Breath Sounds and Their Grading

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Questions and Answers

What grading scale level represents absent breath sounds?

Grade 3

Grade 0 (correct)

Grade 1

Grade 2

Which type of breath sounds is characterized by a rustling or breezy quality?

Tracheal

Bronchovesicular

Vesicular (correct)

Bronchial

Where are bronchovesicular breath sounds typically found?

Periphery of the lungs

Upper part of sternum and between scapula (correct)

Larynx and Trachea

Most areas of the chest

What is the normal inspiratory to expiratory (I:E) ratio for vesicular breath sounds?

2-3:1 Signup and view all the answers

Which type of bronchial sound is described as having a metallic quality?

Amphoric Signup and view all the answers

What is a common cause of diminished breath sound intensity?

Bronchial obstruction Signup and view all the answers

Which characteristic is true for tracheal breath sounds?

There is a pause between inspiration and expiration Signup and view all the answers

What is the typical appearance of the expiratory phase in bronchovesicular breath sounds?

Louder, longer, and higher pitched Signup and view all the answers

Which of these best describes the tubular type of bronchial breathing?

High-pitched, conducted sound without modification Signup and view all the answers

What is the cause for the production of vesicular breath sounds?

Distension and separation of alveolar walls Signup and view all the answers

What characterizes bronchophony?

Increase in loudness and clarity of sound. Signup and view all the answers

Aegophony can be observed under which condition?

Consolidation. Signup and view all the answers

What does whispering pectoriloquy indicate?

Large cavity communicating with a bronchus. Signup and view all the answers

What is the primary sign of post-tussive suction?

Indication of a superficial collapsible cavity. Signup and view all the answers

What does a succussion splash signify in terms of lung pathology?

Hydropneumothorax. Signup and view all the answers

Which feature differentiates pleural rub from crepitations?

Pleural rub increases in sound with stethoscope pressure. Signup and view all the answers

What sound is characteristic of stridor?

High-pitched whistling or grating. Signup and view all the answers

Which condition associates with tracheal rales?

Serious illness with retained respiratory secretions. Signup and view all the answers

In which condition would you expect decreased vocal resonance?

Pleural effusion. Signup and view all the answers

What is the primary feature of crepitations?

No effect with stethoscope pressure. Signup and view all the answers

What clinical condition is indicated by shifting dullness during percussion?

Hydropneumothorax Signup and view all the answers

In the context of Grocco's triangle, what characterizes its boundaries?

A curved line connecting the mid-spinal line and lower lung resonance Signup and view all the answers

Which statement best describes William's tracheal resonance?

Tympany in the first or second intercostal space near the sternum Signup and view all the answers

Wintrich's sign indicates the presence of what?

A lung cavity communicating with a bronchus Signup and view all the answers

What do Gerhardt's sign and Friedreich's sign have in common?

Both involve changes in percussion pitch due to position Signup and view all the answers

Which respiratory physiology concept explains why higher frequencies are lost in smaller airways?

Dampening effects of airway structure Signup and view all the answers

What position should a patient ideally be in for auscultation of the lower respiratory tract?

Leaning forward with arms crossed Signup and view all the answers

What is the primary clinical finding associated with Garland's triangle?

A small area of resonance adjacent to the spine Signup and view all the answers

What is recommended for a more accurate auscultation examination?

Ensure direct contact of stethoscope with skin Signup and view all the answers

What is the sound frequency range of normal breathing sounds generated in larger airways?

200-2000 Hz Signup and view all the answers

What primarily causes wheeze sounds during breathing?

Obstruction of small airways Signup and view all the answers

Which of the following characteristics is associated with rhonchi?

Low-pitched and snoring quality Signup and view all the answers

What type of wheeze is characterized by multiple tones appearing in both inspiratory and expiratory phases?

Polyphonic wheeze Signup and view all the answers

What causes the sound of crepitations during breathing?

Snapping open of small airways during airflow Signup and view all the answers

Which condition is most likely to produce fine crepitations?

Alveolitis Signup and view all the answers

What distinguishes monophonic wheezes from polyphonic wheezes?

Monophonic wheezes involve single tones from local pathology Signup and view all the answers

What type of crepitations occurs specifically during expiration?

Expiratory crepitations Signup and view all the answers

Which of the following is NOT a characteristic of discontinuous adventitious sounds?

Continuous and melodic Signup and view all the answers

How are coarse crepitations produced?

By air passing through accumulated secretions in larger airways Signup and view all the answers

Which of the following conditions is likely to present with early crepitations?

Chronic bronchitis Signup and view all the answers

Study Notes

Grading of Breath Sound Intensity

Breath sounds are graded on a scale of 0 to 4, with 0 being absent and 4 being louder than normal.

Graphical Representation of Breath Sounds

Normal breath sounds can be visualized using a graph with the upstroke representing inspiration and the downstroke representing expiration.
The length of the stroke represents the duration of the breath sound, the thickness represents the loudness, and the angle between the upstroke and downstroke represents the pitch.

Types of Normal Breathing

Vesicular breathing is the most common type of breathing and is heard in most areas of the chest.
Tracheal/Bronchial breathing is heard over the larynx and trachea.
Bronchovesicular breathing is heard in specific areas of the chest between the scapula and the first and second intercostal spaces.

Vesicular Breath Sounds

Characteristics:
- Sounds like rustling or breezy air.
- Inspiration is longer than expiration, with a ratio of 2-3:1.
- Inspiration has a higher pitch.
- There is no pause between inspiration and expiration.
Location:
- Most of the chest, but louder in the infra-clavicular, axillary, and infrascapular areas.
- Diminished in the lower margins of the lungs and over the scapular areas.
Mechanism of Production:
- Produced by the distention and separation of alveolar walls by the influx of air during inspiration.

Bronchial Breathing

Tubular Breathing:
- High-pitched sounds from the bronchioles are conducted to the chest wall without modification, often associated with consolidation.
Amphoric Breathing:
- Low-pitched with high-pitched overtones, giving a metallic quality.
- Seen in open pneumothorax due to bronchopleural fistula and large communicating cavities.
Cavernous Breathing:
- Low-pitched with a hollow quality, often associated with cavities.

Bronchovesicular Breath Sounds

Characteristics:
- A combination of vesicular and bronchial breath sounds.
- Expiration is louder, longer, and higher pitched than inspiration, with a hollow quality.
Location:
- Upper part of the sternum.
- Up to the 3rd or 4th dorsal spine between the scapula.
- Sometimes over the lung apices, particularly on the right side.
Mechanism of Production:
- Produced by the combination of the vesicular and bronchial breath sounds due to air-containing lung tissue being interposed between a large bronchus and the chest wall.

Tracheal (Bronchial) Breath Sounds

Characteristics:
- Character is aspirate or guttural.
- Expiration is longer and louder than inspiration.
- Expiration has a high pitch.
- The ratio of inspiration to expiration is 1:1.
- There is a pause between inspiration and expiration.
Location:
- Larynx and trachea.

Diminished Intensity of Breath Sounds

Causes:
- Defective Production: Bronchial obstruction or emphysema.
- Defective Transmission: Pleural effusion, pneumothorax, thickened pleura, thick chest wall, fibrosis.

Special Findings in Percussion

These findings are used to help diagnose various chest conditions.
Shifting dullness: Seen with hydropneumothorax.
S-shaped curve of Ellis: Seen with moderate pleural effusion.
Obliteration of Traube's space: Seen with left-sided pleural effusion.
Grocco's triangle: This paravertebral triangle of dullness is seen in patients with pleural effusion.
Garland's triangle: A small area of tympany (subtympanic) on the opposite side of the effusion in moderate to massive pleural effusions.
William's tracheal resonance: An area of tympany over the first or second intercostal space, close to the sternum, seen in cases of consolidation or fibrosis interposing between the trachea or a major bronchus and the chest wall, known as “pulled trachea syndrome".
Wintrich's sign: This sign is seen in a lung cavity communicating with a bronchus, pneumothorax, or mediastinal tumor, where the percussion note is higher pitched with the mouth open than closed.
Gerhardt's sign: This sign is seen in a lung cavity containing both fluid and air, the percussion note is lower pitched when the patient is recumbent than when standing or sitting.
Friedreich's sign: This sign is seen in a lung cavity, the percussion note is higher pitched during forced inspiration than during expiration.

Grocco’s Triangle

The triangle is formed by three lines:
- Medially: The mid-spinal line from the level of the effusion to the level of the tenth dorsal vertebra.
- Below: A horizontal line extending outwards from the tenth dorsal vertebra along the lower limit of lung resonance.
- Laterally: A curved line connecting these two lines.

Auscultation (Lower Respiratory Tract)

Patient Position:
- Front: Sitting or standing.
- Back: Preferably sitting and leaning forward with the neck flexed and arms crossed in front.
- For difficult auscultation, the patient can be turned sideways or the stethoscope can be slipped underneath them.
Breathing Advice:
- Ask the patient to breathe through their mouth or cough successively.
- The examination should be done in a quiet room, using a stethoscope.
- The diaphragm of the stethoscope should be used to assess the patient.
- The examination should be conducted directly on the skin, not over clothing.

Normal Physiology of Breath Sounds

Mechanism of Sound Production:
- Larger Airways (Pharynx, trachea, and lung): Sounds are mostly produced due to turbulence and act as the source of sound.
- Smaller Airways: Sounds are filtered and not the primary source of sound. High frequencies are lost due to dampening as they travel from larger to smaller airways.
Sound Frequencies:
- Larger Airways: 200-2000 Hz
- Smaller Airways: 200-400 Hz

Variations of Vocal Resonance

Bronchophony: An increase in the loudness and clarity of spoken sounds, heard in consolidation and just above the level of pleural effusion.
Aegophony: A selected amplification of high-frequency sounds, making the "E" sound like "A," often heard in consolidation.
Whispering Pectoriloquy: The whispered sound is heard clearly and distinctly as if uttered directly into the external ear, often seen in a large cavity communicating with a bronchus or massive consolidation near a bronchus.

Other Auscultatory Features

Post-Tussive Suction: This sign is seen in a superficial collapsible cavity, often associated with active tuberculosis. It indicates a cavity, and is a suction sound heard after the patient coughs.
Succussion Splash (Hippocrates Succussion): This feature is seen with hydropneumothorax (a mix of air and fluid in the pleural space), and is a tinkling or splashing sound heard when the patient is shaken while the diaphragm is placed at the air-fluid level.
Coin Test:
- Sound: High-pitched metallic or tympanic note.
- Procedure: Place one coin flat on the affected side of the chest and percuss with another coin perpendicularly on it, while simultaneously auscultating from the opposite direction of the same affected side.
- Used to diagnose: Massive pneumothorax/hydropneumothorax.

Pleural Rub

Description: A harsh, discontinuous, localized, non-musical, superficial grating sound produced by the rubbing of inflamed pleural surfaces against each other.
Timing: Heard during both phases of respiration, but disappears when the breath is held.
Causes: Dry pleurisy, consolidation, infarction.

Crepitations (Rales/Crackles)

Description: These are discontinuous, intermittent breath sounds of varying intensity.
Timing: Heard primarily during inspiration, but can also be heard during expiration.
Localization: Localized, often to a small area, and may clear after coughing.
Associated with: No pain, no tenderness.

Differences between Pleural Rub and Crepitations

Feature	Pleural Rub	Crepitations
Phases	Both inspiratory and expiratory	Inspiratory/expiratory or both
Localization	Localized to a small area	Widespread
Change after coughing	No change	May clear after coughing
Stethoscope pressure	Increases the sound	No effect
Associated chest pain	Yes (pleuritic)	No pain

Stridor

Description: High-pitched whistling or grating sound caused by upper airway obstruction.
Location: Louder over the neck than the chest.
Indicates: Extrathoracic upper airway obstruction (e.g., vocal cord paralysis, supraglottic growths).

Tracheal Rales (Death Rattle)

Description: Usually heard over the trachea or lungs in seriously ill patients who are unable to cough out their respiratory secretions.

Post-Tussive Crepitations

Description: Appear after a bout of coughing, usually absent otherwise.
Causes: Early pneumonia, early tuberculosis, lung abscess.

Vocal Resonance

Increased: Seen in consolidation, large cavity, bronchopleural fistula.
Decreased: Seen in pleural effusion, pneumothorax, fibrosis, collapse, asthma, emphysema, thick pleura.
Note: Vocal resonance is increased in upper lobe fibrosis due to the "pulled trachea" syndrome.

Adventitious Sounds (Flowchart 3D.1)**

These are abnormal breath sounds heard during auscultation.

Continuous Adventitious Sounds

Wheeze:
- High-pitched sounds (400 Hz) with a hissing/shrill quality (sibilant).
- Primarily caused by obstruction of small airways.
- Airflow limitation is essential for their production.
- Wheezes are musical and sinusoidal in quality.
Rhonchi:
- Low-pitched sounds (150-200 Hz) with a snoring quality (sonorous).
- Usually produced by air moving through tracheobronchial passages with mucus or respiratory secretions.

Classification of Wheezes/Rhonchi

Monophonic: Single tones, often due to local pathology causing bronchial obstruction (e.g., tumor, foreign body aspiration, bronchostenosis).
Polyphonic: Multiple tones, often heard in both inspiration and expiration, often caused by dynamic compression (e.g., COPD, bronchial asthma, tropical pulmonary eosinophilia).
Sequential Inspiratory Wheeze: A series of sequential, but not overlapping inspiratory sounds, often associated with deflated areas of the lung, as seen in lung fibrosis and alveolitis.

Discontinuous Adventitious Sounds (Rales/Crepitations/Crackles)

These sounds are brief, sharp, non-musical, and often heard during inspiration, but can also occur during expiration.

Crepitations

Mechanism of Production:
- Bubbling sounds: air passing through accumulated secretions.
- Sudden snapping opening: Of successive small airways during airflow.
Types:
- Fine Crepitations: Snapping opening of successive small airways.
- Coarse Crepitations: Bubbling sounds in larger airways.
Classification:
- Inspiratory Crepitations: Occur during inspiration.
- Expiratory Crepitations: Occur during expiration.
Conditions causing crepitations:
- Early: Acute bronchitis, chronic bronchitis.
- Mid: Bronchiectasis, resolving phase of pneumonia, pulmonary edema (late phase).
- Late: Interstitial lung disease, asbestosis, hypersensitivity pneumonitis, sarcoidosis, early pneumonia, pulmonary edema.
Specific Crepitations:
- Coarse leathery crepitations
- Velcro crepitations. These are often specific to certain conditions.
Note:* This is a summary of the information provided in the image. Further details, diagnoses, and specific clinical interpretations require a professional medical assessment.

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Description

This quiz focuses on the grading of breath sounds, their graphical representation, and the types of normal breathing. It covers characteristics of vesicular, tracheal/bronchial, and bronchovesicular breathing to enhance your understanding of respiratory sounds.