Auscultation of lungs and heart

Basic of heart and lungs sounds, Chest assessment, location of the auscultation, identification, fundamental of nursing, physical examination,

1. AUSCULTATION LUNGS & HEART Anil Patidar MTIN, CHARUSAT

2. Auscultation is the act of listening to sounds made by internal organs and vessels of the human body. This is usually done with a device called a stethoscope. It is a technique used to examine the respiratory system (breath sounds), cardiovascular system ( heart sounds and vascular bruits) and gastrointestinal system (bowel sounds).

3. Anatomy of Lungs The right lung is divided into 3 main lobes which are separated by the These lobes are: the superior, middle and inferior lobes. The left lung is separated by the oblique fissure into 2 main lobes: the superior and inferior.

4. Auscultation points Auscultate point Location APEX of the lungs bilaterally 2cm superior to medial 1/3 of clavicle Superior Lobes anterior 2nd intercostal space mid clavicular line Superior Lobes posterior Between C7 & T3 Middle lobe right anterior only 4th intercostal space mid- clavicular line Inferior Lobes bilaterally anterior 6th intercostal space, mid-axillary line Inferior Lobes bilaterally posteriorly between T3 & T10

5. Identification of Inter Costal Space From the angle of Louis, move your fingers to the right and you will feel a gap between the ribs. This gap is the 2nd  Intercostal space

6. How to Auscultate Lung Sounds

7. Anterior Lung Auscultation Points Start at: the apex of the lung which is right above the clavicle 2nd intercostal space to assess the right and left upper lobes. 4th intercostal space you will be assessing the right middle lobe and the left upper lobe midaxillary at the 6th intercostal space you will be assessing the right and left lower lobes.

8. Posterior Lung Auscultation Points Start right above the scapulae  to listen to the apex of the lungs. Then find  C7 (which is the vertebral prominence) and go to T3 …in between the shoulder blades and spine. This will assess the  right and left upper lobes . Then from  T3 to T10  you will be able to assess the  right and left lower lobes .

9. Normal Breath Sounds Bronchial Bronchovesicular Vesicular Tracheal

10. Name of sound Duration of sound Intensity of Expiratory sound Pitch of expiratory sound Location where heard normally Bronchial inspiration will be slightly SHORTER than expiration Loud Relatively high Over on manubrium (Larger Proximal airway) Broncho vesicular: inspiration and expiration will be EQUAL Intermediate Intermediate anteriorly: 1st and 2nd intercostal space near the sternum posteriorly: between the scapulae Vesicular: inspiration will be slightly GREATER than expiration Soft Relatively Low auscultated anteriorly and posteriorly and heard over peripheral lung fields Tracheal Inspiration and expiration will be about to Equal Very Loud Relatively high Over the trachea in the neck

11. Adventitious Sounds A) Discontinuous Lung Sounds: These are extra sounds heard  LESS   than 0.2 seconds during a full respiration cycle. Coarse Crackles: Crackles are also known as: rales Auscultated during inspiration and can extend into expiration as well Low-pitched, wet bubbling sound May be heard in patient with fluid overload, pneumonia etc. Coarse Crackles: Crackles are also known as: rales Auscultated during inspiration and can extend into expiration as well Low-pitched, wet bubbling sound May be heard in patient with fluid overload, pneumonia etc. Pleural Friction Rub: Auscultated during inspiration and expiration Low-pitched/harsh grating sound Patients may have pain when breathing in and out due to inflammation of pleural layers May be heard in patients with pleuritis

12. B) Continuous Lung Sounds: These are extra sounds heard  MORE  than 0.2 second during a full respiration cycle High Pitched, Polyphonic Wheeze Also known as: Sibilant Wheeze Auscultated mainly in expiration but may be present during inspiration Sounds like a high-pitched musical instrument with MORE than one type of sound quality May be heard in patients with asthma Low-pitched, Monophonic Wheeze Also known as: Sonorous Wheeze or Rhonchi Auscultated mainly in expiration but may be present at anytime Sounds like a low-pitched whistling tune or whine with ONE type of sound quality May be heard in patients with COPD or pneumonia etc. Stridor Auscultated during inspiration high-pitched whistling or gasping sound with harsh sound quality May be seen in children with conditions such as croup or epiglottitis or anyone with an airway obstruction etc.

13. Heart sound Heart sounds are caused by the closure of heart valves. The first sound you hear is  S1  and is caused by the closure of the   atrioventricular valves (AV) TRICUSPID AND MITRAL VALVES.  This sounds like “ LUB ”. S1 The second sound you hear is  S2  and is caused by the closure of the s emilunar valves (SL) AORTIC AND PULMONIC VALVES . This sounds like “ DUB ”. S2 S 3 –associated with blood flowing into the ventricles S 4 –associated with atrial contraction Four heart sounds can be recorded by phonocardiography, but normally only the first and the second heart sounds, are audible through a stethoscope

14. Normally, the AV valves close at the same time and the same is true for the SL valves. However, in some people these valves may close asynchronously and this would cause a split in sound. S1 split : Tricuspid and mitral valves closing asynchronously S2 split : Aortic and pulmonic valves closing asynchronously

15. Heart Auscultation Sites Remember the mnemonic “ A ll  P atients  T ake  M edicine” . This represents the order of auscultate the heart. 

16. The Base  of the heart includes the aortic and pulmonic areas , and S2 will be loudest at the base. Aortic and pulmonic murmurs are heard best at the base with the patient leaning forward and sitting up with the diaphragm of the stethoscope. The Apex  of the heart includes the tricuspid and mitral areas, and S1 will be loudest at the apex. S3 and S4 along with mitral stenosis murmurs will be heard best at this position with the patient lying on their left side with the bell of the stethoscope.

17. Basics about S3 & S4

18. Heart Murmur Cardiac murmurs are abnormal heart sounds in the form of noises resulting from turbulent blood flow, Murmurs may be: Systolic murmurs, if they occur during systole. Diastolic murmurs, if they occur during diastole Causes: Stenosis (narrowing) of heart valves Incompetence of heart valves Increase of blood flow or decrease of blood viscosity (as in anemia ).

19. Two Basic Types of Valvular Diseases Valvular stenosis: narrowing of the valve valvular insufficiency (incompetence): valve is unable to close fully; so there is regurgitation

20. Thank You