Charting lung sounds involves the precise documentation of acoustic findings from the lungs gathered during a physical assessment. Accurate charting is necessary for tracking a patient’s respiratory status over time and quickly communicating changes or concerns to the care team. Using uniform terminology ensures that every clinician interprets the documented findings in the same way, supporting continuity of care and appropriate treatment decisions.
Establishing the Baseline Assessment
Charting lung sounds begins with a foundational assessment of the patient’s general respiratory status. The initial documentation must include objective metrics such as the respiratory rate (RR), which is the number of breaths per minute. For an adult, a normal resting rate typically falls between 12 and 20 breaths per minute; counts outside this range, such as tachypnea (fast) or bradypnea (slow), must be recorded.
The rhythm of breathing must be noted, characterizing it as regular or irregular, and the depth as shallow, normal, or deep. A description of the work of breathing (WOB) provides context for the lung sound findings.
The term “unlabored” is used to describe breathing that appears easy and effortless. If the patient is experiencing difficulty, the chart entry must specify the signs of labored breathing. These signs include the use of accessory muscles (such as the sternocleidomastoid or abdominal muscles) or the presence of intercostal retractions or nasal flaring.
Standard Terminology for Lung Sounds
Adventitious sounds are abnormal noises heard in addition to the expected vesicular or bronchial breath sounds. Precise terminology is required to differentiate these sounds, which reflect underlying pathology. They are categorized by their pitch, duration, and whether they are continuous or discontinuous.
Wheezes are continuous, musical sounds generated by air moving through narrowed airways. Sibilant wheezes are high-pitched, whistling sounds, most commonly associated with bronchospasm in conditions like asthma. Sonorous wheezes, often historically referred to as rhonchi, are lower-pitched, snoring or gurgling sounds. These suggest secretions in the larger airways.
Crackles, previously called rales, are discontinuous, non-musical sounds that resemble a series of short, explosive pops. They result from the sudden opening of small, collapsed airways or alveoli, usually during inspiration. Fine crackles are delicate, high-pitched, and sound like hair being rubbed together.
Coarse crackles are lower-pitched, louder, and longer in duration, sounding like bubbling or Velcro being torn apart. These originate in the larger bronchi and may sometimes clear or change after a patient coughs.
Stridor is a harsh, high-pitched, crowing sound heard predominantly on inspiration. This indicates a serious obstruction of the upper airway, such as the larynx or trachea.
The pleural friction rub is a distinct, non-musical sound that is harsh and grating, often described as a creaking noise. This sound occurs when inflamed pleural surfaces rub against each other during the respiratory cycle. It is typically heard during both inspiration and expiration and is often localized to a specific spot on the chest wall.
Structuring the Chart Entry by Location
The final component of accurate charting is specifying the exact anatomical location and timing of the sounds. Lung sounds are charted using a standardized system of lobes and regions to pinpoint the finding. The lobes are the right upper, middle, and lower (RUL, RML, RLL) and the left upper and lower (LUL, LLL).
Documentation must also use general anatomical markers such as apices (the top-most portion), bases (the lowest portion), and the anterior, posterior, or lateral chest wall. Specifying laterality, such as unilateral (one side) or bilateral (both sides), is necessary for a complete entry.
A normal finding is concisely documented using the abbreviation CTAB, meaning “Clear to Auscultation Bilaterally,” indicating no adventitious sounds were heard. A specific abnormal entry might read: “Fine crackles noted in bilateral posterior bases during late inspiration” or “Sonorous wheezes heard over RUL that cleared with productive cough.” This structured approach ensures the chart entry is specific, actionable, and immediately understandable by any clinician.