Auscultation

Auscultation is the process of listening to the sounds of air passing through the
tracheobronchial tree and alveolar spaces.

From: Acute Care Handbook for Physical Therapists (Fourth Edition), 2014

Related terms:

Wheeze, Blood Pressure, Crackle

View all Topics

Learn more about Auscultation

IS4Learning—A Multiplatform Simula-

tion Technology to Teach and Evaluate
Auscultation Skills
Daniel Pereira, ... Miguel Tavares Coimbra, in Health Professionals' Education in the
Age of Clinical Information Systems, Mobile Computing and Social Networks, 2017

Abstract
Auscultation is currently both a powerful screening tool, providing a cheap and
quick initial assessment of a patient’s clinical condition, and a hard skill to master.
Acquiring this skill is not only intrinsically difficult but our teaching methods
are inadequate due to a variety of practical issues. In this chapter, we will discuss
the difficulties of the art of auscultation, how we currently teach this skill and
describe a novel simulation technology, IS4Learning, that can be used in three
different teaching settings enabling us to train and evaluate students in the art of
auscultation.

> Read full chapter

Confirmation of Endotracheal Intuba-
tion
M. Ramez Salem, Anis S. Baraka, in Benumof and Hagberg's Airway Management,
2013

d Epigastric Auscultation and Observation for Abdominal Dis-

tention
Auscultation of the epigastric area to elicit air movement in the stomach has
been suggested as a routine maneuver after endotracheal intubation, even before
auscultation of the chest.14,15,25,26 However, normal vesicular breath sounds from
the lungs can be transmitted to the epigastric area in tracheally intubated patients
who are thin or small.26 On rare occasions, esophageal intubation may not be
easily distinguishable from endotracheal intubation if epigastric auscultation alone
is used. Furthermore, there are circumstances, such as obstetric emergencies, in
which prepping of the abdomen before induction of anesthesia precludes epigastric
auscultation after intubation.25

Abdominal distention caused by gastric insufflation after compression of the breath-

ing bag in cases of esophageal intubation can be readily observed in most patients.
Occasionally, this sign may not be a reliable indicator of esophageal intubation for
the following reasons16,26,35:

1 Gastric insufflation and abdominal distention might have occurred during

prior mask ventilation.
2 Gastric distention may not be apparent in obese patients.

3 A previously placed nasogastric tube (NGT) can cause intermittent decompres-

sion of the stomach.
4 Gradual gastric filling can be difficult to distinguish from normal abdominal
movements because of the esophageal reflux of gases.

Conversely, gastric distention can occur in patients with congenital or acquired

tracheoesophageal fistula despite placement of the tube in the trachea.33

> Read full chapter

Tracheal Intubation and Airway Man-

agement
Manuel PardoJr. MD, in Critical Care Secrets (Fourth Edition), 2007
23 How is tracheal intubation confirmed?
Auscultation for bilateral breath sounds and absence of stomach inflation should
be done after each intubation attempt. However, these signs may still be present
with an esophageal intubation. Carbon dioxide capnography is one of the most
reliable methods to confirm placement. The laryngoscopic view may be useful. If an
experienced clinician clearly sees the tube between the vocal cords, this is definitive
confirmation. The endotracheal tube itself commonly blocks sight of the vocal
cords, and inexperienced clinicians may insert the tube in the esophagus despite
having a good view of the larynx. Other confirmation methods include fiberoptic
bronchoscopy or an esophageal detector device.

> Read full chapter

Tracheal Intubation and Airway Man-

agement
Manuel PardoJr. MD, in Critical Care Secrets (Fifth Edition), 2013

23 How is tracheal intubation confirmed?

Auscultation for bilateral breath sounds and absence of stomach inflation should
be done after each intubation attempt. However, these signs may still be present
with an esophageal intubation. Carbon dioxide capnography is one of the most
reliable methods to confirm placement. The laryngoscopic view may be useful. If an
experienced clinician clearly sees the tube between the vocal cords, this is definitive
confirmation. The endotracheal tube itself commonly blocks sight of the vocal
cords, and inexperienced clinicians may insert the tube in the esophagus despite
having a good view of the larynx. Other confirmation methods include fiberoptic
bronchoscopy or an esophageal detector device.

> Read full chapter

Malpresentation and Malpositions

Jamee H. Lucas MD, AAFP, ... Ellen L. Sakornbut MD, in Family Medicine Obstetrics
(Third Edition), 2008
C. Auscultation
Auscultation by itself does not determine the fetal position, but it may reinforce what
the examiner suspects from palpation. In the vertex and breech positions, fetal heart
tones are best heard through the fetal back, whereas in a face presentation, they are
heard through the fetal thorax. In vertex presentations, heart tones are heard with
maximal intensity between the umbilicus and the anterior superior iliac spine of the
mother. In breech presentations, this point of maximal intensity is closer to the level
of the umbilicus. In the more common occipitoanterior position, fetal heart tones
are heard best near the midline, whereas in transverse presentations, they are more
lateral; in posterior presentations, the point of maximal intensity is back toward the
mother's flank.

> Read full chapter

Evaluation
Sue Ann Sisto PT, MA, PhD, Kim Ratner PT, BS, in Spinal Cord Injuries: Management
and Rehabilitation, 2009

Auscultation
Auscultation is the act of listening for sounds, often with a stethoscope, to denote the
condition of the lungs, heart, pleura, abdomen, and other organs.5 The stethoscope
does not magnify sound but rather blocks out extraneous room sounds. Of all the
equipment used, the stethoscope quickly becomes a very personal instrument. Time
should be taken to learn its features and make sure it is a good fit to the individual
user. Auscultation is a skill that beginning examiners are eager to learn, but one
that is difficult to master. First, the wide range of normal sounds must be learned.
Once normal sounds are recognized, the clinician can begin to distinguish abnormal
sounds.2

There are some general principles that apply to all auscultatory procedures. The
environment should be quiet and free from distracting noises. The stethoscope
should be placed on the naked skin because clothing obscures sound. The therapist
should listen not only for the presence of sound but also its characteristics: intensity,
pitch, duration, and quality. The sounds are often subtle or transitory, and intense
listening is needed to hear the nuances. Closing the eyes may prevent distraction by
visual stimuli and narrow the perceptual field to focus on the sound. The therapist
should try to target and isolate each sound, concentrating on one sound at a time
and taking enough time to identify all the characteristics of each sound.
One of the most difficult achievements in auscultation is learning to isolate sounds.
Whether it is a breath sound or a heart beat in the sequence of respirations and heart
beats, each segment of the cycle must be isolated and listened to specifically. After
individual sounds are identified, they are put together in sequences. The clinician
should not anticipate the next sound but rather concentrate on the one at hand.6

The patient should sit forward or, if this position is not possible, be placed in a
side-lying position so that the upper and middle lung fields are exposed. The patient
is reminded to breathe only through his mouth. First, he is asked to perform two
repetitions of his normal breathing pattern: natural inspiration and expiration. Then
systematically the stethoscope is placed over each of the auscultation landmarks
(Figure 6-6), proceeding superior to inferior and evaluating at least one breath sound
per pulmonary segment bilaterally.
FIGURE 6-6. Auscultation landmarks for suggested sequence of systematic percus-
sion and auscultation of the thorax. A, Posterior thorax. B, Right lateral thorax. C, Left
lateral thorax. D, Anterior thorax. The pleximeter finger or the stethoscope is moved
in the numerical sequence suggested; however, other sequences are possible. It is
beneficial to be systematic.

(From Seidel HM, Ball JW, Dains JE et al: Mosby's guide to physical examination, ed 5,
St. Louis, 2003, Mosby.)
The presence of abnormal breath sounds or the absence of breath sounds is noted
and compared with the contralateral side. One or two repetitions of a maximal in-
spiration are taken at each landmark, again to note anything abnormal. Adventitious
sounds such as crackles (rales) and wheezes (rhonchi) are also noted. Crackles may
indicate the reopening of previously closed airways or, if nonrhythmic, may be a sign
of fluid in the large airways. Wheezes are continuous and thought to be produced
by air flowing through narrow airways at high velocities. Expiratory wheezes are
associated with diffuse airway obstruction from extensive secretions in the airways
(Figure 6-7).

FIGURE 6-7. Anatomical representations of adventitious breath sounds.

(From Seidel HM, Ball JW, Dains JE et al: Mosby's guide to physical examination, ed 5,
St. Louis, 2003, Mosby.)

Breath sounds are generated by air flow turbulence throughout the lung fields
during inspiration and expiration. There are four types of breath sounds: tracheal,
bronchial, vesicular, and bronchovesicular. Tracheal breath sounds are auscultated
directly over the trachea. They are loud and high pitched with a pause of equal
duration between inspiration and expiration. Bronchial breath sounds, which can be
heard over the manubrium between the clavicles or posteriorly between the scapulae,
are similar to tracheal breath sounds but the inspiration is shorter. Vesicular breath
sounds can be heard over the peripheral lung fields and are identified by a long
inspiration and short expiration with a faint, low-pitched sound and no pause
between inspiration and expiration. Bronchovesicular breath sounds can be heard
adjacent to the sternum or posteriorly between the scapulae and have a lower,
medium-pitched sound with no pauses between inspiration and expiration; Table
6-1 illustrates and defines the difference.Auscultation should be carried out last,
after other techniques have provided information that will assist in interpretation.
Too often the temptation is to rush right in with the stethoscope, thereby missing
the opportunity to gather other data that might be useful. Auscultation is also used
to determine the type of treatment and breathing retraining necessary for each
patient's best respiration outcomes. It may provide feedback about the continuing
effectiveness of pulmonary treatment.

TABLE 6-1. Characteristics of Normal Breath Sounds

Type Pitch Amplitude Duration Quality Normal Loca-

tion
Bronchial (tra- High Loud Inspiration  Harsh, hollow Trachea and
cheal) < expiration tubular larynx
Bronchovesicu- Moderate Moderate Inspiration =- Mixed Over major
lar  expiration bronchi where
fewer alveoli
are located:
posterior, be-
tween scapu-
lae especially
on right; an-
terior, around
upper sternum
in first and
second inter-
costal spaces
Vesicular Low Soft Inspiration  Rustling, like Over peripher-
>  the sound of al lung fields
expiration the wind in where air flows
the trees through small-
er bronchioles
and alveoli

From Jarvis C: Physical examination and health assessment, ed 4, Philadelphia, 2004,

Saunders, Table 18-1, p 455.

Indeed, clinicians must always be open to what has been described as the “clinical
pearl of unexpected findings”7: the key (one among many) to a successful physical
examination is to respect your judgment and your instinct whenever you find that
which you had not expected to find—that is, when your sense of the expected or of
what you might call the normal has been violated. Pay attention when that happens
even if it doesn't seem to make sense or you can't explain it easily.

> Read full chapter

Pulmonary System
Paul E.H. Ricard, in Acute Care Handbook for Physical Therapists (Fourth Edition),
2014

Auscultation
Auscultation is the process of listening to the sounds of air passing through the
tracheobronchial tree and alveolar spaces. The sounds of airflow normally dissipate
from proximal to distal airways, making the sounds less audible in the periphery
than the central airways. Alterations in airflow and ventilation effort result in dis-
tinctive sounds within the thoracic cavity that may indicate pulmonary disease or
dysfunction.

Auscultation proceeds in a systematic, side-to-side, and cephalocaudal fashion.

Breath sounds on the left and right sides are compared in the anterior, lateral, and
posterior segments of the chest wall, as shown in Figure 4-4. The diaphragm (flat
side) of the stethoscope should be used for auscultation. The patient should be
seated or lying comfortably in a position that allows access to all lung fields. Full
inspirations and expirations are performed by the patient through the mouth, as the
clinician listens to the entire cycle of respiration before moving the stethoscope to
another lung segment.

FIGURE 4-4. Landmarks for lung auscultation on (A) anterior, (B) posterior, and (C)
lateral aspects of the chest wall.

(Courtesy Peter P. Wu.)

All of the following ensure accurate auscultation:

•
 Make sure stethoscope earpieces are pointing up and inward (toward your
patient) before placing in the ears.
• Long stethoscope tubing may dampen sound transmission. Length of tubing
should be approximately 30 cm (12 in) to 55 cm (21 to 22 in).12
• Always check proper function of the stethoscope before auscultating by listen-
ing to finger tapping on the diaphragm while the earpieces are in place.
• Apply the stethoscope diaphragm firmly against the skin so that it lays flat.

• Observe chest wall expansion and breathing pattern while auscultating to help
confirm palpatory findings of breathing pattern (e.g., sequence and symme-
try). For example, decreased chest wall motion palpated earlier in the left lower
lung field may present with decreased breath sounds in that same area.

Breath sounds may be normal or abnormal (adventitious or added) breath sounds;

all breath sounds should be documented according to the location and the phase
of respiration (i.e., inspiration, expiration, or both) and in comparison with the
opposite lung. Several strategies can be used to reduce the chance of false-positive
adventitious breath sound findings, including the following:

• Ensure full, deep inspirations (decreased effort can be misinterpreted as de-

creased breath sounds).
• Be aware of the stethoscope tubing's touching other objects (especially venti-
lator tubing) or chest hair.
• Periodically lift the stethoscope off the chest wall to help differentiate extrane-
ous sounds (e.g., chest or nasogastric tubes, patient snoring) that may appear
to originate from the thorax.

To maximize patient comfort, allow periodic rest periods between deep breaths to
prevent hyperventilation and dizziness.

Normal Breath Sounds.

Clinically, tracheal or bronchial and vesicular breath sounds generally are document-
ed as “normal” or “clear” breath sounds; however, the use of tracheal or vesicular
breath sounds is more accurate.

Tracheal, Bronchial, or Bronchovesicular Sounds.

Normal tracheal or bronchial breath sounds are loud tubular sounds heard over
the proximal airways, such as the trachea and main stem bronchi. A pause is
heard between inspiration and expiration; the expiratory phase is longer than the
inspiratory phase. Normal bronchovesicular sounds are similar to bronchial breath
sounds; however, no pause occurs between inspiration and expiration.11,12
Vesicular Sounds.

Vesicular sounds are soft rustling sounds heard over the more distal airways and
lung parenchyma. Inspiration is longer and more pronounced than expiration be-
cause a decrease in airway lumen during expiration limits transmission of airflow
sounds.11,12

Note: In most reference books, a distinction between normal bronchial and bron-
chovesicular sounds is made to help with standardization of terminology. Often,
however, this distinction is not used in the clinical setting.

Clinical Tip
The abbreviation CTA stands for “clear to auscultation.”

Abnormal Breath Sounds.

Breath sounds are abnormal if they are heard outside their usual location in the chest
or if they are qualitatively different from normal breath sounds.14 Despite efforts to
make the terminology of breath sounds more consistent, terminology may still vary
from clinician to clinician and facility to facility. Always clarify the intended meaning
of the breath sound description if your findings differ significantly from what has
been documented or reported. Abnormal breath sounds with possible sources are
outlined in Table 4-5.

TABLE 4-5. Possible Sources of Abnormal Breath Sounds

Sound Possible Etiology

Bronchial (abnormal if heard in areas where vesic- Fluid or secretion consolidation (airlessness) that
ular sounds should be present) could occur with pneumonia
Decreased or diminished (less audible) Hypoventilation, severe congestion, or emphyse-
ma
Absent Pneumothorax or lung collapse

Adventitious Breath Sounds.

Adventitious breath sounds occur from alterations or turbulence in airflow through
the tracheobronchial tree and lung parenchyma. These sounds can be divided into
continuous (wheezes and rhonchi) or discontinuous (crackles) sounds.12,14

The American Thoracic Society and American College of Chest Physicians have
discouraged use of the term rhonchi, recommending instead that the term wheezes
be used for all continuous adventitious breath sounds.15 Many academic institutions
and hospitals continue to teach and practice use of the term rhonchi; therefore it is
mentioned in this section.

Continuous Sounds

WHEEZE.

Wheezes occur most commonly with airway obstruction from bronchoconstriction

or retained secretions and commonly are heard on expiration. Wheezes also may be
present during inspiration if the obstruction is significant enough. Wheezes can
be high pitched (usually from bronchospasm or constriction, as in asthma) or low
pitched (usually from secretions, as in pneumonia).

STRIDOR.

Stridor is an extremely high-pitched wheeze that occurs with significant upper

airway obstruction and is present during inspiration and expiration. The presence of
stridor indicates a medical emergency. Stridor is also audible without a stethoscope.

Clinical Tip
Acute onset of stridor during an intervention session warrants immediate notificat-
ion of the nursing and medical staff.

Rhonchi.

Low-pitched or “snoring” sounds that are continuous characterize rhonchi. These

sounds generally are associated with large airway obstruction, typically from secre-
tions lining the airways.

Discontinuous Sounds

Crackles.
Crackles are bubbling or popping sounds that represent the presence of fluid or
secretions, or the sudden opening of closed airways. Crackles that result from fluid
(pulmonary edema) or secretions (pneumonia) are described as “wet” or “coarse,”
whereas crackles that occur from the sudden opening of closed airways (atelectasis)
are referred to as “dry” or “fine.”

Clinical Tip
Wet crackles also can be referred to as rales, but the American Thoracic Soci-
ety–American College of Chest Physicians has moved to eliminate this terminology
for purposes of standardization.15

Extrapulmonary Sounds.
These sounds are generated from dysfunction outside of the lung tissue. The most
common sound is the pleural friction rub. This sound is heard as a loud grating
sound, generally throughout both phases of respiration, and almost always is asso-
ciated with pleuritis (inflamed pleurae rubbing on one another).12,14 The presence
of a chest tube inserted into the pleural space also may cause a sound similar to a
pleural rub.

Clinical Tip
Asking the patient to hold his or her breath can help differentiate a true pleural
friction rub from a sound artifact or a pericardial friction rub.

Voice Sounds.
Normal phonation is audible during auscultation, with the intensity and clarity of
speech also dissipating from proximal to distal airways. Voice sounds that are more
or less pronounced in distal lung regions, where vesicular breath sounds should
occur, may indicate areas of consolidation or hyperinflation, respectively. The same
areas of auscultation should be used when assessing voice sounds. The following
three types of voice sound tests can be used to help confirm breath sound findings:

1. Whispered pectoriloquy. The patient whispers “one, two, three.” The test is
positive for consolidation if phrases are clearly audible in distal lung fields.
This test is positive for hyperinflation if the phrases are less audible in distal
lung fields.
2. Bronchophony. The patient repeats the phrase “ninety-nine.” The results are
similar to whispered pectoriloquy.
3. Egophony. The patient repeats the letter e. If the auscultation in the distal lung
fields sound like a, then fluid in the air spaces or lung parenchyma is suspected.

> Read full chapter

Disorders of the Cardiovascular System

Colin C. Schwarzwald, in Equine Internal Medicine (Fourth Edition), 2018
Pulmonary Auscultation
Auscultation of the lungs should reveal normal breath sounds with the horse at rest,
while ventilating into a rebreathing bag, and after exercise. Decreased or absent
airway sounds or large airway sounds in the ventral portions of the thorax indicate
a pleural effusion, a common finding in biventricular or right-sided heart failure.
Moist or bubbling (fluid) sounds or crackles (i.e., rales) are uncommonly auscultated
in the lungs of horses with pulmonary edema and left-sided heart failure. Instead,
tachypnea associated with harsh bronchovesicular breath sounds is usually heard, as
horses with chronic left-sided CHF seem to develop more interstitial than alveolar
pulmonary edema. When alveolar edema does develop, respiratory distress may
be severe, crackles may become evident, and free fluid may be auscultated in the
trachea. On rare occasion, primarily with peracute left-sided heart failure, froth
will be visible at the nares and the horse will cough and expel large quantities of
pulmonary edema (Fig. 9.10). Such horses demonstrate severe respiratory distress
(marked tachypnea and dyspnea), anxiety, and agitation.

Fig. 9.10. Peracute pulmonary edema in a horse with a ruptured chorda tendinea.
The photo was taken immediately after euthanasia. An important note is that tracheal
froth is often a postmortem artifact, particularly when observed hours after death.

> Read full chapter

PHYSICAL EXAMINATION PROCE-

DURES
PATRICIA HRYNCHAK, in Clinical Procedures in Primary Eye Care (Third Edition),
2007
Carotid bruit
Auscultation for a systolic bruit is an easy rapid technique to gain information in
the diagnosis of significant carotid stenosis. 77% of patients with an audible
bruit have been shown to have significant stenosis (Lawrence & Oderich 2002)
on angiography. However, only about 57% of patients with significant stenosis
(over 50%) will have an audible bruit (Lawrence & Oderich 2002). Combining a
history of amaurosis fugax and ocular signs such as venous stasis retinopathy or
other signs of ocular ischaemia with the presence of a bruit increases diagnostic
accuracy significantly. More sensitive testing for carotid stenosis includes duplex
ultrasound scanning or the carotid arteries and carotid angiography, which are
arranged through a referral to a family physician or internist.

Another technique infrequently used to determine carotid insufficiency is oph-

thalmodynamometry. In ophthalmodynamometry the relative ophthalmic artery
pressure is measured by applying pressure to the sclera while watching for the
pulsation (diastolic pressure) and collapse (systolic pressure) of the arterial tree at
the optic nerve head. The technique requires only the ophthalmodynamometer,
which is small and portable, and a direct ophthalmoscope or a binocular indirect
ophthalmoscope. There is concern with this technique that the ophthalmic artery
may become permanently occluded when measuring the systolic pressure. The
technique is also prone to error, with patient cooperation being crucial and may
require an assistant to read the values. In addition, a clear ocular media is required
for adequate visualisation of the retinal vasculature. The results are dependent on
the intraocular pressure and are compared to the patient's brachial blood pressure
to determine if the values are within normal limits (the diastolic should be within 45
to 60% of the diastolic blood pressure and the systolic should be within 57 to 70%
of the brachial artery blood pressure).

> Read full chapter

Murmurs
Andrew N. Pelech, in Nelson Pediatric Symptom-Based Diagnosis, 2018

Auscultation
Thorough auscultation in the cooperative patient may take as long as 5-10 minutes
and should include listening in the principal areas of the precordial auscultation
(tricuspid, pulmonary, mitral, and aortic) with both the bell and diaphragm of the
stethoscope, with the patient in the supine, sitting, and standing positions. These 4
areas serve as a guide to auscultation of the heart (Fig. 8.5). These are the optimal
sites for listening to sounds that arise within the chambers and great vessels:

FIGURE 8.5. Diagram showing systolic murmurs audible at various locations. Less
common conditions are shown in smaller type. AS, aortic stenosis; ECD, endocardial
cushion defect; HOCM, hypertrophic obstructive cardiomyopathy; IHSS, idiopathic
hypertrophic subaortic stenosis; PAPVR, partial anomalous pulmonary venous re-
turn; TAPVR, total anomalous pulmonary venous return.

(From Park MK. Park's Pediatric Cardiology for Practitioners. 6th ed. Philadelphia:
Elsevier; 2014:33, Figure 2-12.)

1. The tricuspid area is represented by the fourth and fifth intercostal spaces
along the left sternal edge but extends to the right of the sternum as well as
downward to the subxiphisternal area.
2. The pulmonary area is the second intercostal space along the left sternal
border. Murmurs that are best heard in this area may also extend to the left
infraclavicular area and often lower, along the left sternal edge to the third
intercostal space.
3. The mitral area involves the region of the cardiac apex and generally is at
the fifth intercostal space in the midclavicular line. This area may also extend
medially to the left sternal edge and laterally to the region of the axilla.
4. The aortic area, although centered at the second right intercostal space, may
extend to the suprasternal area, to the neck, and inferiorly to the third left
intercostal space. The margins of these areas are ill defined, and auscultation
should not be limited to these sites and may extend to the axillae, neck, back,
or infraclavicular areas.
 A step-by-step auscultation—first for heart sounds, subsequently for systolic mur-
murs, and then separately for diastolic murmurs—is essential. The ability to clearly
characterize the S2 is perhaps more crucial than for any other sound; the effects
of respiration are important. The components of the S2 in childhood are normally
split with inspiration and become single on expiration. A loud pulmonary closure
sound should suggest the possibility of pulmonary artery hypertension. The S2 may
be widely split and/or fixed in association with right ventricular volume overload or
delayed right ventricular conduction. Normal inspiratory splitting of the S2 should be
sought and established in all patients. As timing may be difficult in the infant with
a rapid respiratory rate, the presence of splitting at any time during the respiratory
cycle may be accepted as normal.

The right ventricle is normally just beneath the sternum. This proximity generally
makes sounds emanating from the right heart louder and less diffuse. In addition,
right heart sounds and murmurs are more influenced by the effects of respiration.

> Read full chapter

ScienceDirect is Elsevier’s leading information solution for researchers.

Copyright © 2018 Elsevier B.V. or its licensors or contributors. ScienceDirect ® is a registered trademark of Elsevier B.V. Terms and conditions apply.