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Intermediate Lung Sounds

auscultation course contents image

The goal of this intermediate course is to expand your observational skills when auscultating breath sounds. The course lessons include voiced sounds: bronchophony, egophony and whispered pectoriloquy. We also provide auscultation lessons on several types of wheezes, crackles and stridor. Each of these lung sound lessons includes audio, text and dynamic waveform. The anatomy pages use illustrations to reveal an example of each lung sound (anatomy not yet available on smartphones).

Using this course

Each lesson in this course includes text describing the heart or lung abnormality and a simulated torso indicating the stethoscope chestpiece location. An audio recording of the sound is provided. Phonocardiograms or waveforms are included with each lesson. These waveforms can be a highly useful aid in learning to recognize heart murmurs. In addition, short videos clips illustrate the heart's motion for each abnormality. These animations indicate the origin of each murmur. Blood flow is also animated. For lung sounds, the source (location) of the sound can be revealed.

After completing a lesson, use the lesson table of contents to navigate to another lesson.

When all lessons have been completed, we recommend using the auscultation practice exercises or quiz. In order to gain a certificate of achievement, please complete the course lessons and practice drill during one session. Most users complete the course in 30-45 minutes.



Authors and Reviewers

Authored by Diane Wrigley, PA. Medically reviewed by Dr. Barbara Erickson, PhD, RN, CCRN.




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Lessons


Lesson #1: Vesicular - Diminished


Diminished vesicular sounds are of lower intensity and are less full or robust than vesicular sounds. These sounds can occur in patients who move a lowered volume of air, such as in frail, elderly patients or shallow breathing patients. They are also heard with obese or highly muscular patients, where tissue mass impedes sound. They exhibit a normal inspiration to expiration ratio of 3 to 1, or 4 to 1.


Lesson #2: Bronchophony - Healthy


Ask the patient to say "99" several times while auscultating the chest walls. Over healthy lung areas, "99" is not understandable. This is because sound is impeded in normal lungs. Compare this voiced breath sound to the recording in the "Bronchophony - Abnormal" lesson.


Lesson #3: Bronchophony - Abnormal


Ask the patient to say "99" several times while auscultating the chest walls. Over consolidated areas "99" is understandable. This is because acoustic filtering is reduced in consolidated lung tissue, which allows better sound transmission. Compare this breath sound to the recording in the "Bronchophony - Healthy" lesson.


Lesson #4: Egophony - e


Egophony is a voice sound with a nasal quality, often described to be like a goat's bleating. Egophony has higher intensity over abnormal areas. Over healthy lung areas, egophony will not be present. Ask the patient to say "Eeee" several times and auscultate the chest walls. Over healthy lung areas, the sound is understandable as an "E". Compare this sound to the recording in the "Egophony - a" lesson.


Lesson #5: Egophony - a


Egophony is a voiced sound with a nasal quality, often described to be like a goat's bleating. Egophony has higher intensity over abnormal lung areas. Ask the patient to say "Eeee" several times. Auscultate the chest walls. Over consolidated lung areas, the sound is heard as an "A" (aaay). Compare this sound to the recording in the "Egophony - e" lesson.


Lesson #6: Whispered Pectoriloquy - Healthy


When a patient whispers '1-2-3', the voice high frequencies, or soft vowel sounds are dampened in a normal lung. Ask the patient to whisper '1-2-3' several times while auscultating the chest walls. Over healthy lung areas, '1-2-3' is not intelligible. Compare this sound to the recording found in the "Whispered Pectoriloquy - Abnormal" lesson.


Lesson #7: Whispered Pectoriloquy - Abnormal


Voice high frequencies are more readily transmitted to the chest wall in abnormal lungs as compared to normal lungs. Ask the patient to whisper "1-2-3" several times while auscultating across the chest walls. The lung area is abnormal if the "1-2-3" sound is understood. This is the abnormal '1-2-3'. Compare this sound to the recording found in the "Whispered Pectoriloquy - Normal" lesson.


Lesson #8: Wheeze - Expiratory


Wheezes are adventitious lung sounds that are continuous with a musical quality. Wheezes can be high or low-pitched. High-pitched wheezes may have an auscultation sound similar to squeaking. Lower-pitched wheezes have a snoring or moaning quality. The proportion of the respiratory cycle occupied by the wheeze roughly corresponds to the degree of airway obstruction. Wheezes are caused by narrowing of the airways.


Lesson #9: Wheeze - Monophonic


Monophonic wheezes are loud, continuous sounds occurring in inspiration, expiration or throughout the respiratory cycle. The constant pitch of these sounds creates a musical tone. The tone is lower in pitch compared to other adventitious breath sounds. The single tone suggests the narrowing of a larger airway. These lung sounds are heard over anterior, posterior and lateral chest walls. These sounds can be more intense over lung areas affected by partial obstructions.


Lesson #10: Wheeze - Polyphonic


Polyphonic wheezes are loud, musical and continuous. These breath sounds occur in expiration and inspiration and are heard over anterior, posterior and lateral chest walls. These sounds are associated with COPD and more severe asthma.


Lesson #11: Crackles - Early Inspiratory (Rales)


Early inspiratory crackles (rales), as suggested by the title, begin and end during the early part of inspiration. The pitch is lower than late inspiratory crackles. A patient's cough may decrease or clear these lung sounds. Early inspiratory crackles suggest decreased FEV1 capacity and are characteristic of COPD.


Lesson #12: Crackles - Late Inspiratory (Rales)


Late inspiratory crackles (rales) begin in late inspiration and increase in intensity. They are normally higher-pitched and can vary in loudness. These adventitious breath sounds resemble the noise made when hook and loop fasteners are being separated. These sounds are heard over posterior bases of the lungs. They may clear with changes in posture or several deep breaths. They do not clear with coughing.


Lesson #13: Stridor


Stridor is caused by upper airway narrowing or obstruction. It is often heard without a stethoscope. It occurs in 10-20% of extubated patients. Stridor is a loud, high-pitched crowing breath sound heard during inspiration but may also occur throughout the respiratory cycle most notably as a patient worsens. In children, stridor may become louder in the supine position. Causes of stridor are pertussis, croup, epiglottis, aspirations.


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