Clinical Pearl Wednesday #28

Use that stethoscope! Too many providers are trigger happy with ordering chest x-rays in individuals with a cough.

It amazes me how lacking some people’s assessment skills are, especially when listening to lung sounds.

If a relatively healthy patient presents with fever and cough, and you auscultate crackles in a lower lobe of their lung, will the chest x-ray reveal any information that will change the outcome of how you are going to treat this individual? Probably not. It is more than likely pneumonia and they need appropriate antibiotics.

You need to be able to differentiate between rales/crackles, rhonchi and wheezing. These sounds tell you important information about what is happening inside the lungs.

Rales/Crackles = Generated by small airways snapping open on inspiration. This occurs in interstitial lung disease, pulmonary edema, and infection.

Wheezes = High-pitched musical sounds caused by air movement through constricted small airways. This usually indicates asthma, COPD, and focal masses.

Rhonchi = Course loud sounds caused by constriction or secretions in the larger airways. They are heard in patients with COPD, bronchiectasis, pneumonia, bronchitis and cystic fibrosis.

Stridor = High-pitched sounds originating from the constriction of the upper airway and occur on inspiration. It is different because it comes more from the neck rather that the chest. It commonly occurs in children with croup but also is present in epiglottis, foreign bodies lodged in the airway and tumors.

I see chest x-rays ordered all the time for simple asthma, pneumonia, bronchitis, etc. It really is unnecessary in many cases. Use that stethoscope, learn how to differentiate between the various abnormal lung sounds and know what to do in each instance. This will save your patients money, time, and radiation exposure.

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