sounds.
