Reference
Pocket card
A single page for a quick look at the bedside. The details are in the lessons.
Four questions
- When? Inspiration or expiration, early or late
- What does it sound like? Musical or explosive, fine or coarse
- Where? Focal or diffuse, one side or both
- What changes it? Coughing, deep breathing, position, treatment
Then ask: Has the source changed? Has the flow changed? Has the path changed?
Normal sounds
| Sound | Where | Insp : Exp |
|---|---|---|
| Vesicular | Peripheral lung | Insp. long and loud, exp. short and faint |
| Bronchovesicular | Upper parasternal, between the scapulae | About equal |
| Bronchial | Manubrium (abnormal over the periphery) | Exp. loud and long, silent gap between phases |
| Tracheal | Neck | Both phases loud, silent gap between them |
Adventitious sounds
| Sound | What you hear | Phase | Think of |
|---|---|---|---|
| Fine crackles | Velcro, hair rubbed between the fingers | Mid to late insp. | Fibrotic ILD, congestion. Unchanged by coughing |
| Coarse crackles | Bubbling, gurgling | Early to mid insp. | Bronchiectasis, secretions, pneumonia. May change with coughing |
| Polyphonic wheeze | Several whistles at once | Expiration | Asthma, COPD. Diffuse obstruction |
| Monophonic wheeze | A single whistle | Mostly exp. | If fixed at one site, local narrowing: CT, bronchoscopy |
| Rhonchus | Snoring, rumbling | Mostly exp. | Secretions. Check the response to coughing |
| Stridor | Loud tone, strongest over the neck | Mostly insp. | Laryngeal or tracheal narrowing: emergency |
| Squawk | Short chirp | Insp. | HP, other ILDs. Ask about exposure |
| Pleural friction rub | Creaking, footsteps on snow | Mostly both phases | Pleurisy, infarction. Localises to the pleura |
Physical examination patterns
| Condition | Breath sounds | Voice transmission tests* | Tactile fremitus | Percussion |
|---|---|---|---|---|
| Consolidation | Bronchial, crackles | Increased | Increased | Dull |
| Pleural effusion | Diminished / absent (may be bronchial at the upper border) | Diminished (egophony may be heard at the upper border) | Diminished | Dull |
| Pneumothorax | Diminished / absent | Diminished | Diminished | Hyperresonant |
| Obstructive atelectasis | Diminished | Diminished | Diminished | Dull |
| Emphysema / hyperinflation | Diminished, prolonged exp. | Diminished | Diminished | Hyperresonant |
*Bronchophony, whispered pectoriloquy, egophony. These pairings are typical tendencies. Imaging makes the definitive diagnosis.
Red flags
- Wheeze disappearing and breath sounds becoming diminished in a severe attack: silent chest
- Inspiratory stridor, especially after extubation
- New, unilateral loss of breath sounds
- Fixed monophonic wheeze at one site (especially with haemoptysis)
- A pleural rub with pleuritic pain: remember pulmonary embolism
A good note template
[Side] [zone] [surface], [posture, breathing] → background sound [normal / diminished / bronchial]. [Phase] [distribution] [adventitious sound], [unchanged / reduced] after coughing.