Heart and breath sounds:

Listening with skill

MARY-BETH MORIARTY, RN, BSN
MARY-BETH MORIARTY is a clinical nurse in the coronary intensive care unit at Saint Francis Hospital and Medical Center in
Hartford, Conn.

Auscultating heart and lung sounds is a fundamental component of a

physical assessment. Making sense of what you hear takes knowledge,
a sharp ear, and practice.

Listening to heart and lung sounds is a routine—but challenging—part of your patient

care. Even in the best circumstances these sounds can be difficult to hear. In addition,
heart sounds last slightly more than 0.10 seconds, and their pitch begins at the lowest
level detectable by the human ear.1 Knowledge of technique, which I will cover here,
and frequent practice will sharpen your ear.

Let's start with preparation. Before you even place your stethoscope on your patient's
chest, you want as much quiet as possible. First, explain what you're going to do and
make sure the patient is comfortable before you begin. If a television is on in the
room, turn the volume off. If there's a lot of noise in the hallway, close the door. You
may need to do this anyway to ensure privacy during the exam.

Use a stethoscope with a bell and a diaphragm. (If your stethoscope is electronic, it
will have bell and diaphragm modes that you can alternate between with the press of a
button.) The bell is best suited for hearing low-pitched sounds, and the diaphragm for
high-pitched sounds. The ear pieces—no matter what type of stethoscope you are
using—should fit snugly and align with the angle of your ear canals.

To avoid transmission of extraneous noise, be sure to remove any item you may have
hung on your stethoscope. (Avoid the habit some nurses have of using their
stethoscope to hang rolls of tape, tourniquets, or a hospital badge.) Then, expose the
patient's chest and place the head of the stethoscope directly on the skin instead of
listening through the patient's gown. Stand at the patient's right side with the
stethoscope tubing extended across the chest. Make sure that the tubing is not
touching the chest or resting on the sheets or side rail.

You may begin auscultation at the top (base) of the heart and proceed down to the
apex, or follow the reverse order, listening first at the apex and proceeding up to the
base.2,3 Either approach is acceptable; what is important is that you use the same
approach for the entire exam. Here, I'll describe the base-to-apex approach.

Start with the patient supine with the head of the bed elevated 30 degrees. Auscultate
all areas first with the diaphragm. To begin, place it firmly against the right side of the
chest in the second intercostal space close to the sternum. Then move to the left side
and listen in the same space at the left sternal border. Continue down the left sternal
border, auscultating in the third and fourth intercostal spaces. Finish by auscultating
the apex, which is usually found in the fifth left intercostal space just below the nipple
—the midclavicular line.

Repeat the sequence, using the bell of the stethoscope. When you position the bell,
use just enough pressure to create a seal between it and the skin. Exerting greater
pressure than that will stretch the skin across the bell, creating a diaphragm and
thereby reducing your ability to hear low-pitched sounds.

Identifying sounds in systole and diastole

At each auscultation point, concentrate first on identifying the primary heart sounds—
S1 and S2. These are best heard with the diaphragm. S1 coincides with closure of the
mitral and tricuspid valves and the beginning of ventricular systole. It's most intense
over the apex. S1 is a lower-pitched, more pronounced sound than S2.

S2 indicates closure of the aortic and pulmonic valves and the onset of diastole. It's
best heard in the second intercostal space at the right sternal border. S2 is higher-
pitched than S1 and has a clipped, closing sound.

In patients with normal heart rates, diastole is a few hundredths of a second longer
than systole, making it easier to identify S2. However, diastole shortens with
tachycardia, and this difference disappears, making it more difficult to distinguish
between S1 and S2 in a tachycardic patient. When that's the case, continue to auscultate
and place the index finger of your free hand on the patient's carotid artery. Lightly
palpate the pulse. S1 is the sound you'll hear at the same time you feel the pulse.4

After you've identified S1 and S2, shift your focus to detecting extra heart sounds.
When you do hear one, note when it occurs in relation to S1 and S2. If the extra sound
follows S1 or S2 very closely, you may actually be hearing a splitting of that heart
sound.

Remember S1 and S2 coincide with the closure of two valves, each of which produces
its own sound. The closures of the mitral valve (M1) and of the tricuspid valve (T1 )
usually occur so close together that the human ear is able to detect only one sound,
S1.4

But a delay in tricuspid valve closure may leave enough time for the ear to hear M1
and T1 separately. A split S1 is best heard in the fifth intercostal space at the left
sternal border. It's an uncommon sound, but can occur in patients with right bundle
branch block.4

Aortic (A2) and pulmonic (P2) valve closures produce S2. Delayed pulmonic valve
closure can occur during inspiration because venous return—blood coming into the
right side of the heart—increases with inspiration. This increase in volume prolongs
right ventricular systole and thus delays pulmonic valve closure, producing a split S2.5
During expiration venous return falls, so there's no delay in P2 closure and the split
disappears. This kind of splitting is a normal or physiologic finding.

In some cases, though, a split S2 may be abnormal. A wide gap between A2 and P2 can
occur with right bundle branch block. A split S2 heard during expiration is called a
reverse, or paradoxical split. It's associated with left bundle branch block, ventricular
pacing, advanced left ventricular failure, and aortic stenosis. A fixed split—one heard
on both inspiration and expiration—occurs with atrial septal defects (ASD). S2 heart
sounds are best heard in the second and third intercostal spaces along the left sternal
border.

An S3 heart sound also comes very soon after S2, occurring early in diastole as the
mitral and tricuspid valves open and blood rushes into the ventricles. An S3 is normal
in children and young adults, especially women and patients with a thin build. In
those over 40 years of age, however, S3 is an abnormal finding indicating ventricular
dysfunction. In this case blood from the atrium is trying to enter a ventricle that wasn't
completely emptied in the previous contraction.

Because it's an early diastolic sound, S3 can be difficult to distinguish from a

physiologic S2 split. However, unlike a split S2 sound, an S3 remains constant during
the respiratory cycle. Its pitch is softer and best heard with the bell. An S3 heard at the
apex is one of the first clinical findings in left ventricular failure. An S3 in the third to
fifth intercostal spaces at the right sternal border indicates right heart failure.5

An S4 is heard just before S1, making it a late diastolic sound. It occurs when atrial
contraction pumps volume into a stiff, noncompliant ventricle. You'll most often hear
an S4 in a patient with a condition that causes left ventricular hypertrophy, such as
hypertension or aortic stenosis. Compliance can also be affected by ischemia, so you
may also hear an S4 in a patient who's recently had an MI. You won't hear an S4 in a
patient with atrial fibrillation, however, because in this case there's no atrial
contraction.

Like S3, S4 is best heard with the bell at the apex. When you have difficulty hearing
these sounds, try turning the patient toward his left side. This maneuver brings the
heart closer to the anterior chest wall and thus improves sound transmission.

Listening for murmurs

Murmurs are sounds created by turbulent blood flow. They can occur at any time
during the cardiac cycle. When you detect a murmur, you need to listen for a minute
or more to determine its characteristics—the timing, pitch, quality, intensity, and
pattern. You'll also want to identify where you hear it the loudest and if the sound
radiates to other areas.

To establish timing, focus on whether you hear the murmur continuously, during
systole (after S1 and before S2) or during diastole (after S2 and before S1). When the
murmur is confined to either systole or diastole, determine whether you hear it at the
beginning (early), middle (mid), or end (late).

Systolic murmurs typically fall into two categories: mid-systolic and holosystolic (or
pansystolic). A mid-systolic murmur begins after S1 and concludes before S2. You
should notice a distinct gap between the two heart sounds and the murmur. Pay
particular attention to the gap before S2. It will help you to distinguish a mid-systolic
murmur from a holosystolic murmur, which is heard immediately after S1 and right up
to S2 without any pauses.
Once you've established its timing, shift your focus to the murmur's actual sound. Is it
high-pitched, low-pitched, or somewhere in between? How would you describe its
quality? Is it harsh or musical? Rumbling or blowing? What is its intensity? Do you
have to really concentrate to hear a faint sound? Or do you notice the sound as soon as
you put your stethoscope on the chest?

Murmurs are graded on a six-point scale. In a grade I murmur, the sound is barely
audible, whatever the patient's position. A grade II murmur is faint; a grade III is
moderately loud, and a grade IV is somewhat louder and may be accompanied by a
thrill. A grade V murmur is loud enough to be heard with the stethoscope held just
above the chest wall. It is accompanied by thrills, as is a grade VI murmur, which is
so loud that you can hear it without a stethoscope.6

Listen also for a particular pattern or shape to a murmur. Some murmurs begin softly
and then become louder (crescendo). Others start out very loud and then taper off
(decrescendo). You may also hear a murmur that combines the two patterns just
described. It will start off softly, grow increasingly louder until it peaks, and then
taper off (crescendo-decrescendo). Lastly, you may find the murmur does not change
at all, making it a plateau murmur.

After you've established these characteristics, concentrate on the murmur's location.

Where do you hear it best? Is it most noticeable at the apex or in the second or third
intercostal space? Does the sound travel or radiate to the neck, back, or axilla? The
answers to each of these questions will help you hone in on the murmur's possible
cause.

Not every murmur is worrisome

While it's true that most murmurs are associated with some form of valve dysfunction,
not every murmur is cause for alarm. Systolic murmurs often occur in patients with no
other evidence of cardiac disease, in which case they're known as innocent or
physiologic murmurs. These murmurs are created by turbulent flow as the left
ventricle ejects blood through the aortic valve into the aorta.

Innocent murmurs are mid-systolic and have a quick crescendo-decrescendo pattern.

They are usually medium-pitched, faint, and best heard in the area of the aortic valve
—the second intercostal space at the right side of the sternum—with little or no
radiation.

When the increase in turbulence occurs because of an increase in flow associated with
conditions that raise heart rate or circulating volume—for example, anemia,
pregnancy, or fever—the murmur may also be called a flow murmur. A flow murmur
has the same characteristics as an innocent murmur but disappears when the condition
causing the increased flow is resolved.

Systolic murmurs that indicate heart disease

A systolic murmur that's associated with cardiac disease is usually preceded by an

ejection sound that coincides with the opening of the affected valve. This is a high-
pitched, sharp, clicking sound that's best heard with the diaphragm. A description of
how to identify specific murmurs is provided here and in the "Identifying murmurs"
box.

Blood being pushed through a narrowed or stenotic aortic valve creates a mid-systolic
murmur that has a crescendo-decrescendo pattern. An aortic stenosis murmur is often
medium-pitched and varies in quality. It's best heard in the second right intercostal
space and radiates to the carotid arteries or left sternal border. An ejection sound
typically indicates a congenital defect.

Pulmonic stenosis murmurs are also mid-systolic and have a crescendo-decrescendo

pattern. They are medium-pitched and often harsh. They're heard in the second or
third left intercostal spaces and can radiate to the neck or shoulder. Early ejection
sounds are typical. When the murmur is severe, you'll also often hear a wide S2 split.
This type of defect is usually congenital.

Hypertrophic cardiomyopathy can also create a mid-systolic murmur resulting from

the very rapid ejection of blood from the enlarged muscular ventricle. This murmur
has a crescendo-decrescendo pattern that is best heard in the third and fourth left
intercostal spaces at the sternal border. It can radiate down to the apex, but, unlike
aortic and pulmonic stenosis murmurs, its sound doesn't travel up to the neck. The
murmur of hypertrophic cardiomyopathy has a harsh quality and a medium pitch. You
may also often hear an S4 at the apex.2

Holosystolic murmurs occur with mitral or tricuspid valve regurgitation. These

murmurs have a plateau pattern caused by the backward flow of blood through a valve
that should be closed.

Mitral regurgitation produces a high-pitched blowing murmur. It's best heard at the
apex and often radiates to the left axilla. You may also detect an S3, indicating volume
overload in the left ventricle.

Mild mitral regurgitation is often associated with mitral valve prolapse, which is the
ballooning of the posterior valve leaflet into the left atrium during systole. In this case
you'll hear a systolic click or highpitched clicking sound before the murmur. Mitral
regurgitation can also occur with papillary muscle damage, post-MI. If you suspect
this, report it immediately.

Tricuspid regurgitation produces a high-pitched blowing murmur, but it's heard at the
lower left sternal border. This type of murmur, unlike a mitral regurgitation murmur,
can become more intense during inspiration, and it radiates to the right of the sternum
or xiphoid area but not into the axilla.

A ventricular septal defect (VSD) produces a loud, highpitched, harsh holosystolic

murmur. You'll hear this kind of murmur in the third, fourth, and fifth intercostal
spaces as blood flows through the septum from the left to the right ventricle,
producing a plateau pattern. VSD murmurs have a wide range of radiation. They are
often congenital but may occur after an MI, in which case, it's an emergency. Report
it immediately.
Diastolic murmurs that indicate heart disease

Unlike systolic murmurs, diastolic murmurs always indicate heart disease. They can
be early, mid-diastolic, or late. An early diastolic murmur begins immediately after S2
and usually tapers off to silence before the next S1. A mid-diastolic murmur is heard
shortly after S2 and then either tapers off or blends into a late diastolic murmur. You'll
notice the beginning of a late diastolic murmur about half to two-thirds of the way
between S2 and S1. Since it continues up to the next S1, a late diastolic murmur is also
described as presystolic.

Aortic regurgitation is the most common cause of an early diastolic decrescendo

murmur. This is a high-pitched blowing sound that's heard in the second right
intercostal space and Erb's point and may radiate to the left or right sternal border.

A soft aortic regurgitation murmur can be mistaken for breath sounds. To help tell the
difference, have the patient sit up and lean forward. Then ask the patient to exhale and
wait a few seconds before taking the next breath. Any blowing sound you hear now
will be a murmur. You may also detect an ejection sound. Severe regurgitation is
associated with an S3 or S4.

Pulmonic regurgitation is heard in the second left intercostal space and may radiate to
the left lower sternal border. It, too, is a high-pitched, blowing sound that increases
with inspiration. It is usually associated with pulmonary hypertension.

The murmur of mitral stenosis is a low-pitched, rumbling sound. It typically begins

with an opening snap that follows S2. Mild stenosis often produces a mid-systolic
murmur. Murmurs that continue into late diastole are associated with severe disease.4
Mitral stenosis murmurs have little or no radiation. To improve auscultation, position
the patient on his left side and place the bell on the apex.

Tricuspid stenosis produces a murmur heard in the fourth left intercostal space at the
sternal border. It has a low-pitched, rumbling sound that increases with inspiration. In
patients with rheumatic heart disease, it usually occurs in combination with other
valve problems.

How to listen for breath sounds

When you've finished assessing heart sounds, move on to auscultate lung sounds.
Start with the back, and, if possible, have the patient sit up, lean forward, and cross
his arms in front of his chest. This position brings the scapulae up, allowing better
auscultation. If your patient is unable to sit up, turn him from side to side to auscultate
the posterior lung fields. When you do this, keep in mind that the dependent lung is
the best ventilated, making it the side in which you'll be more likely to hear crackles
and wheezes.2

As with the auscultation of heart sounds, place the diaphragm directly on the skin.
Apply firm pressure and auscultate in the intercostal spaces. Try not to listen over
bone. Begin at the top and work your way down the back. Listen in the same area on
both sides of the spine before moving down to the next intercostal space. (See figures
in the "A road map for respiratory assessment" box.)
When you reach the inferior angles or tips of the scapulae, widen your range and
auscultate out along both sides of the chest to the midaxillary line. That way you'll be
sure you've assessed all lung fields. When you're finished, have the patient lie back
with his arms slightly extended from his sides and begin auscultating the anterior
chest.

Use the same approach as you did for the back. In this case, though, the first
auscultation site will be above the clavicle. That's where you'll hear breath sounds in
the apices, or topmost portions of the lungs, and the trachea. Again, move from side to
side and work from top to bottom at the midclavicular line. When you reach the
nipple line, move out along the side of the chest to the midaxillary line. Be sure to
include the sixth and seventh intercostal spaces, because that's where you'll find the
lung bases. Normal or vesicular breath sounds are soft, low-pitched sounds primarily
heard during inspiration. Vesicular sounds can be heard anywhere, but you are more
likely to hear them in the posterior lung fields and less likely to hear them near the
trachea or bronchi.

Tracheal breath sounds, as the name implies, are heard in the neck over the trachea.
These sounds are louder and have a higher pitch than vesicular sounds. Tracheal
breath sounds can be heard during both inspiration and expiration.

Bronchial or tubular breath sounds are coarse, fairly highpitched sounds heard over
the trachea and manubrium. Expiratory sounds last longer than inspiratory. When
auscultated in other areas, bronchial breath sounds are an abnormal finding caused by
air loss in the affected lung tissue. Pneumonia is a common cause of abnormal
bronchial sounds; infection causes the alveoli to fill with fluid, leukocytes, and red
blood cells—a change known as consolidation.

Air loss also affects transmission of vocal sounds. So when you think you hear
abnormal bronchial sounds, ask the patient to say "ee" several times as you continue
to auscultate the area. If there is air loss, you'll hear "ay" instead of "ee." This
phenomenon is called egophony.

Spoken words heard over a consolidated area will be loud and clear rather than the
normal finding, which is muffled and indistinct. Note this change as bronchophony.
Whispered words, too, will be louder and clearer—a finding called whispered
pectoriloquy.

Bronchovesicular breath sounds combine bronchial and vesicular sounds. These

sounds are medium-pitched and last as long during expiration as they do during
inspiration. Bronchovesicular sounds are abnormal when heard anywhere other than
in the first or second intercostal spaces anteriorly and between the scapulae
posteriorly (which is the location of the mainstem bronchi). They are associated with
the early stages of pulmonary disease.

Adventitious sounds, which are also abnormal, fall into two major categories:
wheezes and crackles. Wheezes are continuous sounds with a musical quality.
Wheezing can occur with any condition that narrows the airways. Asthma and chronic
bronchitis are common causes.
High-pitched wheezes have a whistling quality. Lower-pitched snoring sounds, also
referred to as rhonchi, are associated with secretions in the larger airways. If you
suspect that's the case, ask the patient to cough, which may clear the secretions and
improve lung sounds.

Suspect stridor instead of wheezes when you hear a loud high-pitched wheeze in the
upper airways. Stridor signals some degree of upper airway obstruction and becomes
more intense during inspiration. Since this kind of obstruction can lead to respiratory
arrest, report this finding immediately.

Crackles are distinct scratchy sounds with a shorter duration than wheezes. Fine
crackles sound much the same as rubbing a few strands of hair between two fingers or
against the diaphragm of a stethoscope. If the patient has a lot of chest hair, wet it
down lightly before auscultating an area and be sure to hold the diaphragm firmly to
eliminate this extraneous sound.

Fine crackles are thought to be caused by the sudden equalization of pressure as

airways pop open. Fine crackles that are heard late in inspiration in the lung bases are
an early sign of congestive heart failure. Coarser crackles are associated with air
flowing through secretions or lightly closed airways.

Crackles may also be heard in a normal person with shallow respirations, upon
awakening, for example. Have the patient cough and then breathe deeply; the crackles
may have cleared.

Technique improves with practice

The more you practice auscultating heart and lung sounds, the easier it will be to
identify what they signify or suggest. Yet, no matter how experienced you become, in
some patients, auscultation may still pose a challenge. A patient's size and weight can
affect the transmission of sound—decreased breath sounds, for instance, may be a
result of obesity.

An increase in the anterior-posterior diameter of the chest can make it almost

impossible to auscultate heart sounds. In this case, you may be able to hear only when
you turn the patient to the left side, bringing the left ventricle closer to the chest wall
or by auscultating in the epigastrium just below the xiphoid process of the sternum.7

This technique may also be helpful if the patient has a lot of muscle or adipose tissue
that muffles heart and lung sounds. When you're examining a female patient with
large or pendulous breasts, use your free hand to hold the breast up and position the
stethoscope head as close to the chest wall as possible; if that isn't helpful, move her
onto her left side, as described.

If these approaches don't bring much success, you'll need to shift your focus and rely
on other clinical findings to provide the best care possible.

As with any complicated technique, it takes time to master auscultation. Remember

that it's a skill well worth the effort you put into it. It can enable you to identify
problems early and evaluate a patient's progress during treatment and recovery.