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Clinical Practice Keywords Chest/Auscultation/ Interpretation/Assessment Practical procedures This article has been Chest auscultation double-blind peer reviewed How to perform chest auscultation and interpret the findings

lthough the first stethoscope Fig 2. Location of the lung Authors Jaclyn Proctor is respiratory for auscultation was invented lobes (anterior chest) advanced nurse practitioner at in 1816 by René-Théophile- Warrington and Halton NHS Hyacinthe Laennec, the use of A Right lung Left lung Foundation Trust; Emma Rickards is auscultation dates back to Hippocrates, respiratory nurse consultant at who would place his ear to his patient’s Horizontal Liverpool Heart and Chest Hospital chest and listen for sounds. fissure NHS Foundation Trust and Knowsley Auscultation is an important part of an Community Respiratory Service. assessment of the respiratory system and Superior is also used for cardiac and gastrointes- lobe Superior Abstract Chest auscultation is tinal examination. The procedure should lobe frequently used in the clinical always form part of an holistic assessment examination of patients. This article Middle and must be viewed alongside the patient’s lobe explains the clinical procedure for chest clinical history (Box 1). Inferior auscultation and provides a guide to The Nursing and Midwifery Council lobe Inferior interpreting findings. (2018) has included chest auscultation and lobe Oblique fissure interpretation of findings in the Standards Citation Proctor J, Rickards E (2020) of Proficiency for Registered Nurses, and stu- How to perform chest auscultation and dent nurses now learn this skill as under- interpret the findings. Nursing Times graduates. transmitted to the trachea and bronchi. [online]; 116: 1, 23-26.. To undertake a thorough assessment of These sounds are audible when ausculta- the chest, including auscultation, it is tion is performed using a stethoscope. Box 1. essential to understand the anatomy and Chest auscultation involves listening to IPPA assessment physiology of the respiratory system. Fig 1 these internal sounds to assess airflow A commonly used acronym in clinical illustrates the anatomy of the lungs and through the trachea and the bronchial tree examination of the chest is IPPA: Fig 2 highlights the location of the lung (Sarkar et al, 2015). Inspection lobes from an anterior chest perspective. Familiarity with the normal vesicular Palpation Cedar (2018) provides further information breath sounds found at specific locations Percussion on the physiology of breathing. on the chest enables health professionals Auscultation to identify abnormal sounds, which are This is an example of a systemic What is chest auscultation? often referred to as adventitious. It is not assessment tool but other tools are Vesicular breath sounds occur when the always possible to determine from which available (Simpson, 2015) vocal cords vibrate during inspiration and lobe of a lung a sound is emanating. Using expiration, when the vibrations are the four chest X-ray zones can, therefore, be helpful: Fig 1. Anatomy of the lungs l Apical zone: above the clavicles; l Upper zone: below the clavicles and Respiratory bronchioles, Large airways: above the cardiac silhouette; with alveoli and Trachea l Mid zone: level of the hilar structures; pulmonary circulation Right bronchus l Lower zone: bases. Left bronchus Equipment The bell of the stethoscope is generally Smaller airways: used to detect high-pitched sounds – at the - dichotomous apex of the lungs above the clavicle; its dia- branches phragm is used to detect low-pitched Pleural sounds in the rest of the chest (Dougherty membranes – and Lister, 2015). Fig 3 illustrates parts of Outer parietal the stethoscope. Inner visceral Infection prevention Diaphragm The stethoscope is an important tool for

PETER LAMB PETER clinical assessment, but can become

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Fig 3. Parts of the stethoscope Fig 4a. Anterior chest auscultation

Eartips Binaurals

Brace

Tubing

Chestpiece Bell Starting at the top of the chest (first intercostal space), Diaphragm use a ‘stepladder’ approach to listen to breath sounds on the anterior chest finishing at the seventh intercostal space

contaminated by micro-organisms Positioning the patient 6. Position the patient comfortably so you (Longtin et al, 2014). Adherence to local The optimal position for chest ausculta- can access their chest. infection prevention and control policies, tion is sitting in a chair, or on the side of including the cleaning of equipment the bed. However, the patient’s clinical 7. Remove or rearrange the patient’s between every patient contact, is essential. condition and comfort needs to be consid- clothing as necessary to enable you to see Nurses are advised to have a stethoscope ered during the examination and some the chest. for their own use, as sharing equipment patients may only tolerate lying at a 45° may increase infection risk and main- angle. Both these positions will facilitate 8. See whether the stethoscope feels cold. taining clean ear tips can be difficult. the assessment (Ferns and West, 2008). Warm it between your hands if necessary Non-sterile gloves are not required rou- You may need help to support the patient before applying it to the chest to avoid dis- tinely for this procedure. Nurses need to in a comfortable position during the comfort for the patient. assess individual patients for the risk of examination. exposure to blood and body fluids (Royal 9. Position the ear tips in your ears so they College of Nursing, 2018) and to be aware The procedure point slightly forward towards the nose; of local policies for glove use. 1. Ensure your stethoscope has been this will help to create a seal and will cleaned following local infection preven- reduce external noise. Preparing the environment tion and control guidance. and patient 10. Holding it between the index and Listening to a patient’s chest to establish 2. Discuss the procedure with the patient middle finger of your dominant hand, breath and any other sounds requires a quiet and gain informed consent. place the chest piece of the stethoscope area, so that health professionals can fully flat on the patient’s chest using gentle appreciate what they hear and interpret 3. Check that the patient is kept warm and pressure. their clinical relevance (Sarkar et al, 2015). the area is free from drafts. Chest auscultation requires the chest 11. Using a ‘stepladder’ approach (Fig 4a) and back to be exposed, so measures should 4. Screen the bed to maintain patient pri- listen to breath sounds on the anterior be taken to ensure the patient’s privacy and vacy and dignity. chest. This technique allows you to com- dignity is maintained at all times. A chap- pare one side of the chest with the other erone should be offered for the assessment 5. Decontaminate your hands according to in a systematic manner and detect any

PETER LAMB PETER if this is considered appropriate. local policy. asymmetry. The stethoscope should be in

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Fig 4b. Posterior chest auscultation Fig 4c. Right lateral chest auscultation

Start at the first intercostal space of the posterior chest Move from the peak of the axilla to between the seventh moving downwards, avoiding the scapula, to the seventh or eight rib on the right and left. intercostal space

contact with the chest for a full cycle of 19. Record findings in the patient’s notes often louder than usual breath sounds and inspiration and expiration at each point on (Box 2). in some patients it is audible from some the stepladder (Ferns and West, 2008). distance or when the patient breathes Interpreting findings through the mouth. With a stethoscope 12. Use the step ladder approach for the There are several adventitious sounds but you may also be able to hear a wheeze over posterior chest (Fig 4b); avoid the scapula the main ones to be aware of are crackles, the patient’s trachea (Sarkar et al, 2015). as lung sounds cannot be heard through wheeze and absent breath sounds. Wheeze is often referred to as a musical bone (Ferns and West, 2008). sound and is sometimes considered to be a Crackle precondition for conditions such as air- 13. Ask the patient to move their right arm Crackles are generated within the small flow obstruction (Simpson, 2015). to the side so the right lateral chest can be airways; they predominantly occur during Clinical conditions such as asthma are assessed (Fig 4c). Starting with the upper the inspiratory phase but can happen on associated with a high-pitched musical lobe move to the middle lobe, and finally expiration. Clinical conditions where wheeze that may be more evident on expi- the lower lobe at the bottom (Ferns and crackles maybe present include pneu- ration. An inspiratory wheeze (stridor) West, 2008). monia, pulmonary fibrosis, chronicusually results from an upper airway obstructive pulmonary disease (COPD), obstruction such as laryngeal oedema or 14. Repeat on the left side where the lung is lung infection and heart failure. the presence of a foreign body. A wheeze made up of an upper lobe and lower lobe. Crackles can be categorised as coarse or on both inspiration and expiration could fine; distinguishing between these can be be due to secretions in the airways (Welch 15. Replace the patient’s clothing and make significant – coarse crackles may indicate and Black, 2017) and the patient may need them comfortable. pneumonia, while fine crackles may sug- to be advised how to clear their chest gest pulmonary oedema. of secretions. 16. Explain your findings to the patient It takes practice to learn to differentiate and check whether they have any ques- between coarse and fine crackles and inter- Absent breath sounds tions. pretation remains subjective. This describes a lack of audible breath sounds on auscultation. It could be caused 17. Decontaminate your stethoscope. Wheeze by lung disorders that inhibit the trans- Wheeze often occurs on expiration, but mission of sounds, for example, a pneu-

PETER LAMB PETER 18. Decontaminate your hands. can also occur on inspiration. Wheezing is mothorax, pleural effusion or areas of lung

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Table 1. Quality of normal breath sounds Breath sound Intensity and Inspiratory: Positions to hear sounds pitch expiratory ratio Tracheal Very loud, high Inspiratory and Over the trachea (above the pitch expiratory sounds subclavicular notch) equal

Bronchial Loud, relatively Inspiratory sound Over the manubrium high pitch shorter than (just above the clavicles) expiratory

Bronchovesticular Medium Inspiratory and First and second intercostal loudness, expiratory sounds spaces next to the sternum intermediate equal and between the scapula pitch

Vesticular Soft, relatively Inspiratory sound Most of the lung field low pitch longer than expiratory

Box 2. Recording the findings exercise tolerance and increased breath- References lessness. She reported pain on right lower Cedar SH (2018) Every breath you take: the of chest auscultation process of breathing explained. Nursing Times; 114: aspect of the posterior chest. On assess- 1, 47-50. Accurate recording is essential to ment, Ms Green reported no underlying Dougherty L, Lister S (2015) The Royal Marsden enable clinical comparison to be made respiratory disease. Chest auscultation Manual of Clinical Nursing Procedures. Chischester: when the patient is reassessed (Table 1). identified reduced air entry on the right Wiley. Ferns T, West S (2008) The art of auscultation It is important to record: lower lobe and additional coarse crackles evaluating a patient’s respiratory pathology. l Location of auscultation – for on inspiration in the right mid zone. British Journal of Nursing; 1: 6, 772-777. example, “anterior, posterior and In this case the auscultation findings Longtin Y et al (2014) Contamination of stethoscopes and physician’s hands after a lateral chest assessed” and clinical history suggest a diagnosis of physical examination. Mayo Clinic Proceedings; 89: l Quality – description of quality or pneumonia. 291-299. timbre can be used to differentiate Raphael Garbet*, aged 45, was admitted Nursing and Midwifery Council (2018) Future between two sounds that have the Nurse: Standards of Proficiency for Registered via his GP with increased breathlessness Nurses. Bit.ly/NMCFuture same pitch and loudness – for and an audible wheeze. He had recently Royal College of Nursing (2018) Tools of the Trade: example, harsh, rustling, tubular, started treatment for asthma. His symp- Guidance for Health Professionals on Glove Use snoring (Sarkar et al, 2015) toms had been present for 24 hours and he and the Prevention of Contact Dermatitis. London: RCN. l  Location of sounds: if there are had been using his salbutamol inhaler but Sarkar M (2015) Auscultation of the respiratory abnormal sounds, where did you remained symptomatic. His personalised system. Annals of Thoracic Medicine; 10: 3, 158-168. hear them? asthma action plan suggested he should Simpson H (2015) Respiratory assessment. British Journal of Nursing; 15: 9, 484-488. visit his GP. On assessment, Mr Garbet was Welch J, Black C (2017) Respiratory problems. In: using accessory muscles to breathe and Adam S et al (eds) Critical Care Nursing Science consolidation. All these conditions pre- was pale. He was only able to complete and Practice. Oxford: Oxford University Press. vent airflow reaching parts of the lung due short sentences and was breathless at rest. to a pathological change in the function of Chest auscultation revealed inspiratory/ NMC proficiency the lung. expiratory wheeze in all lung fields on the This practical procedure will help you to left and right side. meet the NMC (2018) proficiency standard (nursing procedures: 2.8) to: In this case, the auscultation findings Case studies Use evidence-based, best practice Emma Green*, aged 65, attended the emer- along the clinical history suggest a diag- approaches to undertake chest gency department with history of a pro- nosis of acute exacerbation of asthma. auscultation and interpret findings.

PETER LAMB PETER ductive cough for five days, reduced * The patients’ names have been changed

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