The nurse gives the patient which instruction when auscultating breath sounds?

by | Updated: Oct 30, 2022

Are you ready to learn about breath sounds, lung sounds, and auscultation? I sure hope so because that is what this study guide is all about.

As a Respiratory Therapist (or student), it goes without saying that you must fully know and understand auscultation and listening to lung sounds. This is also true for nursing and medical students as well.

The good news is — we created this study guide to help make the learning process much easier for you. So if you’re ready, let’s go ahead and dive right in.

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What are Breath Sounds?

These are the sounds that come from the lungs during inhalation and exhalation that can be heard during auscultation.

When an abnormality is heard in a patient’s breath sounds, this indicates that other health issues may be present, such as:

• Asthma
• Chronic Obstructive Pulmonary Disease (COPD)
• Foreign body obstruction
• Accumulation of fluid
• Heart failure
• Infection
• Inflammation of the airways
• Pneumonia

By listening to the quality, duration, and intensity of breath sounds, healthcare professionals can learn a lot more about a patient’s condition in order to provide the most appropriate forms of treatment.

What is Auscultation?

Auscultation is a simple, non-invasive procedure that involves the use of a stethoscope to listen to the sounds produced by the body. For the sake of this guide, we’re focusing specifically on the lungs.

A stethoscope amplifies the sounds within the lungs so that we can hear and have an idea of what’s going on with the patient’s condition.

When performing lung auscultation, the bell or diaphragm of the stethoscope is placed on the patient’s chest and/or back. Both sides can be compared with one another and the sounds of each lung should be compared as well.

Types of Breath Sounds:

Whether you’re a Respiratory Therapist, student, or even if you’re a nurse or a part of a different medical profession, knowing the types of breath sounds is extremely important.

Especially for Respiratory Therapists and physicians, but arguably just as important for nurses and other professions as well.

Here are the Types of Lung Sounds to Know:

1. Vesicular (Normal)

Vesicular is just another name for normal breath sounds. They are low-pitch sounds that you would expect to hear as air flows through an open airway.

The sounds are usually soft and can be heard throughout both the inspiratory and expiratory phases of breathing.

2. Crackles (Rales)

Crackles, also known as rales, are short, explosive, lung sounds that are commonly heard in the small or middle airways of the lungs.

When crackles are heard during auscultation, it can be associated with fluid or secretions in the lungs. Crackles can occur on both inspiration and expiration but are more common during the inspiratory phase.

There are Two Types of Crackles:

• Fine crackles
• Coarse crackles

Fine crackles indicate that fluid is in the smaller airways. They have a higher frequency and a shorter duration. These are often heard in patients with CHF and pulmonary edema and can be treated with diuretic medications such as Lasix.

Coarse crackles are lower in pitch and longer in duration. They are caused by secretions in the large airways. They’re often referred to as Rhonchi, which we’ll talk more about in just a bit.

3. Wheezes

Wheezes are high-pitched abnormal breath sounds that are heard as air flows through a narrowed airway. They sound kind of like a whistle and are most audible during the expiratory phase of breathing.

If bilateral wheezing is heard in both lungs, this is an indication of bronchoconstriction which can be treated with a short-acting bronchodilator like albuterol.

When wheezes are heard in only one lung, this is referred to as unilateral wheezing which indicates that a foreign body obstruction is present. In this case, a bronchoscopy is indicated. Wheezes are also heard when patients are fluid overloaded, as with CHF and pulmonary edema.

4. Rhonchi

Rhonchi is an abnormal breath sound that can be heard when air moves through larger airways that have excess amounts of mucus or secretions.

These lung sounds are often low-pitched and are audible during the expiratory phase. The main difference between rhonchi and wheezes is that rhonchi sounds are low and dull while wheezes are high and squeaky.

As a Respiratory Therapist, when you hear rhonchi, you should recommend suctioning or bronchial hygiene therapy.

5. Stridor

Stridor is a high-pitched lung sound that is heard when an upper airway obstruction is present. It is most often heard during the inspiratory phase of breathing.

Several medical conditions can cause stridor, including the following:

• Croup
• Epiglottitis
• Post-extubation laryngeal edema
• Foreign body aspiration

It can be treated with cool mist and racemic epinephrine. And in severe cases, which would be considered as a medical emergency, intubation and mechanical ventilation would be indicated.

6. Diminished Breath Sounds

These are lung sounds that are heard when there is decreased air movement in the lungs.

It’s common for patients with COPD or an acute asthma attack to have diminished breath sounds because they aren’t moving much air in and out of the lungs.

Then, after a bronchodilator is administered, if you listen to their breath sounds again, you’ll often hear wheezes. This is actually sign that the patient has improved because the bronchodilator is working and has opened up the airways some.

7. Pleural Friction Rub

A pleural friction rub is a loud grating sound that is heard over the lungs when inflamed pleura rub together. It is caused by decreased levels of fluid in the pleural space.

This lung sound is often heard in patients with pleurisy.

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What are Vesicular Breath Sounds?

As mentioned earlier, vesicular breath sounds are another name for normal breath sounds. They are low-pitched and basically sound as you would expect air to sound as it flows through an open airway. 

The sounds are usually soft and can be heard throughout both phases of the breathing cycle.

What are Adventitious Breath Sounds?

Adventitious breath sounds are the abnormal sounds that occur over the lungs and airways during auscultation.

Adventitious breath sounds are commonly associated with a wide array of heart and lung conditions. The type, duration, location, and intensity of each adventitious breath sounds can help medical professionals diagnose and treat medical conditions.

This is why knowing the differences between each type of abnormal breath sound is so important for healthcare practitioners. 

What are the Causes of Abnormal Breath Sounds?

There are several causes of abnormal breath sounds. Each of which is specific to the type of breath sound the patient is experiencing.

We covered a few already, but let’s go through a few more of the specific causes of abnormal lung sounds.

• Crackles – Lung sounds that are caused by air moving through secretions of the small or middle airways.
• Wheezes – Lung sounds that are caused by air moving through a narrowed or constricted airway.
• Rhonchi – A lung sound that is caused by air moving through secretions in the larger airways.
• Stridor – A lung sound that occurs when an upper airway obstruction is present.
• Diminished – Present when there is decreased air movement in the lungs.
• Pleural Friction Rub – A lung sound that is heard when inflamed pleura rub together due to decreased levels of fluid in the pleural space.

There are hundreds of causes of abnormal breath sounds — these are just a few of the common examples that you should be familiar with.

What is the Treatment for Abnormal Breath Sounds?

Abnormal breath sounds are often associated with common and treatable medical conditions. As a Respiratory Therapist or medical professional, you will be required to recommend the proper medication or treatment method for each of the different types of abnormal lung sounds. 

Here are the Common Treatment Strategies for Abnormal Breath Sounds:

1. Metered-Dose Inhaler (MDI)

This is a pressurized inhaler that delivers a bronchodilator (dilates the airways), corticosteroid (suppresses inflammation), or a combination of both.

By opening the airways and suppressing the inflammatory process, it can help restore breath sounds to normal.

2. Nebulizer

This is a device that delivers an aerosolized form of medication into the alveoli of the lungs via inhalation. They are commonly used to deliver bronchodilator medications, like albuterol, which can alleviate bronchoconstriction. 

Nebulizers can help deliver other medications as well which can treat other types of abnormal breath sounds.

3. Incentive Spirometry

This is a simple, inexpensive, and effective tool that is useful in helping a patient achieve normal lung function. This device mimics natural sighing or yawning, which in turn improves lung expansion and gas exchange.

To use the device, the patient needs to place the mouthpiece spirometer in their mouth and perform deep breathing exercises.

It is recommended to check with a physician before using one of these devices.

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4. Chest physiotherapy (CPT)

This is also considered a simple and effective method of normalizing abnormal breath sounds. CPT includes various techniques in order to naturally clear lung secretions through the use of vibration (or shaking), proper positioning, breathing exercises, and coughing techniques.

5. Antibiotics

Antibiotic therapy is designed to fight infections and destroy microorganisms that affect lung functionality. By fighting the infection, antibiotics also help with airway inflammation and secretions which can improve abnormal breath sounds.

Keep in mind that there are many different types of treatment for abnormal lung sounds. These are just a few common examples that you should be familiar with.

What are Bronchial Breath Sounds?

Bronchial breath sounds are hollow lung sounds that can be heard in both normal and abnormal conditions. These sounds are normal when heard over the trachea, however, they are abnormal when heard over the lung fields.

For example, let’s say you’re auscultating a patient and hear bronchial breath sounds over the right lower lobe. This is a common finding in patients with pneumonia and it indicates that consolidation is present.

Let’s break down a sample TMC Practice Question on the topic of bronchial breath sounds:

Example TMC Practice Question:

A 63-year-old male patient was recently admitted to the ICU. While auscultating the lungs, you hear bronchial breath sounds over the right lower lobe. This would indicate which of the following?

A. The patient has normal lungs
B. Pneumothorax in the right lung
C. Pleural effusion in the patient’s right lower lobe
D. Consolidation in the patient’s right lower lobe

Bronchial breath sounds are normal when heard over the trachea. However, if you hear bronchial breath sounds over the lung periphery, this is an abnormal finding.

To get this one right, you had to know that bronchial breath sounds are sometimes heard in patients with pneumonia. And for the TMC Exam, you must remember that patient with pneumonia usually show signs of consolidation.

A pneumothorax or pleural effusion are not identified by bronchial breath sounds which means that we can rule those out immediately.

So by using what we know about breath sounds, as well as the process of elimination, you can easily determine that the correct answer has to be D. 

The correct answer is: D. Consolidation in the patient’s right lower lobe

This practice question was taken straight from our TMC Test Bank. It’s one of our bestselling packages where we break down hundreds of these practice questions that cover every topic you need to know for the TMC Exam.

Each question comes with a detailed rationale that explains exactly why the answer is correct.

If you thought the sample question above was helpful, definitely consider checking it out.

What are Bronchovesicular Breath Sounds?

Bronchovesicular breath sounds are normal sounds that are heard in the mid-chest area or over the scapula. Unlike other normal breath sounds, bronchovesicular breath sounds have tubular quality.

These sounds are the combination of bronchial breath sounds heard near the trachea and vesicular sounds in the alveoli.

Bronchovesicular breath sounds have equal periods of inhalation and exhalation, so the I:E ratio is typically 1:1. However, the differences in pitch and intensity are often audible during the expiratory phase.

What are Diminished Breath Sounds?

As previously mentioned, diminished breath sounds are soft, distant lung sounds with a lower volume and intensity. These sounds are often present in patients with decreased lung volumes.

They are also present in patients with severe obstructive conditions. That isn’t to say that this is always the case. There are several causes of diminished breath sounds.

Here are Some Examples:

• Obese patients
• Patients with increased muscle mass
• Patients with air or fluid around the lungs
• Patients with an increased chest wall thickness
• Patients with lung hyperinflation

Each of these examples make it more difficult to hear lung sounds during auscultation which is the root cause of the diminished classification. 

Also note that during diminished breath sounds, the inspiratory phase is usually much longer than the expiratory phase. This means that a patient with diminished breath sounds will have an I:E ratio of 3:1. In other words, the inspiratory phase of breathing is three times longer than the expiratory phase. 

When are Coarse Breath Sounds Heard?

Coarse breath sounds are actually a type of crackles (rales). They are clicking, bubbling, or rattling sounds that occur during the inspiratory phase of breathing when air moves through secretions that have accumulated in the larger airways.

Coarse breath sounds are typically loud and low-pitched and are longer in duration. Most patients with copious amounts of secretions exhibit coarse breath sounds during auscultation of the affected lung area.  

When are Pneumonia Breath Sounds Heard?

Pneumonia is a respiratory infection caused by harmful microorganisms and is characterized by consolidation and a productive cough. Patients with pneumonia often have greenish or yellowish secretions which, again, are indicative of an infection. 

If a patient has pneumonia, you will likely hear crackling, bubbling, or rumbling sounds during auscultation. Wheezing is also a possibility is some areas of the lungs as well.

Crackles in patients with pneumonia are often heard only on one side of the chest or when the patient is lying down. In addition to crackles and wheezes, low-pitch rhonchi sounds may also be audible during the expiratory phase of breathing.

Additionally, as previously mentioned, bronchial breath sounds are also commonly heard in patients with pneumonia.

What are Stridor Breath Sounds?

Stridor is a high-pitched lung sound that is typically created by an upper airway obstruction. It is mostly audible during inhalation but can also be heard during exhalation in patients with a deteriorating condition.

These sounds commonly occur in extubated patients as a complication of endotracheal intubation. In children, stridor is very audible when they are lying on their back in the supine position.

Other causes of stridor include croup, pertussis, aspiration, epiglottis, choking, severe anaphylactic shock, tonsillitis, laryngitis, lung cancer, deviated septum, and blood transfusion reactions.

How to Perform Auscultation?

Auscultation is a technique that is used to listen to and examine the heart and lungs. It can also be used in the abdomen and other areas of the body with major blood vessels as well. But for the sake of this article, we’re focusing strictly on the lungs.

In order to assess a patient’s lung sounds, auscultation must be performed using a stethoscope in order to hear the sounds as the patient breathes. Let’s go through the process of performing auscultation on a patient.

Here are the Steps for Performing Auscultation:

1. Explain the procedure to the patient to establish trust and rapport.
2. Stand close to the patient in order to gain access to the target area. In this case, the target area is the lungs.
3. If the diaphragm (face) of the stethoscope is cold, warm it by rubbing the surface to avoid startling the patient.
4. Place the eartips of the stethoscope in your ears and adjust them as desired. They should fit comfortably and snuggly in your ears.
5. Hold the diaphragm of the stethoscope firmly against the patient’s skin with a moderate amount of pressure. Instruct the patient to take slow, deep breaths through an open mouth.
6. As the patients breathes, listen to the sounds and try to identify their intensity, location, strength, pattern, and duration.
7. Always listen to the patient’s anterior side first. Start at the apices and then move downward towards the lung bases. Then repeat the process on the posterior side.
8. Compare the right lung to the left lung. Also compare the anterior to the posterior side.
9. Document the findings in the patient’s chart.

What is the Best Stethoscope for Auscultation?

In order to perform auscultation and listen to breath sounds effectively, you need to get your hands on a high-quality stethoscope. The 3M Littmann Classic III is hands down our favorite and is also our top recommendation for medical professionals and students.

This stethoscope is our top recommendation because it provides the best bang for your buck.

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While this one is hands-down our favorite, there are plenty of other high-quality stethoscopes on the market that deserve consideration as well.

If you’re interested in learning more about the best of the best, check out our full list of the Best Stethoscopes for Medical Professionals.

Now that you have a good understanding of breath sounds and auscultation, let’s take it a step further by going through some more practice questions on this topic.

Practice Questions on the Topic of Lungs Sounds and Auscultation:

1. What are fine crackles?
They are high-pitched, discrete, discontinuous crackling sounds heard during the end of respiration. They are not typically cleared by a cough.

2. What are medium crackles?
They are lower, moist sounds that are heard during the mid-stage of inspiration. They are not typically cleared by a cough.

3. What is rhonchi?
It’s a loud, low, coarse breath sound that sounds like a snore and is most often heard continuously during inspiration or expiration. Coughing may clear this sound and it usually means that there is an accumulation of mucus in the trachea or large airways.

4. What are coarse crackles?
They are loud, bubbly noises heard during inspiration. They are not typically cleared by a cough

5. What are wheezes?
They make a musical noise that sounds like a squeak. They are most often heard continuously during inspiration or expiration but are usually louder during the expiration phase.

6. What is a pleural friction rub?
It is a dry, rubbing, or grating sound, usually caused by inflammation of the pleural surfaces. This sound can be heard during inspiration and expiration. It is usually the loudest over the lower lateral anterior surface.

7. What is stridor?
It’s a harsh or high-pitched respiratory sound that is caused by an obstruction of the upper airway.

8. What are vesicular breath sounds?
These are normal breath sounds. They are heard over most lung fields. They are low pitch, soft, and usually have short expirations. They are more prominent in thin people or children and can be diminished in obese or very muscular patients.

9. What are bronchovesicular breath sounds?
They are heard over the main bronchus area and over the upper right posterior lung field. They have a medium pitch and the expiratory phase is usually equal to the inspiratory phase of breathing.

10. What are bronchial breath sounds?
They are heard only over the trachea in healthy patients. They have a high pitch with loud and long expirations. The expiratory phase is sometimes a bit longer than the inspiratory phase. If they are heard over the lung fields, this is a sign of pneumonia.

11. What is auscultation?
It is the process of listening to sounds of the body with the aid of a stethoscope. As Respiratory Therapists, we are particularly focus on the lungs.

12. Where are bronchovesicular breath sounds heard?
They are heard around the sternum or center of the chest.

13. What breath sound is common with a pleural effusion?
Decreased or absent breath sounds.

14. What do fine crackles sound like?
The make a popping sounds and are higher in pitch.

15. What do coarse crackles sound like?
Bubbling/rumbling, discontinuous, and not as sharp as fine crackles.

16. What should be noted when listening to crackles?
The location of the sound, duration, pitch, and when the sound occurs (whether on inspiration or expiration).

17. What is the mechanical cause of crackles?
The small airways opening during inspiration and collapsing during expiration. They can also occur when air bubbles go through secretions or incompletely closed airways during expiration.

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18. What does a wheeze sound like?
It is a continuous, high pitched, hissing sound. Wheezes tend to be longer than crackles and they usually occur on expiration.

19. What does rhonchi sound like?
It has a much lower pitch than a wheeze. It tends to be longer in duration than crackles.

20. What does rhonchi normally imply?
It implies that a larger airway is obstructed by secretions.

21. What makes stridor sound different than others sounds?
It can usually be heard without a stethoscope.

22. If stridor does exist, what does it mean?
It usually means that there is a medical emergency that requires immediate attention.

23. What does a pleural rub sound like?
It sounds like brushing, similar to coarse crackles. In this case, the patient will likely be in pain and be able to localize it to where the sound can be heard.

24. What is the mechanical main cause of a pleural rub?
The pleural surfaces are inflamed or roughened and are rubbing each other which is why the sound can be heard.

25. How should a patient be positioned before auscultation?
They should preferably be sitting up. At the least, ensure that they are not leaning against anything.

26. What are the normal breath sounds?
Tracheal, Vesicular, Bronchial, and Bronchovesicular.

27. Breath sounds can be classified into what three categories?
Normal and Abnormal (Adventitious).

28. What are bronchovesicular breath sounds?
They are heard over the main bronchus area and upper right posterior lung fields. They are intermediate in intensity and pitch. The expiration phase is usually equal to the inspiration phase. They are normally heard in the 1st and 2nd intercostal spaces.

29. What are vesicular breath sounds?
Vesicular breath sounds are soft and low pitched lung sounds. They consist of a quiet, wispy inspiratory phase followed by a short, almost silent, expiratory phase. They are heard over most of the lung fields. They are more prominent in children and thin adults.

30. What are the abnormal breath sounds?
Rales, Crackles, Rhonchi, Wheezes, and Absent/Diminished.

31. What are the adventitious breath sounds?
They are the same as the abnormal breath sounds that were just mentioned.

32. What is the sequence of steps in the examination of the chest and lungs?
Inspection, Palpation, Percussion, then Auscultation.

33. What is the difference in medium crackles and coarse crackles?
Medium crackles are lower, more moist, and are heard during the mid-stage of inspiration. They are not cleared with a cough. Coarse crackles are loud, bubbly noises that are heard during inspiration. Also, they are not cleared with a cough.

Final Thoughts

So there you have it. That wraps up our massive study guide on breath sounds, abnormal lung sounds, and auscultation. I hope that this information was helpful, and I hope that it helps makes the learning process much easier for you. 

Again, knowing the ins and outs of breath sounds is (obviously) very important for, not only doctors, but for nurses and Respiratory Therapists as well. Not to mention, it’s never too early to learn and master this information as a student, either.

So be sure to go through this information several times until it sticks. Thank you so much for reading all the way to the end and as always, breathe easy my friend. 

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Medical Disclaimer: This content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Please consult with your physician with any questions that you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you read in this article.

References

The following are the sources that were used while doing research for this article:

• —. Workbook for Egan’s Fundamentals of Respiratory Care. 12th ed., Mosby, 2020.
• Faarc, Heuer Al PhD Mba Rrt Rpft. Wilkins’ Clinical Assessment in Respiratory Care. 8th ed., Mosby, 2017.
• Rrt, Des Terry Jardins MEd, and Burton George Md Facp Fccp Faarc. Clinical Manifestations and Assessment of Respiratory Disease. 8th ed., Mosby, 2019.
• Zimmerman, Barret. “Lung Sounds – StatPearls – NCBI Bookshelf.” NCBI Bookshelf, 27 Sept. 2019, www.ncbi.nlm.nih.gov/books/NBK537253.
• “Wheezes, Crackles and Rhonchi: Simplifying Description of Lung Sounds Increases the Agreement on Their Classification: A Study of 12 Physicians’ Classification of Lung Sounds from Video Recordings.” PubMed Central (PMC), 22 June 2020, www.ncbi.nlm.nih.gov/pmc/articles/PMC4854017.

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Medical Disclaimer: The information provided by Respiratory Therapy Zone is for educational and informational purposes only. It should not be used as a substitute for professional medical advice, diagnosis, or treatment. Please consult with a physician with any questions that you may have regarding a medical condition.