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 helps in diagnosing various respiratory diseases and conditions by detecting changes in the normal breath sounds or the presence of adventitious (abnormal) sounds like crackles, wheezes, and rubs.

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 bronchioles and produce a more hollow, echoing sound.
• 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 indicative of fluid in the lung bases from atelectasis, fibrosis, or pulmonary edema.
• Wheezes: high-pitched sounds heard during expiration from constriction in the smaller bronchioles, typically related to obstructive lung disease such as asthma, COPD, or pneumonia.
• 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.

Abnormal breathing patterns

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.

Paroxysmal breathing

Definitions

Paroxysmal breathing

A breathing pattern in which the chest moves inward during inhalation and outward during exhalation. The abdomen may move in on inhale and out on exhale, opposite of normal breathing.

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 reduced FEV1 values (below 70%) and high residual volume.

Chronic obstructive pulmonary disease (COPD)

• Progressive, chronic disease caused by dysfunction of alveoli, which results in decreased expiration.
• Development of COPD is primarily due to environmental factors such as smoking or pollutants.

GOLD stratification (via the Global Initiative for 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. CF causes an overproduction of secretions from all exocrine glands.
• Symptoms: poor weight gain, cough with mucus production, recurrent respiratory infections.
• Diagnosis: blood test and/or sweat electrolyte test.

Definitions

Exocrine gland

A gland that secretes mucus through ducts to epithelial cells. Such secretions can also take the form of sweat, saliva, digestive secretions, and milk.

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.

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. Vital capacity overall is decreased while tidal volume remains normal.

Neuromuscular dysfunction

• Injury to the nervous system decreases the innervation to muscles necessary for ventilation, so muscle activation ceases.
• 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 exacerbate 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

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, wheezing, chest pain, tachycardia, pallor, altered mental status.
• Diagnosis: confirmed through chest x-ray and pulse oximetry.

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 chest x-ray or MRI and blood test. Subjective information is important in recognizing this diagnosis — previous history of DVT, recent surgical procedure, recent long flight, or discontinuation of anti-coagulant medications.

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. Disease can last 10–14 days. Increased incidence in the immunocompromised.
• Symptoms: cough with purulent or bloody sputum, chest pain, dyspnea, weight loss, fatigue.
• Diagnosis: confirmed through chest x-ray, blood test, and sputum test.
• Isolation: the patient is placed in a negative-pressure private room, and all healthcare workers wear N-95 masks before entering to reduce droplet 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).
• 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: limited mobility; avoid excessive movement on the PICC side, and no blood pressures taken 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 water seal (suctions to wall) or Heimlich valve (suctions to canister).

• 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: bed mobility only; ambulation is contraindicated.

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.

Oxygen delivery systems (nasal cannula, face mask)

Devices used to deliver supplemental oxygen.

• Precautions: monitor oxygen saturation (SpO₂); ensure secure tubing.
• 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.
• Do not pull, kink, or dislodge any line.
• Secure tubing to prevent trip hazards or disconnection during transfers or gait.
• Keep drainage systems below insertion sites to prevent backflow.
• Avoid Valsalva or straining with patients who have ICP monitors or chest tubes.
• Monitor vitals, oxygen saturation, and patient tolerance with any line in use.

Common abbreviations used

Definitions

PIV

Peripheral intravenous line.

CVC

Central venous catheter.

PICC

Peripherally inserted central catheter.

A-line

Arterial line.

NG tube

Nasogastric tube.

PEG

Percutaneous endoscopic gastrostomy.

PEJ

Percutaneous endoscopic jejunostomy.

ETT

Endotracheal tube.

SpO₂

Peripheral oxygen saturation.

ICP

Intracranial pressure.

IABP

Intra-aortic balloon pump.