Auscultation and differential diagnosis of pulmonary system, lines and tubes

Auscultation

Auscultation of the pulmonary system, or listening to lung sounds with a stethoscope, is crucial for identifying potential abnormalities in the lungs and airways. It picks up changes in normal breath sounds and adventitious (abnormal) sounds such as crackles and wheezes, which the PTA reports to the supervising PT.

Normal breath sounds

Soft breath sounds heard at all parts of the thoracic cavity, from collarbone to the bottom of the lungs.

• Bronchial breath sounds are heard primarily over the trachea and manubrium (large central airways) and produce a more hollow, echoing sound. Bronchial sounds heard over peripheral lung fields are abnormal and suggest consolidation (e.g., pneumonia).
• Vesicular breath sounds are the normal, low-pitched, soft, rustling sounds heard over most of the lung surface during quiet breathing.

Adventitious breath sounds

Abnormal sounds that can be directly related to pathology.

• Crackles: crackling sound heard during inspiration, typically heard at the lung bases, from collapsed small airways snapping open (atelectasis, fibrosis) or fluid in the airways (pulmonary edema).
• Wheezes: high-pitched sounds heard during expiration from constriction in the smaller bronchioles, typically related to obstructive lung disease such as asthma or COPD.
• Stridor: harsh, vibratory sound that typically occurs during inhalation due to blockage in the airway (as when choking).
• Rhonchi: abnormal, low-pitched, rumbling or gurgling sounds heard during breathing in the larger airways of the bronchi, typically related to bronchitis, pneumonia, asthma, pulmonary edema, and heart failure.
• Diminished or absent breath sounds: often indicate problems with air or fluid in the lungs or reduced airflow to a part of the lungs. Typically related to pneumonia, heart failure, pleural effusion, or pneumothorax.

Breathing patterns

Chest wall and breathing pattern observation

Alongside auscultation, observe the rate, depth, and symmetry of breathing, along with rib cage excursion.

• Rib cage excursion is measured with a tape at the axilla (or 4th intercostal space) and again at the xiphoid process, comparing full exhalation to full inhalation. A normal change at the xiphoid level is about 2-3 inches; reduced excursion is seen in restrictive lung disease and conditions like ankylosing spondylitis.
• Respiratory rate: a normal adult rate is 12-20 breaths per minute.
• Accessory muscle use (sternocleidomastoid, scalenes) signals increased work of breathing and should be reported.

Cheyne-Stokes respiration (CSR)

Definitions

Cheyne-Stokes respiration

An abnormal breathing pattern with cycles of progressively deeper, faster breaths followed by gradually shallower breaths with temporary pauses in breathing (apnea).

• Always considered abnormal and immediately reportable.
• Causes: stroke, advanced congestive heart failure, often associated with end-of-life system failure.

Paradoxical breathing

Definitions

Paradoxical breathing

A breathing pattern in which part of the chest wall or abdomen moves opposite to normal during the breath. In flail chest or intercostal paralysis (e.g., cervical SCI), the chest wall draws inward on inhalation while the abdomen rises. In diaphragm paralysis, the abdomen draws inward on inhalation.

Causes:

• Neurological: spinal cord injuries, Guillain-Barré syndrome, muscular dystrophy.
• Trauma: flail chest (multiple rib fractures), crush injuries, fractured sternum.
• Respiratory: severe COPD, respiratory distress, paralysis of the diaphragm.

Differential diagnosis of the pulmonary system

Obstructive lung disorders

Definitions

Obstructive lung disease

Disorders of the pulmonary system in which a disease process causes difficulty with expelling air, as noted with a reduced FEV1/FVC ratio (below 70%) and high residual volume.

Chronic obstructive pulmonary disease (COPD)

• Progressive, chronic disease caused by abnormalities of the airways (chronic bronchitis) and/or the alveoli (emphysema), which limit expiratory airflow.
• Development of COPD is primarily due to environmental factors such as smoking or pollutants.

GOLD stratification (via the Global Initiative for Chronic Obstructive Lung Disease):

• GOLD 1 (mild): FEV1 ≥ 80%
• GOLD 2 (moderate): FEV1 50%-80%
• GOLD 3 (severe): FEV1 30%-50%
• GOLD 4 (very severe): FEV1 < 30%

Sub-categories of COPD:

• Chronic bronchitis: chronic inflammation of the bronchioles causing increased mucus production with cough, dyspnea, and fatigue. Diagnosed after 3 months of chronic cough per year for at least 2 consecutive years.
• Emphysema: progressive alveolar deterioration with subsequent enlargement of the distal airway, which limits expiratory flow.

Asthma

• Description: chronic inflammation of the trachea and bronchioles, causing smooth muscle constriction and increased mucus production that leads to limited expiratory airflow.
• Causes: pollutants, allergies, exercise, viral infections.
• Symptoms: wheezing, cough, dyspnea, chest tightness.

Cystic fibrosis (CF)

• Description: genetic disorder causing dysfunction of all exocrine glands, including the pancreas, pulmonary, and gastrointestinal systems. A defective CFTR protein disrupts chloride transport, so mucus and other exocrine secretions become abnormally thick and sticky, clogging the airways and pancreatic ducts, while sweat becomes abnormally salty (the basis of the sweat electrolyte test).
• Symptoms: poor weight gain, cough with mucus production, recurrent respiratory infections.
• Diagnosis: blood test and/or sweat electrolyte test.

Bronchiectasis

• Description: chronic disease caused by increased dilation of the bronchi due to an inflammatory process, which increases the difficulty of clearing secretions.
• Symptoms: generalized fatigue, wheezing, dyspnea, recurrent infections, productive cough, chest pain.

Restrictive lung disease

Definitions

Restrictive lung disease

Lung diseases that decrease the ability of individuals to fully expand their lungs. Total lung capacity and vital capacity are decreased, while the FEV1/FVC ratio is normal or increased (contrast with obstructive disease, where FEV1/FVC is below 70%). Patients often breathe with small, rapid breaths.

Neuromuscular dysfunction

• Injury to the nervous system decreases the innervation to muscles necessary for ventilation, so ventilatory muscle strength and activation are reduced.
• Diseases such as spinal cord injury, cerebrovascular accident, multiple sclerosis, and Parkinson’s disease can cause restrictive lung disease.

Trauma or changes to the chest wall

• External or intrinsic changes to the bony thorax, ribs, or pleural spaces can cause restrictive lung disease.
• Examples: ankylosing spondylitis, scoliosis, thoracic burns, rib fractures, hemothorax, pneumothorax.

Interstitial lung disease

• A wide category of diseases that cause permanent scarring and fibrotic changes to the lungs.
• Examples: pulmonary fibrosis, sarcoidosis.

Other pulmonary pathologies

Pneumonia

• Description: acute lung infection that can be caused by aspiration, viral, or bacterial sources, in which lobes of the lung fill with mucus or fluid.
• Symptoms: dyspnea, productive cough, fever, chills, chest pain.

Pulmonary edema

• Description: excessive fluid accumulation in the pulmonary interstitium and alveoli.
• Causes: failure of left ventricle, mitral valve disease, aortic valve disease, narcotic overdose, hypervolemia associated with kidney dysfunction, sepsis, pneumonia, trauma.
• Symptoms: dyspnea, fatigue, productive cough, crackles, wheezing, chest pain, tachycardia, pallor, altered mental status.
• Diagnosis: confirmed through chest x-ray; SpO₂ is often reduced.

Pulmonary embolism

• Description: a clot from the peripheral system has moved to the lungs causing infarction.
• Symptoms: dyspnea, bloody sputum, tachycardia, tachypnea, sweating.
• Diagnosis: confirmed through CT pulmonary angiography (or V/Q scan); a D-dimer blood test helps rule it out. Listen for a history of DVT, recent surgery, a recent long flight, or stopped anticoagulant medications.
• PTA role: if these symptoms appear during a session, stop treatment and report immediately to the supervising PT/RN - pulmonary embolism is a medical emergency, not a finding to treat with therapy.

Pleural effusion

• Description: excessive fluid accumulation between the visceral and parietal pleura, secondary to an inflammatory disease process, congestive heart failure, lung cancer, pneumonia, cirrhosis, or ascites.
• Symptoms: dyspnea, cough, fever, fatigue, chest pain.
• Diagnosis: confirmed with x-ray.

Atelectasis

• Description: collapsing of alveoli due to internal or external compression, neurological deficits, or inability to provide appropriate ventilatory support.
• Symptoms: dyspnea, sharp pain on the impacted side, tachypnea, low oxygen saturation rates.

Tuberculosis

• Description: Mycobacterium tuberculosis is spread through airborne droplets. Incubation period (dormant phase): 2-10 weeks. A patient on effective treatment is generally much less infectious after about 2 weeks. Increased incidence in the immunocompromised.
• Symptoms: cough with purulent or bloody sputum, chest pain, dyspnea, weight loss, fatigue.
• Diagnosis: a skin or blood test (IGRA) shows TB infection; active disease is confirmed with chest x-ray and sputum tests.
• Isolation: the patient is placed in a negative-pressure private room, and all healthcare workers wear N-95 masks before entering to reduce airborne transmission.

Lines and tubes

Vascular access devices

Peripheral intravenous line (PIV)

A short catheter inserted into a peripheral vein, typically in the arm or hand, used to deliver fluids or medications.

• Precautions: avoid dislodging or kinking the line. Monitor for infiltration (coolness, swelling). If an infusion pump alarms for an occlusion, check the tubing for kinks and closed clamps and look at the insertion site, then notify the nurse rather than adjusting the pump.
• Mobility: no restrictions; ensure tubing is secure during mobility.

Central venous catheter (CVC)

A longer catheter placed into a large central vein (e.g., subclavian or jugular) for long-term medication or nutrition. Includes peripherally inserted central catheter (PICC), Hickman catheter, and Port-a-Cath.

• Precautions: avoid blood pressure on the arm with a PICC. Avoid tugging or shoulder ROM without clearance.
• Mobility: no ambulation restrictions; secure the line and avoid vigorous or repetitive shoulder motion on the PICC side.

Arterial access devices

Arterial line (A-line)

A catheter placed in an artery (commonly radial or femoral) to measure blood pressure continuously and draw blood samples.

• Precautions: avoid dislodging; radial wrist should remain neutral.
• Mobility:
  • Radial line: limited but possible.
  • Femoral line: typically bedrest - always check with physician or nurse.

Urinary and digestive tubes

Foley catheter

A tube inserted into the bladder to drain urine into a collection bag.

• Precautions: keep bag below bladder to prevent backflow.
• Mobility: no restrictions; secure tubing and use a portable holder.

Nasogastric tube (NG tube)

Inserted through the nose into the stomach for feeding or gastric decompression.

• Precautions: keep head of bed > 30° during feeding; risk of aspiration.
• Mobility: limited; pause feeding if needed for mobility. Secure during activity.

Percutaneous endoscopic gastrostomy / jejunostomy (PEG/PEJ) tube

A tube surgically inserted into the stomach or jejunum for long-term feeding.

• Precautions: avoid pulling; check placement of gait belt.
• Mobility: minimal restrictions; avoid pressure over the insertion site.

Pulmonary devices

Chest tube

A tube inserted into the pleural space to remove air, fluid, or blood (e.g., in pneumothorax or hemothorax). Can be a water seal drainage system (collection unit that may connect to wall suction) or a portable Heimlich (one-way flutter) valve.

• Precautions: keep collection unit below chest; do not kink or tip.
• Mobility: limited ambulation with a water seal; unlimited ambulation with a Heimlich valve.

Endotracheal tube (ETT)

A tube placed in the trachea via the mouth to provide mechanical ventilation.

• Precautions: avoid head/neck movement.
• Mobility: out-of-bed mobility and ambulation are possible with the nurse, respiratory therapist, and supervising PT coordinating ventilation and monitoring.

Tracheostomy tube

A surgical airway in the trachea for long-term ventilation or airway protection.

• Precautions: ensure secure fit and monitor oxygenation.
• Mobility: allowed with portable O₂ and proper monitoring.

Mechanical ventilator

Delivers controlled breaths to a patient via an ETT or tracheostomy tube.

• Precautions: never disconnect tubing or adjust ventilator settings; if an alarm sounds, stop the activity and notify the RT or RN immediately.
• Mobility: out-of-bed mobility is possible with RT/RN coordination to manage the ventilator circuit during transfers or ambulation.

Oxygen delivery systems (nasal cannula, face mask)

Devices used to deliver supplemental oxygen: a nasal cannula delivers about 1-6 L/min, a simple face mask about 5-10 L/min, and a non-rebreather mask about 10-15 L/min.

• Precautions: monitor oxygen saturation (SpO₂); ensure secure tubing; the PTA does not change the oxygen flow rate without an order.
• Mobility: no restrictions; portable oxygen required for ambulation.

Monitoring devices

Pulse oximeter

A non-invasive monitor of oxygen saturation (SpO₂).

• Precautions: ensure proper signal; false readings from nail polish or cold extremities.
• Mobility: no restrictions.

Telemetry monitor

A device that continuously monitors cardiac rhythm.

• Precautions: leads must remain attached; notify RN if dislodged.
• Mobility: permitted with monitoring; alert staff to changes.

Intracranial pressure (ICP) monitor

Measures pressure inside the skull (often post-TBI or surgery).

• Precautions: head of bed elevated to 30°; no Valsalva maneuvers.
• Mobility: strictly limited - usually bedrest only.

General PTA guidelines for lines and tubes

• Always confirm with RN or RT (respiratory therapist) before initiating mobility.
• Secure tubing to prevent trip hazards or disconnection during transfers or gait.

Precaution vs. contraindication: a precaution means the activity may proceed with modifications and clearance (e.g., a PICC line: no blood pressure cuff on that arm, and avoid vigorous or repetitive shoulder motion on that side). A contraindication means the activity cannot be performed at all (e.g., exercise is contraindicated when resting blood pressure is in hypertensive crisis).

Stop and report: during any mobility session with lines or tubes, stop the activity and notify the supervising PT/RN immediately if the patient develops new or worsening dyspnea, chest pain, a significant drop in SpO2, a change in cardiac rhythm on telemetry, or if a line becomes dislodged or disconnected. As a PTA, your role is to recognize and report these changes to the supervising PT, not to independently alter the plan of care.