Adventitious breath sounds

chapter 52

1. adventitious breath sounds
Abnormal lung sounds heard when listening to the chest as the person
breathes. These may be wheezes, crackles (rales), or stridor. They do
not include sounds produced by muscular activity in the chest wall or
friction of the stethoscope on the chest.

crackle
An adventitious lung sound heard on auscultation of the chest,
produced by air passing over retained airway secretions or the sudden
opening of collapsed airways. 
It may be heard on inspiration or
expiration. A crackle is a discontinuous adventitious lung sound as
opposed to a wheeze, which is continuous. Crackles are described as
fine or coarse.

coarse crackles
Louder, rather long, low-pitched lung sounds. Coarse inspiratory and
expiratory crackles indicate excessive airway secretion. 


fine crackles
Soft, very short, high-pitched lung sounds. Fine, late-inspiratory
crackles are often heard in pulmonary fibrosis and acute pulmonary
edema. 


diminished breath sound
A soft, decreased, or distant vesicular lung sound as heard through a
stethoscope. 


ETIOLOGY 
Diminished breath sounds are common in patients with
poor respiratory effort, splinting, emphysema, and other lung
conditions.


bronchial sounds
Sounds not heard in the normal lung but occurring in pulmonary
disease, indicating infiltration and solidification of the lung. 


2. pleural friction rub
The creaking, grating sounds made when inflamed pleural surfaces
move during respiration. It is often heard only during the first day or
two of a pleurisy. 


Rhonchus/Rhonchi
pl. 
A low-pitched wheezing, snoring, or squeaking sound
heard during
auscultation of the chest of a person with partial airway
obstruction.Mucus or other secretions in the airway, bronchial
hyperreactivity, or tumors that occlude respiratory passages can all
cause rhonchi.
adventitious lung sounds
Crackles and wheezes superimposed on the normal breath sounds;
indicative of respiratory disease. Most adventitious lung sounds can be
divided into continuous (wheezing) and discontinuous (crackles)
according to acoustical characteristics. 


apnea
[″ + pnoe, breathing]

Temporary cessation of breathing and,
therefore, of the body's intake of oxygen and release of carbon
dioxide. 
It is a serious symptom, esp. in patients with other
potentially life-threatening conditions. 


3. bradypnea
[″ + pnoe, breathing]

Abnormally slow breathing.

BREATHING PATTERN, INEFFECTIVE
BREATHING PATTERN, INEFFECTIVE


Diagnostic Division: Respiration 

Definition: Inspiration and/or
expiration that does not provide adequate ventilation.



RELATED FACTORS 
Neuromuscular dysfunction; Spinal cord injury;
Neurological immaturity; Musculoskeletal impairment; Bony/chest wall
deformity; Anxiety [/panic attack]; Pain; Perception/cognitive
impairment; Fatigue; [Deconditioning]; Respiratory muscle fatigue;
Body position; Obesity; Hyperventilation; Hypoventilation syndrome;
[alteration of patient's normal O2 : CO2 ratio (e.g., O2 therapy in
COPD)]



DEFINING CHARACTERISTICS 

Subjective 
[Feeling
breathless]

Objective 
Dyspnea; Orthopnea; Bradypnea;
Tachypnea; Alterations in depth of breathing; Timing ratio; Prolonged
expiration phases; Pursed-lip breathing; Decreased minute
ventilation/vital capacity; Decreased inspiratory/expiratory pressure;
Use of accessory muscles to breathe; Assumption of three-point
position; Altered chest excursion, [paradoxical breathing patterns];
Nasal flaring; [Grunting]; Increased anterior-posterior diameter

bronchovesicular sounds
A mixture of bronchial and vesicular sounds. 


Bruits

A blowing or swishing sound created by turbulence of blood flow

Capillary refill test

Immediate return of color

4. clubbing
An enlarged terminal phalanx of the finger. 
Excessive growth of the
soft tissues of the ends of the fingers gives the fingers a sausage or
drumstick appearance when viewed from above, and a beaked
appearance when viewed from the side. Increased soft tissue is
deposited beneath the cuticle, resulting in a fingertip that is thinner at
the distal interphalangeal joint than at the base of the nail. Clubbing
may be present in chronic obstructive pulmonary disease, interstitial
fibrosis of the lungs, cyanotic congenital heart disease, carcinoma of
the lung, bacterial endocarditis, and many other illnesses.
SYN:
clubbed finger; ; hippocratic finger 


cyanosis
[″ + osis, condition]

A blue, gray, slate, or dark purple
discoloration of the skin or mucous membranes caused by
deoxygenated or reduced hemoglobin in the blood. 
Cyanosis is
found most often in hypoxemic patients and rarely in patients with
methemoglobinemias. Occasionally, a bluish skin tint that superficially
resembles cyanosis results from exposure to the cold. In the very
young patient, cyanosis may point to a congenital heart defect. 


ETIOLOGY 
This condition usually is caused by inadequate
oxygenation of the bloodstream.


TREATMENT 
Supplemental oxygenation is supplied to cyanotic
patients who are proven to be hypoxemic.
See: asphyxia 


Oximetry or arterial blood gas analysis should be used to
determine whether a patient is adequately oxygenated.
Relying only on the appearance of the skin or mucous
membranes to determine hypoxemia may result in
misdiagnosis. 


deep venous thrombosis D.V.T.
A blood clot in one or more of the deep veins of the legs (the most
common site) or the veins of arms, pelvis, neck, axilla, or chest. The
clot may damage the vein or may embolize to other organs (e.g., the
heart or lungs). Such emboli are occasionally fatal. 
See: embolism,
pulmonary 


ETIOLOGY 
DVT results from one or more of the following
conditions: blood stasis (e.g., bedrest); endothelial injury (e.g., after

5. surgery or trauma); hypercoagulability (e.g., factor V Leiden or
deficiencies of antithrombin III, protein C, or protein S); congestive
heart failure; estrogen use; malignancy; nephrotic syndrome; obesity;
pregnancy; thrombocytosis; or many other conditions. DVT is a
common occurrence among hospitalized patients, many of whom
cannot walk or have one or more of the other risk factors just
mentioned.


SYMPTOMS 
The patient may report a dull ache or heaviness in the
limb, and swelling or redness may be present, but just as often
patients have vague symptoms, making clinical diagnosis
unreliable.


DIAGNOSIS 
Compression ultrasonography is commonly used to
diagnose DVT (failure of a vein to compress is evidence of a clot
within its walls). Other diagnostic techniques include impedance
plethysmography and venography. 


TREATMENT 
Unfractionated heparin or low molecular weight
heparin (LMWH) is given initially, followed by several months of
therapy with an oral anticoagulant such as warfarin. The duration of
therapy depends on whether the patient has had previous thrombosis
and whether, at the end of a specified period of treatment, the patient
has an elevated D-dimer level: patients with increased D-dimers after
several months of treatment with anticoagulants are more likely than
other patients to have recurrent clots if their anticoagulant regimen is
discontinued..


COMPLICATIONS 
Pulmonary emboli are common and may
compromise oxygenation or result in frank cardiac arrest. Postphlebitic
syndrome, a chronic swelling and aching of the affected limb, also
occurs often.


PREVENTION 
In hospitalized patients and other immobilized
persons, early ambulation, pneumatic compression stockings, or low
doses of unfractionated heparin, LMWH, or warfarin may be given to
reduce the risk of DVT.


edema
oedema 
pl. [Gr. oidema, swelling]

A local or generalized
condition in which body tissues contain an excessive amount of tissue
fluid in the interstitial spaces. 
Ascites and hydrothorax and
pericardial effusion are words for third spacing of excess fluid in the
peritoneal and pleural cavities and the pericardium, respectively.

6. Generalized edema was previously termed dropsy; it is now known as
anasarca. 


ETIOLOGY 
Edema may result from increased permeability of the
capillary walls; increased capillary pressure due to venous obstruction
or heart failure; lymphatic obstruction; disturbances in renal function;
reduction of plasma proteins; inflammatory conditions; fluid and
electrolyte disturbances, particularly those causing sodium retention;
malnutrition; starvation; or chemical substances such as bacterial
toxins, venoms, caustics, and histamine. Diagnostic studies (e.g., a
thorough history, physical examination, urinalysis, serum chemistries
and liver functions, thyroid function, and chest x-ray) help to
determine the cause and guide treatment.


TREATMENT 
Bed rest helps relieve lower extremity edema. Sitting
with the feet and legs elevated also may reduce edema in the lower
extremities. Dietary salt should be restricted to less than 2 g/day.
Fluid intake may be restricted to about 1500 ml in 24 hr. This
prescription may be relaxed when free diuresis has been attained.
Diuretics relieve swelling when renal function is good and when any
underlying abnormality of cardiac function, capillary pressure, or salt
retention is being corrected simultaneously. One of various effective
diuretics may be used. Diuretics are contraindicated in pre-eclampsia
and when serum potassium levels are very low (e.g., less than 3.0
mEq/dl). They may be ineffective in edema associated with advanced
renal insufficiency. The diet in edema should be adequate in protein,
high in calories, and rich in vitamins. Patients with significant edema
should weigh themselves daily to gauge fluid loss or retention.


PATIENT CARE 
Edema is documented according to type (pitting,
nonpitting, or brawny), extent, location, symmetry, and degree of
pitting. Areas over bony prominences are palpated for edema by
pressing with the fingertip for 5 sec, then releasing. Normally, the
tissue should immediately rebound to its original contour, so the
depth of indentation is measured and recorded. The patient is
questioned about increased tightness of rings, shoes, waistlines of
garments, and belts. Periorbital edema is assessed; abdominal girth
and ankle circumference are measured; and the patient's weight and
fluid intake and output are monitored. Fragile edematous tissues are
protected from damage by careful handling and positioning and by
providing and teaching about special skin care. Edematous extremities
are mobilized and elevated to promote venous return, and lung
sounds auscultated for evidence of increasing pulmonary congestion.
Prescribed therapies, including sodium restriction, diuretics, ACE
inhibitors, protein replacement, and elastic stockings or other elastic

7. support garments, are provided, and the patient is instructed in their
use.


Gallop rhythm
An extra heart sound (i.e., a third or fourth heart sound), typically
heard during diastole.

apex of the heart
The tip of the left ventricle, opposite the base of the heart. The apex
of the heart moves considerably with each heartbeat, and the point of
maximal impulse (PMI) can be felt on the chest wall above the apex.



Heart Base
An aneurysmal murmur (bruit) is usually loud and booming, systolic,
and heard best over the aorta or base of the heart. It is often
associated with an abnormal area of dullness and pulsation and with
symptoms resulting from pressure on neighboring structures.
intercostal space
The interval between ribs, filled by the intercostal muscles. 


intermittent claudication
Cramping or pain in leg muscles brought on by a predictable amount
of walking (or other form of exercise) and relieved by rest. This
symptom is a marker of peripheral vascular disease of the aortoiliac,
femoral, or popliteal arteries. It may be present in patients with
diffuse atherosclerosis, for example, with arterial insufficiency in the
coronary or carotid circulations as well as the limbs.
See: peripheral
vascular disease 


PHYSICAL EXAMINATION 
The patient often has thin or shiny skin
over the parts of the limb with decreased blood flow. Diminished
pulses and bruits (audible blood flow through partially blocked
arteries) may also be present.


DIAGNOSIS 
In patients with a suggestive history, the blood

8. pressure (BP) is measured in the affected limb and divided by the BP
in the arm on the same side of the body. This ratio is called the ankle-
brachial index (ABI); patients with significant peripheral vascular
disease have an ABI of less than 85%. If surgery is contemplated for
the patient, angiography may be used to define anatomical
obstructions more precisely.


TREATMENT 
Affected patients are encouraged to begin a program
of regular exercise, to try to maximize collateral blood flow to the
legs. Oral pentoxifylline improves the distance patients can walk
without pain. For severely limiting claudication, patients may require
angioplasty or arterial bypass surgery to respectively open or bypass
obstructed arteries.

Altered Heart Rate/Rhythm 

[Dys]arrhythmias (tachycardia, bradycardia); EKG [ECG] changes 


Altered Preload 
Jugular vein distention (JVD); Edema; Weight
gain; Increased/decreased central venous pressure (CVP);
Increased/decreased pulmonary artery wedge pressure (PAWP);
Murmurs


Altered Afterload 
Dyspnea; Clammy skin; Skin [and mucous
membrane] color changes [cyanosis, pallor]; Prolonged capillary refill;
Decreased peripheral pulses; Variations in blood pressure readings;
Increased/decreased systemic vascular resistance (SVR);
Increased/decreased pulmonary vascular resistance (PVR); Oliguria;
[Anuria]


Altered Contractility 
Crackles; Cough; Decreased cardiac
output/cardiac index; Decreased ejection fraction; Decreased stroke
volume index (SVI)/left ventricular stroke work index (LVSWI); S3 or
S4 sounds [gallop rhythm] 


Behavioral/Emotional 
Restlessness

apex of the lung
The superior, subclavicular portion of the lung. 


Lung Base
ANATOMY 
The lungs are connected with the pharynx through the
trachea and larynx. The base of each lung rests on the diaphragm,
and each lung apex rises from 2.5 to 5 cm above the sternal end of
the first rib, the collarbone, supported by its attachment to the hilum
or root structures. The lungs include the lobes, lobules, bronchi,

9. bronchioles, alveoli or air sacs, and pleural covering.


murmur
An abnormal sound heard when listening to the heart or neighboring
large blood vessels. 
Murmurs may be soft, blowing, rumbling,
booming, loud, or variable in intensity. They may be heard during
systole, diastole, or both. A murmur does not necessarily indicate
heart disease, and many heart diseases do not produce murmurs.
nasal flaring
Intermittent outward movement of the nostrils with each inspiratory
effort; indicates an increase in the work of breathing.
percussion
[L. percussio, a striking]

1. Striking the body surface (usually with
the fingers or a small hammer) to determine the position, size, or
density of underlying structures. 

2. A technique for mobilizing secretions from the lungs by striking the
chest wall with cupped hands.
precordium
(prē-kor′dē-ă)
pl. 
The area on the anterior surface of the body
overlying the heart and lower part of the thorax. 

precordial,
(prē-kor′dē-ăl)
S1, S2 Normal first and second heart sounds.
S1, S2, etc. first sacral nerve, second sacral nerve, and
so forth.
S3 Ventricular gallop heard after S2, an abnormal heart sound.
S4 Atrial gallop, heard before S1, an abnormal heart sound.
SpO2 The saturation of arterial blood with oxygen as
measured by pulse oximetry, expressed as a percentage.

10. substernal
[L. sub, under, below, + Gr. sternon, chest]

Situated beneath the
sternum.
Supraclavicular
[″ + clavicula, little key]

Located above the clavicle.
suprasternal
L. supra, above, on top, beyond, + Gr. sternon, chest]

Located
above the sternum.
ischemia

[Gr. ischein, to hold back, + haima, blood]

A temporary
deficiency of blood flow to an organ or tissue. 
The deficiency may be
caused by diminished blood flow either through a regional artery or
throughout the circulation.
tactile fremitus
The vibration or thrill felt while the patient is
speaking and the hand is held against the
chest. 

crepitus
A crackling or rattling sound made by a part of the
body, either spontaneously or during physical
examination.

varicose
[L. varicosus, full of dilated veins]

Pert. to
varices; distended, swollen, knotted veins. 


11. venous hum
A murmur heard on auscultation over the
larger veins of the neck.
ventricular systole
Ventricular contraction. 

breath sounds
Respiratory sounds heard on auscultation of
the chest. In a normal chest, they are
classified as vesicular, tracheal, and
bronchovesicular. 

diminished breath sound
A soft, decreased, or distant vesicular lung sound
as heard through a stethoscope. 


ETIOLOGY 
Diminished breath sounds are
common in patients with poor respiratory effort,
splinting, emphysema, and other lung conditions.

vesicular sound
A normal breath sound heard over the entire lung
during breathing. 


bronchophony
[″ + phone, voice]

An abnormal increase in
tone or clarity in vocal resonance.

12. egophony
[Gr. aix, goat, + phone, voice]

An abnormal
change in tone, somewhat like the bleat of a goat,
heard in auscultation of the chest when the subject
speaks normally. 
It is associated with
bronchophony and may be heard over the lungs of
persons with pleural effusion, or occasionally
pneumonia.
whispered pectoriloquy
A sound heard in auscultation of the chest over a
lung with a cavity of limited extent when the
patient whispers.