Understanding Abnormal Breath Sounds in Nursing

Hello and welcome to Simple Nursing Breath Sounds Made Easy. Breath sounds are a standard part of a lot of nursing assessment and yet oftentimes we're not reporting them correctly or in a way that's going to communicate what's really happening with our patients. My name is David Woodruff. I am the editor of Critical Care Nursing Made Incredibly Easy. I hope to make this incredibly easy for you too. So let's talk about the five most common abnormal breath sounds and that would be wheezing, ronchi, rals, strider, and pleural friction rub. Now you may have heard these using different terminology, and we're going to talk about that terminology as we move through, because there is some conflicting terminology which makes it even more confusing as we're trying to understand what it is that's going on with our patient when our patient has an abnormal breath sound. But first of all, let's kind of review a little bit with the anatomy and physiology so that we understand better as to what these sounds mean and where they're coming from. So if you take a look at the upper airway, which would be Those parts, the nose, the mouth, the tongue, the trachea. So the upper part of the airway here, you can see that we have some soft structures in here. How often have you heard somebody snoring away, right? That's because of the soft palate is starting to relax a little bit, and we're getting those soft structures in the upper airway starting to close down a little on the airway, and then we get the snoring sound. So there we can have an upper airway sound, and that's in fact what stridor is caused by, is upper airway obstructions. Or we can have the sound coming from lower in the airways. Now we get down into the bronchi, into the lungs themselves, and the bronchioles and the alveoli. So those are going to cause different kinds of sounds. Now when you think about air movement through the lungs, keep in mind that most of the air movement is going to be in the upper part of the respiratory tract. So way out there in those tiny little alveoli that are way out in the distal parts of the lungs. There's not a lot of air movement. It's more like we're just kind of circulating the air that's there. Yet, if you were to put your hand in front of your face, you can feel air movement going in and out of your nose and mouth. So obviously, there's more air movement in the upper part of the airway than there is in the lower part of the airway. This is important because the more air movement we have, the louder the sound becomes. So we'd expect to have the upper airway sounds be louder, and in many cases, like a strider. you may be able to hear it even without a stethoscope. So back to our diagram here, and now let's talk about each one of these different sounds and where it's occurring in this respiratory tract. Then we're going to talk about the sounds themselves. First of all is wheezing. So wheezing can happen really pretty much anywhere in the respiratory tract, anywhere that there is a narrowing of the airway. And it's like whistling. When you whistle, you purse your lips. So you're making a smaller area for air to get out, and it makes a whistling sound. Same thing happens then with wheezing in the patient's lungs. The airway is decreased in size for some reason. Doesn't mean that we have bronchoconstriction, but it could. It could also be because we have... some secretions that are forming in the airways. Ronchi is more of a harsh, bubbly kind of sound to it. So it's usually caused by having secretions in the airway. There's usually some kind of foreign body, a secretion or maybe an actual foreign body in the airway, and the air is trying to pass by it. It's bubbling past that foreign body. Now, rals are a little different. We also call these crackles. RALs are another type of sound that we typically hear out in the distal parts of the airways So way out there in those tiny little bronchioles and the alveoli Those are going to indicate that we have some fluid that is starting to accumulate Way out there now again because it's way out there and there's not a whole lot of air movement You'd expect that these sounds are not going to be really loud Strider on the other hand is coming from an obstruction of the larger parts of the airway and we'll talk about the difference You know, I mentioned obstruction with ronchi too. So we'll talk about the differences between stridor and ronchi. And then lastly, we have a pleural friction rub, which really is occurring outside the lung and doesn't really have anything to do with the airways. But you can hear it, and oftentimes it'll sound like one of the other sounds, especially oftentimes like ronchi. So the first sound on our list here is wheezing. Let's talk a little bit about wheezing. Here is an airway that is not only... constricted a little bit here. We've got some inflammation going on. It's constricted, but we also have some secretions built up in that airway. This can happen with asthma, with COPD. Any of those inflammatory type of lung diseases are going to cause the lung to produce sputum, produce some mucus and secretions in order to try to wash away and get rid of any inflammation that's in there. So maybe it's allergens or maybe it is Cigarette smoke or whatever the case may be, the body is trying to rid itself of this foreign body by producing the inflammatory response and the end result is this mucus formation. Interstitial lung disease, okay that's more of an autoimmune kind of a problem. Infections, even pulmonary embolism, because we have a mismatch between our ventilation and perfusion, it's going to cause the patient to potentially develop some fluid. And then lastly aspiration, certainly we get foreign bodies down there in the lung. aspirate some coffee or something, for example, and the lung doesn't like it. It's like, okay, that does not belong down here. We're going to have an inflammatory response and get rid of it. So what does wheezing sound like? Wheezing is a high-pitched continuous type of a sound. It's caused by the air going in and out of the lung. whistling past those secretions or that narrowing that is occurring in the airways. Oftentimes it'll be worse on expiration. Now the reason for this is because when you inhale, the chest wall expands and it's gonna pull those airways open more. On expiration, there's relaxation of the chest wall and of course of the airways too, so they become narrower. So we typically are gonna hear wheezing first on expiration and then later on inspiration. So if you're hearing inspiratory and expiratory wheezes, this person's really pretty tight. We need to be fairly concerned with that. So let's listen to what wheezing sounds like. Now hopefully you can hear the sound in and out, that wheezing sound in and out, that whistling sound. Now the next breath sound we're going to talk about here is Rangkai. These are also, so this is the other terminology that we're using, and this is not a consistent terminology. You may use one or the other at your institution. Keep in mind that they really have not done a good job of trying to make these Terminology simplistic and the same everywhere. So, but coarse crackles or bronchi. These are often caused by obstructive pulmonary disease, COPD, bronchitis, bronchiectasis, pneumonia, chronic bronchitis, cystic fibrosis, any condition that is causing inflammation or infection in the lung and is generating mucus. Now, the difference here is that with wheezing, we had this high-pitched whistling kind of a sound. But with Ronkei, instead of the high-pitched whistling sound, we get more of a continuous low-pitched bubbling, rattling type of a sound that you hear both on inspiration and expiration. So the sound is a little different than what we heard with our wheezing. Rather than that high-pitched whistling sound, now we're hearing this continuous low-pitched bubbling or rattling type sound. So let's listen to what Ronkei sounds like. And you can tell it sounds a lot different than the wheezing dead. So this is not that same kind of sound. We're listening for that continuous, low-pitched, bubbling, rattling kind of a sound. All right, our next sound then is rawls. We also call these fine crackles. So we have our coarse crackles, which are ronchi, and then we have our fine crackles, which are rels. Now, when you're assessing these, when you're listening for these, keep in mind where they're occurring. So the coarse crackles, or ronchi, is happening in the airways. So think about where you're listening on the chest when you're listening to these sounds. Then we move down into the fine crackles. Those are going to be out there distally. Generally, bases in the back are where you're going to hear these the best because that's where you're going to hear the alveoli. What's happening with fine crackles or RALs is that we're developing some fluid or secretions that are building up in the alveoli. And this could be caused by pulmonary edema, by pneumonia, or it could be from atelectasis. So those alveoli are starting to collapse. You have the patient take a deep breath, pop some of them open, and you get those fine crackles. So what do riles or fine crackles sound like? Well, it's a brief discontinuous soft kind of a sound. So it's not a continuous in and out because air is not moving past it continuously. Think about the airways again. When you take a breath in, air is moving all the way through the airways, and it's coming all the way back out through the airways. Those are the continuous sounds. But since this is way out there in the alveoli, we have to wait for the air to get all the way down to the alveolus, make the sound, and then... The sound goes away as the person exhales. So this will be at the end of inspiration that you're going to hear this the best. It's discontinuous. It's not all the time. Popping or crackling sound. And, you know, people try to make a lot of different ways to remember what growls sound like. Fire crackling in the fireplace or hair, you know, rubbing your hair between your fingers. Cellophane being crumpled. It's those kind of sounds. But keep in mind, again. You ruffle some cellophane in your hand, and it's going to be a lot louder than what you're hearing when you're hearing RALs because they're way out there in the distal part and the alveoli. Let's listen to some RALs. Okay, can you hear that? At the end of inspiration, so the patient's taking a breath in, sound. Okay, let's listen again. Strider then. Strider is caused by upper airway narrowing. So there's a picture of the airway. You notice the two pictures on the right. We have the picture on the right that's on the left. And it's showing that the patient has a normal open airway. So air is moving in and out. There's no particular sound that you're going to hear coming in and out. But then we get to the one on the right and you can see the airway is very narrowed. So we're going to have, and there's a lot of air movement. So this is actually just like whistling, like if you were to put your lips together and whistle. Same kind of process is occurring here, and that's why it's much louder. Lots of air movement. It's in the upper airway, so that we're going to have a lot more sound that's being produced. Caused by obstruction. Some of the types of obstruction could be epiglottitis, could be pertussis, could be aspiration or croup. Those are all some of the different reasons why a patient might develop a stridor. So what does a strider sound like? A strider is a loud, high-pitched sound. It's whistling, crowing in nature, and it's usually worse on inspiration, interestingly enough, probably because we move air faster during inspiration than we do on expiration. Because inspiration is active, we're pulling the air in, as opposed to... that more passive movement that happens with expiration. So our expiratory time is longer, and therefore it may not produce as much sound as our inspiratory time. So we're listening for it, high-pitched, loud, whistling sound on inspiration. Let's listen. okay you hear that high-pitched whistling kind of sound that's your strider one more time The last type of sound that we're going to talk about here is called a pleural rub or a pleural friction rub. This is caused by having inflammation in the pleura. Now, when we're listening to breath sounds, when we put our stethoscope on somebody's chest and we're listening to breath sounds, you're not going to know just offhand that the sound is coming from the pleura and not from inside the lung because you're hearing a sound over the chest wall. And it could be localized. So you're thinking, well, okay, it sounds like he's got bronchi. in his bases, which really doesn't make a lot of sense because bronchi comes from the airways, but it may sound like that. So in order to differentiate it, we'll have to talk about how the sound is different than other breath sounds and how we're going to be able to differentiate. So inflammation of the pleura, that's what's causing this problem. Pleural effusions, empyemas, hemothorax, anything that has irritated the pleura. So the patient may have just a little inflammation in there that's causing this. And then the end result could be some pleural effusion or empyema. So what does it sound like? It's a symmetrical sound. Now, this makes it very different than all the other breath sounds we've been talking about. Because remember, again, with our respiratory system and the way that we breathe in and out, inspiratory time is shorter than expiratory time. Inspiratory time is faster. And it's... It has more energy to it than expiratory time. But with a pleural friction rub, this will be a very symmetrical sound. So that's different. It's continuous. Okay, so it falls under those other continuous ones. It's obviously not going to be fine riles. And it sounds like leather creaking. It's often localized and doesn't change with a cough. So these are some ways to be able to differentiate. If your patient has this sound and you're like, I don't know if it's bronchi or if it's a pleural friction rub. Well, have them cough. See if it's localized. Typically, a ronchi, you're going to hear it in more than one place. But the pleural friction rub, you may only hear over that one spot where we have irritation and inflammation. So let's listen to what a pleural friction rub sounds like. So can you hear that continuous and symmetrical sound? It sounds about the same on inspiration and expiration. That's much different than the other sounds we've been talking about. Let's listen again. So let's wrap this up here. When we're talking about our different types of breath sounds, wheezing is high-pitched whistling, louder over the chest and back, and this is caused by the big airways. So we've got some secretions or we have some bronchoconstriction of those large airways. Ronchi is caused by bubbling or crackling. That's going to be the sound. And it's throughout our inspiration and expiration. And then rouse is a soft kind of bubbling sound or crackling sound. It's at the end of inspiration, indicating that we've got fluid accumulating in the alveoli or that they're starting to collapse and we have adalactesis. Again, remember that alternate terminology is for ronchi, it's coarse crackles. And for rouse, it's fine crackles. Then we have our strider, a high-pitched whistling sound, louder over the upper airway, and oftentimes you don't even need a stethoscope to hear it. Lastly, we have our pleural friction rub. It's a leathery sound. It's symmetrical. Okay, that makes it much different than all the rest of them, and it's often localized. Thank you for joining me for Breath Sounds Made Easy. My name's David Woodruff, and until next time.

I hope to make this incredibly easy for you too. So let's talk about the five most common abnormal breath sounds and that would be wheezing, ronchi, rals, strider, and pleural friction rub. Now you may have heard these using different terminology, and we're going to talk about that terminology as we move through, because there is some conflicting terminology which makes it even more confusing as we're trying to understand what it is that's going on with our patient when our patient has an abnormal breath sound.

But first of all, let's kind of review a little bit with the anatomy and physiology so that we understand better as to what these sounds mean and where they're coming from. So if you take a look at the upper airway, which would be Those parts, the nose, the mouth, the tongue, the trachea. So the upper part of the airway here, you can see that we have some soft structures in here. How often have you heard somebody snoring away, right?

That's because of the soft palate is starting to relax a little bit, and we're getting those soft structures in the upper airway starting to close down a little on the airway, and then we get the snoring sound. So there we can have an upper airway sound, and that's in fact what stridor is caused by, is upper airway obstructions. Or we can have the sound coming from lower in the airways.

Now we get down into the bronchi, into the lungs themselves, and the bronchioles and the alveoli. So those are going to cause different kinds of sounds. Now when you think about air movement through the lungs, keep in mind that most of the air movement is going to be in the upper part of the respiratory tract. So way out there in those tiny little alveoli that are way out in the distal parts of the lungs. There's not a lot of air movement.

It's more like we're just kind of circulating the air that's there. Yet, if you were to put your hand in front of your face, you can feel air movement going in and out of your nose and mouth. So obviously, there's more air movement in the upper part of the airway than there is in the lower part of the airway. This is important because the more air movement we have, the louder the sound becomes. So we'd expect to have the upper airway sounds be louder, and in many cases, like a strider.

you may be able to hear it even without a stethoscope. So back to our diagram here, and now let's talk about each one of these different sounds and where it's occurring in this respiratory tract. Then we're going to talk about the sounds themselves. First of all is wheezing.

So wheezing can happen really pretty much anywhere in the respiratory tract, anywhere that there is a narrowing of the airway. And it's like whistling. When you whistle, you purse your lips.

So you're making a smaller area for air to get out, and it makes a whistling sound. Same thing happens then with wheezing in the patient's lungs. The airway is decreased in size for some reason.

Doesn't mean that we have bronchoconstriction, but it could. It could also be because we have... some secretions that are forming in the airways. Ronchi is more of a harsh, bubbly kind of sound to it.

So it's usually caused by having secretions in the airway. There's usually some kind of foreign body, a secretion or maybe an actual foreign body in the airway, and the air is trying to pass by it. It's bubbling past that foreign body.

Now, rals are a little different. We also call these crackles. RALs are another type of sound that we typically hear out in the distal parts of the airways So way out there in those tiny little bronchioles and the alveoli Those are going to indicate that we have some fluid that is starting to accumulate Way out there now again because it's way out there and there's not a whole lot of air movement You'd expect that these sounds are not going to be really loud Strider on the other hand is coming from an obstruction of the larger parts of the airway and we'll talk about the difference You know, I mentioned obstruction with ronchi too. So we'll talk about the differences between stridor and ronchi.

And then lastly, we have a pleural friction rub, which really is occurring outside the lung and doesn't really have anything to do with the airways. But you can hear it, and oftentimes it'll sound like one of the other sounds, especially oftentimes like ronchi. So the first sound on our list here is wheezing.

Let's talk a little bit about wheezing. Here is an airway that is not only... constricted a little bit here.

We've got some inflammation going on. It's constricted, but we also have some secretions built up in that airway. This can happen with asthma, with COPD. Any of those inflammatory type of lung diseases are going to cause the lung to produce sputum, produce some mucus and secretions in order to try to wash away and get rid of any inflammation that's in there.

So maybe it's allergens or maybe it is Cigarette smoke or whatever the case may be, the body is trying to rid itself of this foreign body by producing the inflammatory response and the end result is this mucus formation. Interstitial lung disease, okay that's more of an autoimmune kind of a problem. Infections, even pulmonary embolism, because we have a mismatch between our ventilation and perfusion, it's going to cause the patient to potentially develop some fluid. And then lastly aspiration, certainly we get foreign bodies down there in the lung. aspirate some coffee or something, for example, and the lung doesn't like it.

It's like, okay, that does not belong down here. We're going to have an inflammatory response and get rid of it. So what does wheezing sound like? Wheezing is a high-pitched continuous type of a sound.

It's caused by the air going in and out of the lung. whistling past those secretions or that narrowing that is occurring in the airways. Oftentimes it'll be worse on expiration. Now the reason for this is because when you inhale, the chest wall expands and it's gonna pull those airways open more.

On expiration, there's relaxation of the chest wall and of course of the airways too, so they become narrower. So we typically are gonna hear wheezing first on expiration and then later on inspiration. So if you're hearing inspiratory and expiratory wheezes, this person's really pretty tight. We need to be fairly concerned with that.

So let's listen to what wheezing sounds like. Now hopefully you can hear the sound in and out, that wheezing sound in and out, that whistling sound. Now the next breath sound we're going to talk about here is Rangkai. These are also, so this is the other terminology that we're using, and this is not a consistent terminology. You may use one or the other at your institution.

Keep in mind that they really have not done a good job of trying to make these Terminology simplistic and the same everywhere. So, but coarse crackles or bronchi. These are often caused by obstructive pulmonary disease, COPD, bronchitis, bronchiectasis, pneumonia, chronic bronchitis, cystic fibrosis, any condition that is causing inflammation or infection in the lung and is generating mucus. Now, the difference here is that with wheezing, we had this high-pitched whistling kind of a sound. But with Ronkei, instead of the high-pitched whistling sound, we get more of a continuous low-pitched bubbling, rattling type of a sound that you hear both on inspiration and expiration.

So the sound is a little different than what we heard with our wheezing. Rather than that high-pitched whistling sound, now we're hearing this continuous low-pitched bubbling or rattling type sound. So let's listen to what Ronkei sounds like.

And you can tell it sounds a lot different than the wheezing dead. So this is not that same kind of sound. We're listening for that continuous, low-pitched, bubbling, rattling kind of a sound. All right, our next sound then is rawls.

We also call these fine crackles. So we have our coarse crackles, which are ronchi, and then we have our fine crackles, which are rels. Now, when you're assessing these, when you're listening for these, keep in mind where they're occurring. So the coarse crackles, or ronchi, is happening in the airways. So think about where you're listening on the chest when you're listening to these sounds.

Then we move down into the fine crackles. Those are going to be out there distally. Generally, bases in the back are where you're going to hear these the best because that's where you're going to hear the alveoli. What's happening with fine crackles or RALs is that we're developing some fluid or secretions that are building up in the alveoli. And this could be caused by pulmonary edema, by pneumonia, or it could be from atelectasis.

So those alveoli are starting to collapse. You have the patient take a deep breath, pop some of them open, and you get those fine crackles. So what do riles or fine crackles sound like?

Well, it's a brief discontinuous soft kind of a sound. So it's not a continuous in and out because air is not moving past it continuously. Think about the airways again. When you take a breath in, air is moving all the way through the airways, and it's coming all the way back out through the airways.

Those are the continuous sounds. But since this is way out there in the alveoli, we have to wait for the air to get all the way down to the alveolus, make the sound, and then... The sound goes away as the person exhales. So this will be at the end of inspiration that you're going to hear this the best. It's discontinuous.

It's not all the time. Popping or crackling sound. And, you know, people try to make a lot of different ways to remember what growls sound like.

Fire crackling in the fireplace or hair, you know, rubbing your hair between your fingers. Cellophane being crumpled. It's those kind of sounds.

But keep in mind, again. You ruffle some cellophane in your hand, and it's going to be a lot louder than what you're hearing when you're hearing RALs because they're way out there in the distal part and the alveoli. Let's listen to some RALs. Okay, can you hear that?

At the end of inspiration, so the patient's taking a breath in, sound. Okay, let's listen again. Strider then.

Strider is caused by upper airway narrowing. So there's a picture of the airway. You notice the two pictures on the right.

We have the picture on the right that's on the left. And it's showing that the patient has a normal open airway. So air is moving in and out.

There's no particular sound that you're going to hear coming in and out. But then we get to the one on the right and you can see the airway is very narrowed. So we're going to have, and there's a lot of air movement.

So this is actually just like whistling, like if you were to put your lips together and whistle. Same kind of process is occurring here, and that's why it's much louder. Lots of air movement.

It's in the upper airway, so that we're going to have a lot more sound that's being produced. Caused by obstruction. Some of the types of obstruction could be epiglottitis, could be pertussis, could be aspiration or croup. Those are all some of the different reasons why a patient might develop a stridor. So what does a strider sound like?

A strider is a loud, high-pitched sound. It's whistling, crowing in nature, and it's usually worse on inspiration, interestingly enough, probably because we move air faster during inspiration than we do on expiration. Because inspiration is active, we're pulling the air in, as opposed to... that more passive movement that happens with expiration. So our expiratory time is longer, and therefore it may not produce as much sound as our inspiratory time.

So we're listening for it, high-pitched, loud, whistling sound on inspiration. Let's listen. okay you hear that high-pitched whistling kind of sound that's your strider one more time The last type of sound that we're going to talk about here is called a pleural rub or a pleural friction rub. This is caused by having inflammation in the pleura. Now, when we're listening to breath sounds, when we put our stethoscope on somebody's chest and we're listening to breath sounds, you're not going to know just offhand that the sound is coming from the pleura and not from inside the lung because you're hearing a sound over the chest wall.

And it could be localized. So you're thinking, well, okay, it sounds like he's got bronchi. in his bases, which really doesn't make a lot of sense because bronchi comes from the airways, but it may sound like that. So in order to differentiate it, we'll have to talk about how the sound is different than other breath sounds and how we're going to be able to differentiate. So inflammation of the pleura, that's what's causing this problem.

Pleural effusions, empyemas, hemothorax, anything that has irritated the pleura. So the patient may have just a little inflammation in there that's causing this. And then the end result could be some pleural effusion or empyema. So what does it sound like?

It's a symmetrical sound. Now, this makes it very different than all the other breath sounds we've been talking about. Because remember, again, with our respiratory system and the way that we breathe in and out, inspiratory time is shorter than expiratory time. Inspiratory time is faster.

And it's... It has more energy to it than expiratory time. But with a pleural friction rub, this will be a very symmetrical sound.

So that's different. It's continuous. Okay, so it falls under those other continuous ones.

It's obviously not going to be fine riles. And it sounds like leather creaking. It's often localized and doesn't change with a cough.

So these are some ways to be able to differentiate. If your patient has this sound and you're like, I don't know if it's bronchi or if it's a pleural friction rub. Well, have them cough.

See if it's localized. Typically, a ronchi, you're going to hear it in more than one place. But the pleural friction rub, you may only hear over that one spot where we have irritation and inflammation.

So let's listen to what a pleural friction rub sounds like. So can you hear that continuous and symmetrical sound? It sounds about the same on inspiration and expiration. That's much different than the other sounds we've been talking about. Let's listen again.

So let's wrap this up here. When we're talking about our different types of breath sounds, wheezing is high-pitched whistling, louder over the chest and back, and this is caused by the big airways. So we've got some secretions or we have some bronchoconstriction of those large airways. Ronchi is caused by bubbling or crackling. That's going to be the sound.

And it's throughout our inspiration and expiration. And then rouse is a soft kind of bubbling sound or crackling sound. It's at the end of inspiration, indicating that we've got fluid accumulating in the alveoli or that they're starting to collapse and we have adalactesis.

Again, remember that alternate terminology is for ronchi, it's coarse crackles. And for rouse, it's fine crackles. Then we have our strider, a high-pitched whistling sound, louder over the upper airway, and oftentimes you don't even need a stethoscope to hear it.

Lastly, we have our pleural friction rub. It's a leathery sound. It's symmetrical.

Okay, that makes it much different than all the rest of them, and it's often localized. Thank you for joining me for Breath Sounds Made Easy. My name's David Woodruff, and until next time.

Transcript for:Understanding Abnormal Breath Sounds in Nursing

Transcript for:
Understanding Abnormal Breath Sounds in Nursing