AUSCULTATION: What is it? Where is it? Why is it? MPTA ...

reHeart/reLung

AUSCULTATION: What is it? Where is it? Why is it? MPTA Spring Conference, St. Louis Sharon Coffman MMSc PT CCS April 7, 2017 OBJECTIVES

Learner will be able to: 1. identify bony and surface landmarks on a chest wall for lung location and stethoscope placement. 2. apply knowledge of principles of sound to theories that explain various basic lung sounds in normals and in pathology.

3. describe stethoscope placement on a chest wall specifically for: pneumonia, asthma, MI, CHF, COPD.

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reHeart/reLung

CHEST WALL LANDMARKS/ANATOMY for AUSCULTATION:

ANTERIOR VIEW: 1. External Landmarks: Clavicles, Manubrium, Sternum, Xiphoid, Upper Lobe apex, nipple

2. Internal Landmarks: Diaphragm insertion: Lung pleura insertion @ rib 6 anteriorly and rib 8 at mid-clavicular line

3. Stethoscope placement for (8) areas: R apical segment, Upper Lobe R anterior segment, Upper Lobe R medial segment, Middle Lobe R lateral segment, Middle Lobe R anterior basilar segment, Lower Lobe

L apical segment, Upper Lobe L anterior segment, Upper Lobe

L anterior basilar segment Lower Lobe

LATERAL VIEW: 1. Internal landmarks: Lung pleura insertion @ rib 8, mid-axillary line

POSTERIOR VIEW: 1. External Landmarks: Scapula and scapular spines; medial border is T2-T6 levels

2. Internal Landmarks: Lung pleura/Diaphragm insertion at T10 level

3. Stethoscope placement for (8 total) areas:

R posterior segment, Upper Lobe

L posterior segment, Upper Lobe

R superior basilar segment, Lower Lobe L superior basilar segment, Lower, Lobe

R posterior basilar segment, Lower Lobe L posterior basilar segment, Lower Lobe

R lateral basilar segment, Lower Lobe L lateral basilar segment, Lower Lobe

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THEORIES BEHIND LUNG SOUNDS

A. Principles of Sound: Sound through water vs air: bronchial, E to A changes of vocal sound; consider the "megaphone effect" Turbulence vs smooth, laminar: obstruction of flow, possible clot formation Large vs small airways: takes place over 23 splits of the airways in forming the lung tree; high pitch and low pitch are determined by the airway diameter.

B. Sources of "other" sounds during auscultation: a. Patient talking b. Obesity c. Room sounds d. Clothing e. Crepitus *mistaking joint crepitus (listener's digits) f. Chest hair *mistaking chest hair for fine rales g. Nose noise h. Glottal or vocal sounds

C. Mediate Percussion

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reHeart/reLung

LUNG AUSCULTATION TERMINOLOGY

1. Breath Sounds: Assess and adventitious sounds that are extra sounds heard during air movement and volume or loudness/softness

Adventitious: "extra" sounds; rales/crackles, wheezes/rhonchi Volume: Normal: bronchial, bronchovesicular, vesicular

Abnormal: increased/bronchial/tubular, decreased, absent

Adventicious: a. Rales/crackles (course, medium, or fine): discontinuous usually inspiratory sound of

"crackling paper", of gently rolling hair between the fingers, or velcro popping indicating congestion at the bronchiolar or alveolar levels. Fine vs coarse: The fine inspiratory sound of "carbonated water" suggests pulmonary edema or congestion at the alveolar-interstitial level. Mobile vs fixed: Often occurs in CHF if noted symmetrically at bases of a seated patient; fluid may move with positioning and gravity influences to gravity-dependent areas. These fine rales can be called "congestive rales".

b. Wheeze: smooth, high-pitched, whistling quality usually during expiration and indicate bronchospasm or the movement of air through secretions. Rhonchi: smooth, sonorous, low-pitched wheezes sounds indicating congestion. A snoring quality sound is heard.

Volume: a. Bronchial/tubular breath sounds: louder than normal sounds as air moves in and out.

Mimics a megaphone effect and is pathologic if heard over lung fields other than the bronchi. Usually indicates atelectasis or airlessness.

b. Decreased or Diminished breath sounds: softer than normal sounds suggesting pleural effusion or extrapulmonary problem, shallow breathing pattern, or restrictive lung disease such as kyphoscoliosis, or flattened diaphragms. Poor air movement or too slow breathing.

2. Voice Sounds: a. Egophany or "E to A changes: when the patient says "E", you hear "A" over the

area of pathology. Suggests mucous plugging, consolidation, or extensive atelectasis.

b. Bronchophany: Words or letters are louder and clearer than normal; patient says "blue moon" or "1,2,3,". Indicates areas of increased lung density, such as pneumonia or consolidation. Associated with abnormal "bronchial" breath sounds

3. Extrapulmonary Sounds: Friction rubs Pleural inspiratory and expiratory sounds of "leather rubbing", timed w/ breathing cycle; visceral (inner) pleura rubbing against the parietal (outer) pleura. Result: inflammation & pain. Pericardial friction rubs timed with pulse; pericardial sac inflammation or aneurysm presence which rub against the inside of the rib cage.

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PRACTICAL APPLICATION

Practice: You can have someone mimic the following:

a. "nose noise"

b. forced wheeze on expiration

c. mouth vs. nose breathing

d. slow vs. fast inspirations

e. say the letter "E"

CASE SCENARIOS

Take each patient on a 30 ft walk OR do a dry run of a sitting sponge bath.

DX

WHEN do you auscultate? WHERE do you auscultate?

1. Pneumonia, RLL

2. Asthma

3. CHF

4. MI

5. COPD

6. L Pleural Effusion 2 to CA

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REFERENCE LIST

1. Essentials of Cardiopulmonary Physical Therapy. Hillegass, E. and H. S. Sadowsky. W. B. Saunders Company, 1994. 2. Professional Guide to Signs & Symptoms. Springhouse Corporation, Springhouse, Pennsylvania, 1993. 3. Cardiopulmonary Physical Therapy, A Clinical Manual. Watchie, J. W. B. Saunders Company, 1995. 4. Principles and Practice of Cardiopulmonary Physical Therapy. Frownfelter, D. and E. Dean. Third Edition. Mosby-Year Books, Inc. 1996. 5. Cardiopulmonary Physical Therapy. Irwin, S. and J. Tecklin, Third ed. C. V. Mosby Co., 1995. 6. Cardiopulmonary Rehabilitation: Basic Theory and Application, Second Edition. Brannon, F., M. Foley, J. Starr, M. Black. F. A. Davis, Philadelphia, 1993.

7. A Guide to Physical Examination, 2nd Edition. Bates, B. J. B. Lippincott, Co., 1979.

8. APTA Guide to Physical Therapist Practice. Physical Therapy, 77(11), November, 1997. 9. Understanding Heart Sounds and Murmurs with an Introduction to Lung Sounds. Tilkian, A. and M. B. Conover. Third Edition. W.B. Saunders Company, 1993. 10. Lung Sounds, A Practical Guide. Wilkins, R., J. Hodgkin, B. Lopez. Mosby, Co., 1996.

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