Topic 4.

Auscultation of the lungs: additional respiratory sounds (rales, crepitation, pleural

friction sound).
Course Third
specialty Medicine
Number of training hours 2 hours

Venue: classroom, ward.

І. Importance of the topic: Auscultation of the chest is one of the basic, informative methods of
examination of the respiratory patients. It allows hearing normal and pathological changed
sounds produced during act of breathing. Most of the respiratory diseases are accompanied with
certain auscultation phenomena their determining is one of clues at the diagnostic process of the
respiratory patients. In addition, auscultation allows, based on the detection of sound
phenomena, to determine how the localization and the nature of the defeat of the respiratory
system, and to quickly monitor the course of the disease. The use of auscultation of lungs in
combination with the basic and additional methods of examination used in pulmonological
practice, allows to establish a leading syndrome of respiratory involvement, on the basis of
which the nosological diagnosis is determined and a treatment plan is prescribed in accordance
with the state and international standards for the provision of medical care to patients with
therapeutic (in particular , pulmonary) profile.

ІІ. Educational goals:

 learn the technique of auscultation of the lungs

 learn to recognize additional respiratory sounds according to the characteristics
(wheezing, crepitation, pleura friction rub)
 describe the mechanism of occurrence of the additional sounds, characteristics and place
of listening
 distinguish between additional respiratory sounds according to their specific
characteristics
 learn from the definition of additional respiratory sounds to give them a clinical and
diagnostic evaluation.
 to give a comprehensive assessment of the auscultative picture of the lungs, and to
summarize the data obtained during the inquiry, examination, palpation of the chest and
comparative and topographic percussion of the lungs, as well as auscultation of the lungs
 to demonstrate the method of bronchophony
 assessment of bronchophony, its diagnostic importance

ІІІ. Materials for independent work

1. How are additional respiratory sounds classified?
2. What mechanism of formation of dry rales (describe all possible pathogenetic variants)?
3. What is the mechanism of formation of moist rales?
4. What is the similarity and what is the difference between moist sonorous and non-
sonorous rales?
5. Diagnostic value of moist sonorous rales
6. Diagnostic value of moist non-sonorous rales
7. What is crepitation and what is the pathophysiological basis of its occurrence?
8. Diagnostic value of crepitation
9. How to distinguish moist rales from crepitation during lung auscultation
 10. What is the sound of pleura friction rub and what is the pathophysiological basis of its
occurrence?
11. Diagnostic value of the pleura friction rub
12. How to distinguish pleura friction rub from crepitation?
13. How to distinguish pleura friction rub from moist rales?
14. What is the splashing sound (succussio Hippocratis) and what is its diagnostic value?
15. What is the Dripping sound and what is its diagnostic value?
16. What is bronchophony and what is the method of its definition?
When does bronchophony appear to increase, decrease or to be absent?

ІV. Interdisciplinary integration.

Subject To know Practical Skills

1.Previous subject. Biological physics Principles of sound
Normal anatomy formation and spreading
Anatomy of the airways and
lungs, their blood supply
Normal physiology and innervations
Mechanics of breathing, gas
exchange in the lung and
Histology tissues of system organs
Ontogenesis of the
respiratory tract,
histological structure of the
respiratory tract and alveoli
2.The following Internal Medicine Pathological symptoms and To conduct
subjects syndromes of the respiratory auscultation of the
systems diseases lungs and method
of bronchophony,
assess of
qualitative and
quantitative
changes of the
vesicular
respiratory sound,
additional sound,
for further
differential
diagnosis
3.Interdisciplinary Pharmacology Classification and the main
integration. characteristics of drugs used
to treat diseases of the
respiratory system
Pathological changes in the
Pathological structure of the airways and
anatomy lungs and mechanisms that
underlie the qualitative and
Pathological quantitative changes of the
physiology vesicular respiratory sound
and development of
additional sounds
V. Topic content

Additional lung sounds

Additional lung sounds (ALS) are produced in the trachea, bronchi, alveoli, between the
pleural sheets, pathological cavity in the lungs due to the foreign bodies or material in them
(exudates, pus, blood, mucus, fluid, sputum). These masses can be moved by the air passing
through the trachea and bronchi and produce vibrations responsible for accessory sounds.
Three types of the ALS can be heard at the respiratory diseases: rales, crepitation, pleural
friction rub.
Rales are ALS occurring in the trachea, bronchi, and lung cavities. They can be moist and
dry.
Dry rales occur only in the bronchi at narrowing of the luminal. This narrowing can be
caused by:
1. Swelling of the bronchial mucosa due to inflammation.
2. Spasm of the smooth muscles of small bronchi.
3. Accumulation of viscous sputum, which can adhere to the bronchial walls and narrow
the lumen.
4. Formation of fibrous tissue in the walls of separate bronchi.
5. Vibration of the viscous sputum at moving along the large and medium-sized bronchi
during expiration and inspiration.
Depending on the acoustic sensations dry rales are divided into wheezes and buzzing
rales. They are heard in the phase of inspiration and expiration. Dry rales differ in timber, pitch,
loudness. As to the pitch and timber they are divided into high pitched sibilant (wheeze) and
sonorous or buzzing rales. Wheeze develops as a result of narrowing of the luminal of the small
bronchi. Buzzing rales occur in narrowing of larger bronchi or when viscous sputum
accumulates in them.
The intensity of dry rales depends on the intensity of respiration, the degree of
involvement, depth of the involved bronchi.
The amount of dry rales can be different: from solitary to numerous, disseminated all
over the lungs (bronchial asthma, generalized bronchitis).
Dry rales always are sign of bronchitis.
Moist rales are formed as a result of accumulation of fluid secretion (sputum, blood, pus)
in the bronchi or in the pathological cavity when the air is passing through this secretion, air
bubbles of various sizes are formed, burst and produce noise. Such sounds can be heard when air
bubbles are burst if air is blown in water through a narrow tube. These sounds are called moist
rales. Moist rales are heard both at the phase of inspiration and the phase of expiration, but at
inspiration they are louder.
Moist rales may be fine bubbling, medium bubbling, and coarse bubbling according to
the size of the bronchi or cavity where they develop. Fine bubbling rales are formed in small
bronchi, coarse bubbling in large bronchi, large bronchiectases, cavities which communicate
with large bronchi and are filled with secretion. The mechanism of the rales formation in the
large cavities is the same as in the bronchi, because they always contain fluid. Fine rales are
usually more numerous then coarse. They are softer, briefer and more high-pitched than coarse
ones. The sound of coarse rales is louder, longer, and low-pitched. The rales can be heard in
symmetrical areas of the lungs (diffuse bronchitis, marked congestion in the lungs) or on a
limited area of the chest (cavity in the lung, bronchiectasis, focal pneumonia).
Moist rales are divided into two groups: sonorous and non-sonorous. Sonorous character
of the rales results from the presence of consolidated tissue around the bronchi with fluid
secretion or smooth-walled cavities of the lungs which are good conductors of the sound. The
resonator is the cavity itself. Coarse sonorous rales are also called cavitary.
 Dry rales either result from mucosa swelling or presence of viscous sputum in the
bronchi. They are heard in the initial stages of bronchitis or when exudation is stopped. Moist
rales develop when the content of the bronchi is liquid. They are heard at the height of bronchitis
when exudation is liquid or in edema of the lungs when fluid accumulated in the bronchi or in
hemorrhage to the lungs when the bronchi are overfilled with blood or in lung abscess or cavity.
It means that moist rales have higher prognostic significance than dry rales. From moist rales the
most significant are fine rales because they indicate location of the inflammatory process in the
small bronchi, which, on the one hand, can be a sign of ascending bronchitis, on the other is a
danger of transition of the inflammatory process from the small bronchi to the alveoli that is
bronchitis can be complicated with pneumonia. This is especially important in the cases when
fine rales are heard over a limited area.
But there are cases when coarse rales are important. It is when they are heard in the areas
of the lungs where there are no large bronchi (lung apices or lower lobes). These coarse rales
develop in pathological cavities in the lung tissue. These may be abscesses, caverns,
bronchiectases.
Crepitation is an auscultation phenomenon that develops in the alveoli. It is close to the
moist rales. It looks like a fine soft crack appearing when a small bundle of hairs is smoothed out
above the ear. Crepitation appears when alveolar walls are imbued with exudates or transudes. In
the phase of expiration, the walls adhere, in the phase of inspiration they depart at the height of
the maneuver. Therefore, crepitation is heard at the height of inspiration.
Crepitation suggests the presence of the changes in the alveoli and involvement of the
lung tissue itself. Crepitation is heard at inflammation of the lung tissue (initial and final stages
of lobular pneumonia), lung atelectasis, congestion, lung infarction.
At the lobular pneumonia, when the exudate only begins to saturate the walls of the
alveoli induction crepitation develops, at the period of resolution, when the exudate starts
resolve, it is called reduction crepitation.
Crepitation may be physiological. Transient crepitation may develop in elderly persons
with physiological atelectasis (when for a long time the lungs do not participate in respiration
and are collapsed).
At the pulmonary edema profound crepitation is heard at the beginning when the fluid
starts filling the alveoli, later moist rales develop. At the collapse of lung tissue crepitation
appears when air enters into the collapsed portions of the lungs.
Crepitation sounds resemble fine moist rales, but as their significance is different,
because crepitation is formed in the alveoli, but rales - in the bronchi. It is necessary to
differentiate them. The distinctive features are:
1. Crepitation is heard only at the height of inspiration; fine rales both during inspiration
and expiration.
2. Crepitation develops in the alveoli of similar size, the sounds are similar in character;
fine rales develop in bronchi of different size, the sounds are various.
3. Crepitation is more profound that fine rales because each acoustic sphere involves
greater amount of alveoli than bronchi.
4. Crepitation develops simultaneously like a burst; fine rales develop over a time.
5. Crepitation does not change after coughing, while fine rales change (increase in
number, disappear, change their character).
Pleura friction rub develops due to friction of the layers of the pleura, which has become
rough, uneven and dry as a result of a pathological process. In healthy individuals the visceral
and parietal layers of the pleura are smooth; their movement in the process of respiration is
noiseless. Various pathological processes can result in disturbances of the physical properties of
the pleura, which is responsible for more intensive friction of the layers and appearance of
adventitious respiratory sound named a pleura friction rub. These changes are mainly due to
inflammation (pleurisy), which is characterized by fibrin sedimentation on the pleura followed
by formation of thick and uneven areas on its surface. Other factors may also be responsible for
pleura friction rub: tumor of the pleura, toxic involvement (uremia), and dehydration of the
organism (pleura dryness). Pleura friction rub is heard both on inspiration and expiration.
The character of the sound is various: it may resemble tender friction, scratching, rustling
of paper, crunch of snow, and squeak of new leather. The character of the pleura friction rub can
be reproduced when two fingers are rubbed near the ear. Considerably pronounced pleura
friction rub can felt with a hand. Pleura friction rub is characterized by the following: 1) this is
heard both on inspiration and expiration; 2) the sound does not propagate considerably (when
compared with rales) though it sometimes involves larger areas, 3) the sound is intermittent, it
develops in several maneuvers; 4) the sound is superficial, it is heard near the ear, 5) the sound
changes, it appears and disappears. At the chronic diseases of pleura friction rub may be
unchanged for years, 6) pain in the chest is frequent.
Pleura friction rub is usually heard along the median axillary line in the inferolateral
portions of the chest, where the respiratory excursion of the lungs is the greatest.
Not infrequently, it is difficult to differentiate pleura friction rub from moist rales. In this
case the following should be done:
1) Pressing the stethoscope increases pleura friction rub, rales do not change.
2) Cough and deep breathing in do not change pleura friction rub while rales change and
even disappear after coughing.
3) After breathing out the patient is asked to close the mouth and nose and to pull in and
out the abdomen like as abdominal respiration. The movement of the diaphragm causes sliding
of the layers of pleura, if the unclear phenomena are pleura friction rub, they would reappear; if
they are moist rales, they would stop because the air does not move through the airways and
there are no conditions for respiratory sound.
Pleura friction can be heard after pleurisy and is due to shrinkage or uneven thickening of
the layers of pleura.
Accessory respiratory sounds may appear in hydrothorax. They are splashing sound,
dripping sound.
Splashing sound (succussio Hippocratis) can be heard at shaking any cavity containing
air and fluid. This is present in hydropneumothorax. The sound is heard when the physician puts
both hands on the shoulders of the patient and quickly shakes the upper part of the patient's body.
Splashing sound is heard with the ear over the chest of the patient.
Dripping sound also appears in hydro- or pneumothorax, sometimes in a large cavern. It
appears when the drops of fluid drop from the upper cupola of the cavity on the surface of the
fluid. It appears if the patient sits up. Similar bell sound may appear due to a good resonance at
formation of moist rales in a large cavity with smooth walls.

1.Literature:

Basic:
1. Kovalyova O.N., Ashcheulova T.V. Propedeutics to Internal Medicine. Part 1. – Vinnytsya:
NOVA KNYHA, 2006. – 424 p.
2. Kovalyova O.N., Asheulova T.V. Propedeutic to internal disease. – Kharkov: KSMU. –
2005. – 552p.

Additional:
1. NykulaT.D., KhomazjukV.A. Propaedeutics of Internal Medicine and PatientCare: Study
guide of the lecture course. Part I. – Kyiv: NMU, 2005. – 38 p.
2. KhomazjukV.A.,Ostashevska T.G., Krasyuk I.V. Propaedeutics of Internal Medicine and
Patient Care: Study guide for the practical classes. Part I. – Kyiv: NMU, 2005. – 44 p.
3. Kovalyova O.N., Asheulova T.V. General inspection: manual for students. – Kharkov:
“Turbo”. – 2004. – 60p.
4. Kovalyova O.N., Asheulova T.V. Diagnostics of respiratory organs disease: manual for
students. – Kharkov: “Turbo”. – 2004. – 64p.

2. Materials of methodical support of self-training work of students

Tests

1. In a patient with bronchial respiration during the inhale and exhale, hears the additional
respiratory sound, which does not disappear when coughing and intensifies when the
phonendoscope is pushed to the chest. It may be:
a. moist rales
b. pleura friction rub
c. crepitation
d. dry rales
e. pleuro-pericardial sound

2. In a patient with a background of weakened vesicular respiration, when breathing, hears an

additional respiratory sound that resembles a crack in hair or snow. Noise does not change with
coughing and even increases. It may be:
a. moist rales
b. pleura friction rub
c. crepitation
d. dry rales
e. saccadent breathing
3. In a patient with a background of weakened vesicular respiration, when breathing, hears the
additional respiratory sound, which resembles a bloated lobe during inhale and exhale. When
coughing, this noise decreases and partially disappears. It may be:
a. moist rales
b. pleura friction rub
c. crepitation
d. dry rales
e. vesicular respiration with prolonged expiration (stiff)
4. The pleura friction rub is hearing when:
a. cavity in the lungs
b. pleuro-pericardial squads
c. fluid in the pleural cavity
d. bronchial obstruction
e. consolidation of pulmonary tissue
5. For a syndrome of bronchial obstruction, auscultation is characterized by the additional
respiratory sound:
a. high pitched dry rales
b. crepitation
c. moist rales
d. sonorous or buzzing dry rales

Situation tasks
1. A patient with complaints of dry cough has stiff respiration and dry rales during auscultation
of the lungs. Which of the following mechanisms are of occurrence of dry rales: the narrowing of
the lumen of the bronchus, the accumulation of liquid secretion in the lumen of the bronchus, the
accumulation of thick secretion of the bronchus, and the consolidation of the pulmonary tissue?

Answer: Narrowing of the lumen of the bronchus, accumulation of the thick secret in the lumen
of the bronchus.

2. In the patient with complaints of coughing with sputum during auscultation additional
respiratory sounds were heard, which resemble fine bubbling wet rales and crepitations. List the
techniques that you will apply in the differentiation of wet rales and crepitations.
Answer: auscultation with deep breath, coughing.

4. The patient, 33 years old, admitted to the doctor with complaints of pain in the right chest,
which increases with deep breathing, dry cough that occurs when deep breathing, fever. During
examination of the patient the doctor found during percussion - clear lung sound, during
auscultation - vesicular respiration, slightly weakened at the right side at the level V-VIII
intervertebral axillary lines. In the same area, the doctor heard intermittent sounds resembling a
creaking snow, which is better heard at deep breathing and when pressing the phonendoscope.
Which additional respiratory sound was heard by a doctor? What other sounds do you need to
differentiate this sound?

Answer: The pleural friction rub. With moist rales and crepitation

Test questions:
1. What additional respiratory sounds do you know?
2. What are the causes of dry rales? What kinds of dry rales exist?
3. At what phase of breathing can they be auscultated?
4. What are the causes of wet rales? What kinds of wet rales exist?
5. At what phase of breathing can they be auscultated?
6. What does the sonority of rales depend on?
7. What are the causes of crepitating? At what phase of breathing can crepitating be
auscultated?
8. What are the causes of pleural friction rub? At what phase of breathing can pleural friction
be auscultated?
9. What are the causes of splashing sound and dripping sound? What is the method of
auscultation of this phenomenon?
10. What is bronchophony?
11. When does bronchophony appear to increase, decrease or to be absent?

VI. Materials for methodical support of classes

Practical task that should be performed during practical training

1. Auscultation of the lungs
2. Assessment additional lung sounds.
3. Recognizing and assessing bronchophony and whispered pectoriloquy