a u s c u l t a t i o n    t u t o r
Pleural friction rub



Pleural friction rubs occur when inflamed, surfaces of pleurae rub together during respiration. They are
characterized as the “creaking of new leather.” Listen at the spot where the patient feels pleuritic pain.
Rubs may be ephemeral and disappear after several respiratory cycles.
t h e    l u n g s

Diagnosis

Findings on Auscultation

Company it Keeps
Normal
  • Breath sounds symmetric
  • Vesicular throughout
  • Bronchial central
  • Minimal adventitious sounds
  • May have wheezes with forced expiration
  • Nonspecific
  • Mild retraction inhalation
  • Mild bulge exhalation
Consolidation
  • Crackles over area
  • Cough productive of yellow-green, often
    rust streaked, sputa
Open airways
  • Rhonchus or wheeze
  • Late inspiratory crackles
  • Breath sounds present, bronchial in nature
  • Dullness
  • Increased tactile fremitus
Consolidation, obstructed
  • Diminished breath sounds
  • Crackles present
  • Breath sounds are bronchial
  • Dullness
  • Decreased to absent tactile fremitus
Pleural effusion
  • Diminished breath sounds
  • Bronchial breath sounds at superior rim
  • Dullness
  • Decreased tactile fremitus
  • Focal intercostal bulge inhalation and
    exhalation
Asthma/reactive airways
  • Diffusely diminished breath sounds
  • Vesicular breath sounds
  • Prolonged expiratory phase
  • Expiratory wheezes
  • In moderately severe, expiratory and
    inspiratory wheezes
  • Expiratory stridor-type sounds
  • Eczema
  • Accentuated retraction with inspiration
Severe asthma
  • Paucity of wheezes
  • Wheezes may become inspiratory and
    expiratory
  • Diffusely diminished breath sounds
  • Early inspiratory crackles
  • Somnolence because of CO2 narcosis
  • Use of sternocleidomastoid muscles
  • Use of scalene anterior muscles
Upper airway compromise
  • Diffusely diminished breath sounds
  • Vesicular breath sounds
  • Prolonged expiratory phase
  • Inspiratory (usually holoinspiratory) stridor
  • Position of “sniffing the flowers”
  • Accentuated retraction with inspiration
Pneumothorax
  • Locally diminished breath sounds
  • Rub adjacent may be present
  • Tympany over area
  • If tension, trachea deviated to (pushed
    toward) other side
  • If tension, hypotension, sudden cardiac
    collapse
Emphysema
  • A few wheezes
  • Diffusely diminished breath sounds
  • Early inspiratory crackles if severe
  • Tympany throughout
  • Increase anteroposterior diameter
  • Lowered and flattened hemidiaphragms
Chronic bronchitis
  • Normal intensity breath sounds
  • Diffuse wheezes and rhonchi
  • Early inspiratory crackles if severe
  • Chronic cough
  • Productive cough
  • cor pulmonale, clubbing, right S3
Bronchiectasis
  • Midinspiratory crackles over area
  • Bronchial breath sounds over area
  • Dullness over area
  • Increased tactile fremitus
  • Chronic cough produces yellow-green
    sputa
Interstitial lung disease
  • Diffuse, dry, fine crackles
  • Clubbing
  • Often concurrent
  • Pleural disease
Pulmonary edema
  • Lower zones, late coarse crackles
  • A few wheezes, diffuse
  • Peripheral edema
  • Gallop—S3 or S4
  • Cardiomegaly
  • Laterally displaced, PMI, lift or heave
  • Increased JVP
Situs inversus
  • Decreased breath sounds right
  • Anterior
  • Decreased tactile fremitus, right anterior
  • Dullness to percussion, right anterior
  • Liver scratched and palpated in left
    midclavicular line
  • If Kartengener's, recurrent pneumonias
Ausculatory Descriptors of Common Lung Diagnoses
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