a u s c u l t a t i o n    t u t o r
Wheezes



Wheezes arise from turbulent airflow and the vibration of small airways in which there is partial
obstruction to airflow. Wheezes are heard predominantly during expiration. They occur when airways are
narrowed by bronchospasm, edema, collapse, or by intraluminal secretions, neoplasm, or foreign body.
They are diffuse in asthma and bronchitis, usually accompanying a prolonged expiratory phase of
respiration. An isolated wheeze heard in just one area may signal bronchial obstruction by a tumor or
foreign body. Wheezing is neither sensitive nor specific for detecting airflow obstruction.

Asthmatic or Obstructive Breathing: Like bronchial breathing, inspiration is short and expiration
prolonged, but there is no confusing the two. In asthma, the expiratory phase is several times longer
than in bronchial breathing, and the pitch is much higher. The listener is aware that expiration is active,
not passive, and may require significant effort. Frequently, but not always, asthmatic breathing is
accompanied by wheezes audible without the stethoscope. Emphysema produces a similar pattern of
breath sounds, but wheezing is absent and the sound intensity is diminished.
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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