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338 P R I N C I P L E S A N D P R A C T I C E O F C R I T I C A L C A R E

A B
FIGURE 13.13 Assessment of thoracic expansion. (A) Exhalation;
(B) Inhalation. 1

Practice tip
Prior to performing palpation and auscultation of a patient’s
chest, warm your hands and stethoscope diaphragm before
placing them on their skin.

Practice tip

Prior to use, remember to use an alcohol wipe to clean the
earpieces on the stethoscope to protect you from infection.

Auscultation
Careful interpretation of breath sounds and integration
of this assessment data with other findings can provide
important information about lung disorders. Use the dia-
phragm of the stethoscope and ensure full contact with
the skin for optimal listening. For a spontaneously breath-
ing patient, ask them to breathe through their mouth
(nose breathing may alter the pitch of the breath sounds).
Auscultation is performed in a systematic way so as to
compare the symmetry of breath sounds (see Figure
13.12). Normal breath sounds reflect air movement
through the bronchi, and sounds change as air moves
FIGURE 13.12 Sequence of systematic movements for auscultation and
palpation of the anterior (A) and posterior (B) chest. Comparison of the from larger to smaller airways. Sounds also change when
right and left sides of the chest should be performed by moving from side air passes though fluid or narrowed airways. Breath
to side, beginning proximally and moving distally down the chest wall. sounds therefore differ depending on the area auscul-
Palpation and auscultation of the thorax is performed in a sequential tated; the three general types of normal breath sounds are
fashion.
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bronchial, bronchiovesicular and vesicular breath sounds
(see Table 13.2).
hands on the patient’s chest and ask the patient to vocalise
repeatedly the term ‘ninety nine’. Fremitus is decreased
(that is, impaired transmission of sounds) in pleural effu-
sion and pneumothorax. Fremitus is increased over those Practice tip
regions of the lungs were transmission is increased (e.g.
22
pneumonia, consolidation). In mechanically ventilated When performing chest inspection and auscultation, check for
patients, fremitus can be detected over the lungs when symmetry between one side of the body with the other.
there are secretions in the airways.