Respiratory student website
Student Bedside Medicine
A young man wonders about his chest
“funnel chest”: oval pit near the infrasternal
notch or a more extensive concavity
Isolated, Noonan, Marfan, rickets,
tracheomalacia, bronchomalacia, congenital
heart disease (including mitral valve
A young man with an abnormal sternum.
Sternum protrudes from a
Isolated, familial, Marfan, Noonan,
rickets, acromegaly, anomalies of
Pectus carinatum “pigeon breast”
side moves less
well than the less
German: “neun und neunzig”.
The “eu” diphthong was important - not
the number “99” we are taught!
We need English sounds with “eu” like
“toy” or “boy”.
Press entire base of palm and fingertips
against the chest to feel vibrations.
“toy” or “boy”
or mass with an
Leopold Auenbrugger - Austria
1761 Latin treatise on percussion
with four fingers of one hand to
detect pleural effusion, which was
50 years later the work was
“rediscovered” by Corvisart
(Napoleon’s physician) who
made direct percussion a
widely popular exam
Special hammers and
plates were developed.
As equipment was lost,
physicians used their
Flat part of reflex hammer
is often better than the
finger of the other hand.
Clinically important ones!
Dull - Medium pitch/intensity
Resonant - Low pitch, loud
Hyperresonant/tympanitic - Lowest
Sides of posterior chest are
Primarily intended to screen
for pleural effusion.
Mass/consolidation may be
Pt needs to be sitting up
Described soon after the stethoscope was
invented and popularized over the years
for various organs.
Sound is generated by fingers (tapping,
flicking, scratching) and detected with
stethoscope; sound changes pitch and
loudness as it moves over density
Stethoscope at lowest rib.
Light tap or flick from
Sound gets louder and
higher pitched right near
stethoscope. With pleural
effusion, sound change
Easier than indirect
percussion and possible on
more frail patients.
Sensitivity = 96%, Specificity
= 100% for pleural effusion
in one study. Superior to
False positives = elevated
False negatives = small
effusions in patients
recumbant for hours.
Summer, 1816: saw children
tapping on ends of a log
and listening at each end.
Next day, rolled a notebook
of paper up into a cylinder
to listen to a woman’s chest.
Heard the heart and lungs
better than ever.
Began to experiment
with materials and
Settled on a wooden
cylinder 1 foot long
and 1.5 in. in
Three years of research resulted in “De
l’Auscultation Mediate”. He coined the term
“stethoscope” (inspector of the chest).
Known as a “cylindromaniac” and was
opposed strongly by the “percussionists” Corvisart.
It took many years before the percussionists
The reason why we must
examine the posterior,
lateral, and anterior chest.
Can actually do it all from
behind by going under
the lifted arm.
Breath sounds are what we hear with
our native ears as patient is breathing
through the nose and mouth.
Lung sounds are what we hear with the
stethoscope and is the preferred
terminology for describing the exam.
Decreased Lung Sounds
Poor effort, thick chest, diffuse
obstructive or restrictive disease
Local airway obstruction, effusion,
Vesicular Lung Sounds
Soft, rustling, 3:1 inspiration to expiration
These are the “normal lung sounds” heard
over most of the lung periphery.
Bronchial Lung Sounds
Bronchial, tracheal, tubular lung sounds.
Louder, higher pitched, and prominent
Heard anteriorly in normals over the
trachea/main stem bronchi.
Should only be heard in the upper,
anterior, central chest in patients.
Bronchial lung sounds heard anywhere
else (where vesicular should be heard) are
a sign of consolidation with an open
Laennec heard and named various
abnormal sounds which were later called
He called most of these some form of
“rale” - French for “rattle”.
Laennec could not use the term rale at
It reminded patients of the phrase “le
rale de la mort” (the death rattle) and
made him unpopular with the patient
Tuberculosis was rampant and Laennec
died of TB in 1826 at the age of 45.
Laennec developed a synonym for rales:
Rhoncus in Latin meant “rattle” and in
Greek meant “snoring” and patients and
families did not know what it meant.
However, the English who studied
Laennec’s work didn’t know what these
terms meant either and they got
Further Term Confusion
Rale muquex ou
Rale humide ou
Rale sibilant sec ou
Rale set sonore ou
Fine rale, crepitation
American Thoracic Society -1977
“Every physician seems to have his own
British/American investigations resulted in
new published nomenclature that was
supposed to get everyone communicating
“continuous” if long (>250 msec)
“discontinuous” if short (< 250 msec)
Continuous Adventitious Sounds
Late inspiratory squeak
Musical, higher pitched; hissing, squeaking,
Indicates bronchiolar obstruction
Expiratory before inspiratory
Inspiratory and expiratory: worse
disease than expiratory alone.
A hiss, whistle, or shriek; very similar to a
Better heard over upper sternum.
Indicates upper airway obstruction
either inside or outside the thorax .
The obstruction closest to the beginning
of the airflow movement creates the
Inside thorax = expiratory stridor
Above thorax = inspiratory stridor
Inspiratory stridor (upper airway obstruction above
thorax) should not be confused with wheezing.
Inspiratory wheezing would always be
accompanied by expiratory wheezing.
Lower pitched, polytonal, usually
A snoring, gurgling, bubbling sound.
Indicates expiratory collapse or secretions
of/in larger bronchi.
Late inspiratory “squeak” should not be
confused with a wheeze because an
inspiratory-only wheeze should not exist.
Heard in pulmonary fibrosis, allergic
alveolitis, and BOOP
Discontinuous Adventious Sounds
High pitched, mid-to late inspiratory;
usually over dependent parts of lung; not
changed by cough or position
Like locks of hair rubbed by your ear
Lower pitched, longer, louder “popping
sound”; early inspiration and/or
expiration; any lung region; change with
Like Velcro pulled apart
Normals may have a few fine crackles over
lower lobes with deep breathing.
Fine crackles: left heart failure,
pulmonary fibrosis, asbestosis,
Coarse crackles: bronchopneumonia,
Pure pneumonia may have no crackles at
all. Any crackles should be coarse,
reflecting the bronchial component.
Loud and creaky as two inflamed pleural
surfaces rub; confused with rhonchi or
coarse crackles; often highly localized
Lower pitch, loudest during inspiration
which helps distinguish it from rhonchi.
“Goat sound”: any spoken vowel (usually
“E”) is transmitted through the lung to the
overlying chest wall as a nasal “ay”
The change may be subtle
Most sensitive sign of consolidation;
occasional false (+) with patchy fibrosis
Increased tactile fremitus
Bronchial (tubular) lung sounds
Egophony (most sensitive)
Whispered pectoriloquy and
bronchophony are worse than egophony
and can be skipped.
If a dense infiltrate is clearly present on
imaging, but there are no bronchial lung
sounds and no egophony:
Worry about a closed airway (mucus
Dullness to percussion
Elevated dullness boundary by
Decreased lung sounds
Layer of consolidation findings
over effusion (due to atelectasis)
findings may be more
generalized over effusion.