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Wednesday, September 24, 2008

There's no such thing as coarse lung sounds

The rest of this week I thought I would discuss some of the basic lungsounds. I know this might sound hilarious, but there are some people who have listened to lungs for 20 years and still have no clue how to describe them.

To be fair, however, different books can describe the same sounds differently. Lets take crackles for instance. Some books say that a crackle is either fine, medium or coarse, while others say it's rhonchi, rhales and fine crackles.

On a side note, someone in my RT department (we won't name names) keeps charting "Coarse" under lungsounds. Allow me to share this information with you: there is no such lung sound as coarse.

What is coarse? Is it a coarse wheeze? Is is rhonchi? Actually, it could be both. It could be a coarse wheeze or coarse rhonchi. But, so, where is it? RUL? RML? RLL? LUL? LLL?

So we need to be more specific.

The majority of the time, however, a coarse wheeze is actually rhonchi. if you can isolate it to one particular lobe, its more likely a wheeze. But if it's continuous throught all the lungfields, it is probably not a wheeze.

Why do I say this? Because rhonchi is usually heard over a wheeze and is usually hard throughout the lungs. The low pitched coarseness of rhonchi is usually in the upper, larger airways where sound travels better, and it produces a noise that is more easily heard.

A wheeze, for definition purposes, is not a low pitched coarse sound but high pitched whistling sound. And because it comes from the small bronchial tubes in the lungs, it is NEVER heard audibly. I will discuss wheezes at a later date.

Today I want to discuss rhonchi and coarse.

There was a practice NBRC test that asked this question: You are listening to lung sounds and you hear a coarse sound throughout on inspiration and expiration. How do you best describe this sound? a) a wheeze b) rhonchi c) crackles d) a and c.

Do you want to know what the answer was? It was (drum roll please) "b" rhonchi.

If you are charting coarse, you should actually be charting rhonchi. In a lot of patients you have that loud sound on inspiratory and expiratory. It may even sound like snoring. This is not a wheeze, it is rhonchi. What you are hearing is secretions rumbling on inspiratoin and expiration.

This is probably the toughest lung sound to pick out because it's not taught very well in school. Even many doctors chart this is coarse or as a wheeze and assume it is bronchospasm.

Yet, as soon as the RT does the STAT breathing treatment, the patient feels no better and the peek flow is the same before and after. Yet, three weeks later and after the insurance company is out $10,000 because of useless breathing treatments, the patient still has those treatments ordered.

And all of that because the doctor heard rhonchi and had no idea it was not a wheeze.

Rhonchi can also produce a bubbly sound over the throat and upper airway, which almost sounds like fluid is in there. You have the patient cough and usually this goes away. However, sometimes those secretions are further embedded in the upper airway, and this causes the COARSE sound you hear.

Sometimes these secretions are embedded by the vocal cords, and produce an audible sound. As I wrote in my last post, any lung sound that is audible is not a wheeze: it is rhonchi. Either that, or it is stridor.

Stridor is usually an audible inspiratory high-pitched sound. It is usually caused because of swelling near the vocal cords. It can be the result of croup or post extubation. It can be caused due to laryngospasms. And, despite contrary belief, it is a common lung sound in adults too. Only, it usually gets charted as a wheeze, so no one ever talks about it.

However, some RT books describe stridor as any noise inspiratory and expiratory that is heard in the throat. (Dana Oakes, "Clinical Practitioner's Pocket Guide to Respiratory Therapy," describes it this way).

To hear this noise, all you have to do is take your stethoscope and set it over the throat. If you hear it loud and clear their, then the noise you heard in the lower airways was this same sound.

Yet, it is true, many times doctors only listen to the posterior lungs and hear this high pitched sound and call it a wheeze, when it is actually upper airway stridor or rhonchi. A lot of older patients get secretions stuck right up behind the vocals, and they produce this high pitched sound. This happens sometimes for no reason on healthy adults, or it can happen on those with NGs, or simply OTL (Out To Lunch) patients or SGD (She's gonna die) patients.

I'm to the point now that I get so irritated when a doctor orders a treatment because a patient has upper airway swelling or secretions and no otherwise signs of shortness of breath, that if the doctor is still standing there, I will listen to the throat and say, "What you hear isn't a wheeze, it's stridor."

"Don't you know a wheeze by now," a doctor said to me once.

"Yes, and that's a stridor."

Of course I don't do that very often, only when I'm extremely busy and don't have time for such nonsensical treatments, very tired, or simply irritated. Unfortunately that doesn't happen enough around here, so our doctors continue to go uneducated.

Now I say doctors, I know there are some nurses and even a few RTs who have no clue what lung sounds are actually bronchospasm and which are secretions. I suppose this will be a continual battle.

However, there are some really smart doctors and RNs that I work with who know the difference, and don't call me every time they hear "COARSE" lung sounds.

Tomorrow I will expound a little about crackles and then maybe wheezes.


Genevieve said...

your posts are so thorough, I wish my doctors were as thorough when they listen to my lungs and spout the word coarse. chessly

Unknown said...

Im a new RN, really enjoyed your post and also learned from it. Ditto on constantly asking for respiratory treatments. But when you hear rhonchi or strider in upper airways & the patient is unable to produce a productive cough, how can we help the patient get rid of these secretions stuck in there? I've also heard the term "gurgling" in upper aiways is that due t fluids going the wrong ways, secretions or both? When we hear any of these 3 sounds, is aspiration soon to follow?

Thanks so much for your post and I would love to hear your answer to these questions. Please keep posting!

Unknown said...

Thank you for the Info as I am a student and still learning these. I heard this sound on a pt last night and the RRT told me this was coarse breath sounds. Do I try and convince them since I'm a student or go along with it and just know better? Thank you.

John Bottrell said...

There's an old saying that you can't teach an old dog new tricks. That in mind, it's better to let sleeping dogs lie. During the course of your long career you can teach the truth to those who will listen.

Unknown said...

Thank you for the information! I was reading the H&P of a patient and was puzzled by the term "course". I actually have never heard the term. Thank you for putting your link on allnurses.