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PubMed2002

Helping family physicians improve their cardiac auscultation skills with an interactive CD-ROM.

INTRODUCTION: There have been few studies of the cardiac auscultation skills of residents and family physicians. This study assessed a group of family physicians' cardiac auscultation skills and use of a computerized self-instructional program to improve these skills. METHODS: Forty-two volunteer family physicians participated in an initial assessment of cardiac auscultation skills using test recordings of 12 common heart sounds. They were provided with a CD-ROM instructional program and were asked to devote 15 hours of self-study to the program and to return in 9 months for reassessment. RESULTS: The 42 family physicians in the initial assessment identified 39% of the heart sounds. Twenty-one returned for reassessment and showed significant improvement. Their initial mean score was 4.3 of 12 (35%), and their final mean score was 8.0 of 12 (67%). They found the CD-ROM program to be a valuable resource. The feature most liked was the unlimited opportunity to review sounds, cases, and tutorials. Most frequent problems related to computer access or skills. Eleven respondents reported using the program to resolve patient problems in their clinical practices. DISCUSSION: The cardiac auscultation skills of a group of volunteer family physicians showed low initial scores that improved significantly after self-study with a CD-ROM instructional program. The program was a valuable self-instructional aid, and physicians used it as a resource in clinical practice. However, only 50% of the initial group completed the self-study and returned for final assessment. Providing more support and assistance in the initial phase, especially with computer use, may enable completion of similar computerized self-study programs.

CD-ROM↗

PubMed1988

Comparison of auscultation with two-dimensional and Doppler echocardiography in patients with suspected mitral valve prolapse.

Auscultation was compared to two-dimensional echocardiography (2D echo) and Doppler ultrasonography in 140 consecutive patients referred for evaluation for suspected mitral valve prolapse (MVP) to asses the precision of the two diagnostic methods. Ninety patients (64%) had midsystolic clicks, of which 42 (47%) had MVP by echocardiography; 6 patients (4%) had MVP by 2D echo but no click on examination. In 15 (17%) of the 90 patients, a click was heard only in the standing or squatting positions and 2D echo did not detect prolapse in the supine position in 10 (67%) of the 15. With auscultation as the reference standard for MVP, 2D echo has a sensitivity of 47% and a specificity of 89%. Of the 140 patients, 51 (36%) had systolic murmurs; Doppler detected mitral and/or tricuspid regurgitation in 26 (50%). In 23 (16%) patients, there was Doppler evidence of mitral or tricuspid regurgitation even though systolic murmurs were not heard. Auscultation shows a 53% sensitivity and 73% specificity for systolic murmurs, using Doppler ultrasonography as the reference standard. Of 48 patients with MVP by 2D echo, 15 (13%) had associated mitral regurgitation by Doppler. The results indicate that 2D echo and Doppler ultrasonography should be interpreted in concert with auscultation for the diagnosis of mitral valve prolapse and for therapeutic decision making.

Adult↗

PubMed1995

Comparison of intrapartum electronic fetal heart rate monitoring versus intermittent auscultation in detecting fetal acidemia at birth.

OBJECTIVE: Our purpose was to compare continuous intrapartum electronic fetal heart rate monitoring with intermittent auscultation for detecting fetal acidemia at birth. STUDY DESIGN: Data from a previously published randomized trial of electronic fetal heart rate monitoring versus intermittent auscultation were analyzed to identify any differences between the two methods in detecting fetal acidemia at birth. Fetal acidemia at birth was defined as the presence of cord blood arterial pH < 7.15. RESULTS: A total of 1419 patients with umbilical cord blood acid-base measurements were identified, 739 in the electronic FHR monitoring group and 680 in the auscultation group. Electronic FHR monitoring had significantly better sensitivity (97% vs 34%, p < 0.001), lower specificity (84% vs 91%, p < 0.001), higher positive predictive value (37% vs 22%, p < 0.05), and higher negative predictive value (99.5% vs 95%, p < 0.001) in detecting fetal acidemia at birth. In addition, electronic FHR monitoring was significantly better in detecting all types of acidemia: metabolic (95.5% vs 26.5%, p < 0.001), mixed (95% vs 37.5%, p < 0.001), and respiratory (100% vs 41.5%, p < 0.001). CONCLUSION: These data suggest that electronic FHR monitoring is superior to intermittent auscultation in detecting fetal acidemia at birth.

Acidosis↗

PubMed1995

Intrapartum electronic fetal heart rate monitoring versus intermittent auscultation: a meta-analysis.

OBJECTIVE: To use a meta-analysis of all published randomized trials to determine whether the use of continuous electronic fetal heart rate monitoring (EFM) as the main method of intrapartum fetal surveillance is associated with improved pregnancy outcome compared to intermittent auscultation. DATA SOURCES: We used the MEDLINE data base and reference lists of articles to identify all published randomized trials of EFM versus intermittent auscultation. METHODS OF STUDY SELECTION: A total of nine randomized trials published in peer-review journals were identified. The selection criterion was the use of EFM or intermittent auscultation as the main intrapartum fetal surveillance technique. DATA EXTRACTION AND SYNTHESIS: A total of 18,561 patients were included in the nine published randomized trials, 9398 in the EFM group and 9163 in the auscultation group. Measures of pregnancy outcome included cesarean delivery, cesarean for suspected fetal distress, overall use of forceps or vacuum, use of forceps or vacuum for suspected fetal distress, overall perinatal mortality, and perinatal mortality due to fetal hypoxia (intrapartum or early neonatal death) attributable to the method of intrapartum monitoring. The meta-analysis showed that the patients monitored electronically had a significantly higher overall cesarean rate (odds ratio [OR] 1.53, 95% confidence interval [CI] 1.17-2.01), higher cesarean rate for fetal distress (OR 2.55, 95% CI 1.81-3.53), overall increased use of forceps or vacuum (OR 1.23, 95% CI 1.02-1.49), increased use of forceps or vacuum for suspected fetal distress (OR 2.50, 95% CI 1.97-3.18), and decreased perinatal mortality due to fetal hypoxia (OR 0.41, 95% CI 0.17-0.98). CONCLUSION: Electronic fetal monitoring is associated with increased rates of surgical intervention and decreased perinatal mortality due to fetal hypoxia.

Cardiotocography↗

PubMed2006

Use of the Rapiscope vs chest auscultation for detection of accidental bronchial intubation in non-obese patients undergoing laparoscopic cholecystectomy.

STUDY OBJECTIVE: Main stem bronchial intubation is not always detected by routine means and may occur more frequently during laparoscopic procedures. Tracheal tube positional changes in non-obese patients undergoing laparoscopic cholecystectomy were detected by either the Rapiscope (Cook Critical Care, Bloomington, Ind) or chest auscultation. DESIGN: Prospective, double-blind, crossover study. SETTING: University hospital. PATIENTS: Forty non-obese patients (BMI <28 kg.m(-2)), aged 18 to 80 years, American Society of Anesthesiologists risk class I-III, who underwent elective laparoscopic cholecystectomy were enrolled in this double-blind, prospective study. INTERVENTIONS: After endotracheal intubation by one anesthesiologist, two other anesthesiologists assessed the tracheal tube's positioning by either the Rapiscope or chest auscultation; the results of one anesthesiologist's measurement were concealed from the other. MEASUREMENTS: Assessments of the endotracheal tube tip's position were performed after intubation, head-down, and head-up positioning, after maximal abdominal insufflation and before extubation. At the same time points, Sp(O2), ET(CO2), and peak inspiratory pressures were also recorded. MAIN RESULTS: Postintubation Rapiscope assessment revealed normal tracheal positioning of the tube's tip in all patients. Changes in tube's position were subsequently detected by the Rapiscope in 16 patients. In 8 cases, the tip moved endobronchially. Half of the endobronchial intubations occurred after maximal abdominal insufflation and the other half after changing the table position from neutral to 30 degrees head-down. Chest auscultation detected bronchial intubation in two cases only (P = .01). There were 4 additional events of downward movements and 4 events of cephalad migration of the tube's tip identified by the Rapiscope only. ET(CO2), Sp(O2), and peak inspiratory pressures did not change in patients who did experience bronchial intubation. CONCLUSION: The Rapiscope detected significantly more events of endobronchial intubation as compared with chest auscultation; it could be considered useful during procedures where tracheal tube movements are potential.

Adolescent↗

PubMed1990

Value and limitations of auscultation in the management of congenital heart disease.

With advances in technology, especially that of ultrasonography, the art and science of auscultation could become relegated to that of an obsolete technique. Physicians in a cardiovascular training program involved in learning modern instrumentation diagnostic techniques often become expert in these areas before they have mastered the use of the stethoscope. Although the technology of ultrasonic examination, cardiac catheterization, and angiocardiography must be learned, the value of auscultation of the heart cannot be ignored. Many highly competent physicians who are responsible for diagnosis and treatment of the pediatric patient, including some pediatric cardiologists, may not be aware that they have not yet become experts at auscultation. The skill of auscultation of the heart must be learned by supervised experience with patients in whom a wide variety of normal and abnormal heart sounds and murmurs can be heard. Once learned, the skill can be maintained only by frequent practice in hearing and evaluating both subtle and obvious sounds emanating from the heart and from the pulmonary and systemic blood vessels.

Cardiac Catheterization↗

PubMed1997

Lung auscultation in airway challenge testing.

The appearance of wheezes and changes in inspiratory breath (vesicular) sound intensity (BSI) were monitored in patients undergoing routine methacholine challenge test (MCT). The results were compared with changes in spirometry and to airway hyper-responsiveness (AH). Fifty-four patients were examined. Spirometry was performed before and after the inhalation of cumulative doses of methacholine starting from 25 micrograms; a fall in forced expiratory volume in 1 s (FEV1) by 20% or more was considered as significant. Lung auscultation was performed by two observers simultaneously using a special stethoscope placed sequentially over the posterior right and left upper (interscapular region, 5 cm from the fourth thoracic vertebra) and lower lung zones (5 cm below the scapulae). Symptoms were recorded by the patients on a visual analogue scale. In 27 patients, the MCT was positive (MCT+) and in 27 patients it was negative (MCT-). Wheezes were identified at PD20 in 12 MCT+ patients while reduced BSI alone was found in 11 patients; in four patients, auscultation was normal. In 20 MCT+ patients, either wheezes, diminished BSI or both were heard, one to several steps before reaching PD20. In the MCT- group, wheezes were detected in two patients and diminished BSI in four. In MCT+ patients, the mean (+/-SD) perception of symptoms at end-challenge was 33% (+/-26), whereas in MCT- patients, it was 13.6% (+/-22). Complete inter-observer agreement was found in 95.7% of auscultations performed (Kappa coefficient = 0.846). Coupled to spirometry, lung auscultation may prove useful in airway challenge testing provided the concept is accepted that wheeze appearance and, by extension, an acute decrease in BSI, is as legitimate a manifestation of AH as a fall in FEV1.

Adolescent↗

PubMed2005

A PDA-based instructional tool to monitor students' cardiac auscultation during a medicine clerkship.

Cardiac auscultation is an important skill for medical students to master but students' exposure to cardiac auscultation is often unmonitored. The objective of this study was to gather data at the point of care about students' cardiac auscultation experience on a required medicine rotation using a Personal Digital Assistant (PDA) 'murmur form'. During an eight-month period, 120 M3 students used the authors' PDA-based learning tool to record information on 940 heart sounds and murmurs. Some 93% of all heart sounds/murmurs reported by students were verified by either a faculty member (56%) or a supervising resident (43%). A PDA can be a useful tool to monitor students' experiences of cardiac auscultation and to track direct observation of such skills by faculty or residents. Medical students are eager to use technology at the point of care to practice their clinical skills.

Clinical Clerkship↗

PubMed1999

Does the Murphy eye reduce the reliability of chest auscultation in detecting endobronchial intubation?

UNLABELLED: Bilateral breath sounds are routinely auscultated after endotracheal intubation to verify that the endotracheal tube (ETT) tip is properly positioned. We conducted the present study to ascertain whether the eye of the Murphy tube has an influence on the reliability of auscultation of breath sounds in detecting endobronchial intubation. Twenty patients undergoing scheduled oral and maxillofacial surgery participated in this study. After the induction of general anesthesia, either the Magill tube or the Murphy tube was inserted through the nose into the trachea. The fiberoptic bronchoscope was inserted through the ETT, and the distance from the nares to the carina of the trachea was measured. When breath sounds from the left side of the chest changed and disappeared while the ETT was being advanced, the distance from the nares to the ETT tip was measured. Unilateral auscultatory change was not observed until the ETT tip was advanced beyond the carina and inserted 1.5+/-0.4 cm into the right mainstem bronchus when the Magill tube was used and 2.0+/-0.4 cm when the Murphy tube was used (P < 0.01). Breath sounds disappeared when the ETT tip was further advanced up to 3.2+/-0.3 cm from the carina. We demonstrated that the eye of the Murphy tube reduces the reliability of chest auscultation in detecting endobronchial intubation. IMPLICATIONS: The Murphy eye was designed to allow ventilation of the lung when the bevel of the endotracheal tube is occluded. We demonstrated that the eye of the Murphy tube reduces the reliability of chest auscultation in detecting endobronchial intubation.

Adult↗

PubMed2004

Comparative diagnostic performances of auscultation, chest radiography, and lung ultrasonography in acute respiratory distress syndrome.

BACKGROUND: Lung auscultation and bedside chest radiography are routinely used to assess the respiratory condition of ventilated patients with acute respiratory distress syndrome (ARDS). Clinical experience suggests that the diagnostic accuracy of these procedures is poor. METHODS: This prospective study of 32 patients with ARDS and 10 healthy volunteers was performed to compare the diagnostic accuracy of auscultation, bedside chest radiography, and lung ultrasonography with that of thoracic computed tomography. Three pathologic entities were evaluated in 384 lung regions (12 per patient): pleural effusion, alveolar consolidation, and alveolar-interstitial syndrome. RESULTS: Auscultation had a diagnostic accuracy of 61% for pleural effusion, 36% for alveolar consolidation, and 55% for alveolar-interstitial syndrome. Bedside chest radiography had a diagnostic accuracy of 47% for pleural effusion, 75% for alveolar consolidation, and 72% for alveolar-interstitial syndrome. Lung ultrasonography had a diagnostic accuracy of 93% for pleural effusion, 97% for alveolar consolidation, and 95% for alveolar-interstitial syndrome. Lung ultrasonography, in contrast to auscultation and chest radiography, could quantify the extent of lung injury. Interobserver agreement for the ultrasound findings as assessed by the kappa statistic was satisfactory: 0.74, 0.77, and 0.73 for detection of alveolar-interstitial syndrome, alveolar consolidation, and pleural effusion, respectively. CONCLUSIONS: At the bedside, lung ultrasonography is highly sensitive, specific, and reproducible for diagnosing the main lung pathologic entities in patients with ARDS and can be considered an attractive alternative to bedside chest radiography and thoracic computed tomography.

Aged↗

PubMed2004

A novel multimedia tool to improve bedside teaching of cardiac auscultation.

Training in cardiac auscultation is a core element of undergraduate teaching but recent studies have documented a remarkable decline in auscultatory skills. Therefore there is an interest in new ways to teach cardiac auscultation. In analogy to phonocardiography, an electronic system for simultaneous auscultation and visualisation of murmurs was sought. For this purpose, an electronic stethoscope was linked to a laptop computer and software created to visualise auscultatory findings. In a preliminary trial in undergraduate students, this approach greatly facilitated teaching. Amalgamating traditional phonocardiography with a multimedia approach, this system represents a novel tool for bedside teaching of cardiac auscultation.

Education, Medical, Undergraduate↗

PubMed2000

Efficacy and safety of methacholine bronchial challenge performed by auscultation in young asthmatic children.

The measurement of bronchial reactivity is an important aid in the diagnosis of asthma, but the technique using spirometry is not feasible in young children. The aim of the present study was to determine the efficacy and safety of a modification of the chest auscultation method in the assessment of bronchial reactivity to inhaled methacholine in young asthmatic children. One hundred forty-six young children with asthma (mean age, 4.3 yr) underwent bronchial challenges with nebulized methacholine using the auscultation method (PCW). The end point was defined as the appearance of wheezing, oxygen desaturation, or tachypnea. For comparison, 30 children and young adults with asthma underwent bronchial provocation with methacholine using spirometry (PC(20)). A positive response using the auscultation method was observed in 95.9% of the younger children, and wheezes alone or in combination with other signs appeared in 80.8% of them. The mean desaturation at the end point was 4.6% (PCW) and 5.0% (PC(20)), with a similar pattern in the two groups. Cough was not helpful in determining the end point. We conclude that the modified auscultation method is effective and safe, with wheeze appearing at the end point in the large majority of the children.

Adolescent↗

PubMed1989

Detection of pneumonia by auscultation of the lungs in the lateral decubitus positions.

Forty-five acutely ill, coughing patients, three with acute dyspnea and cardiomegaly, and 37 control subjects were placed in lateral decubitus positions for auscultation of their dependent lungs to determine if this maneuver would elicit inspiratory crackles, signs of pneumonia. In the upright position, auscultation of the lungs was normal in all control subjects and in lateral decubitus positions their dependent lungs revealed transient late inspiratory crackles in seven of the 37 (18.9%), and transient inspiratory peeling sounds in two others (5.4%). Thirteen acutely ill, coughing patients, free of prior cardiac and pulmonary diseases, had persistent late inspiratory crackles induced in one or both dependent lungs when placed in lateral decubitus positions. These dependent lungs also revealed increased numbers of crackles in three patients, late inspiratory squeaks in four, and wheezes in three others. In the upright position, auscultation of the lungs was normal in 10 of these patients, and a few basilar crackles were heard in three others. All of these abnormal findings cleared after treatment with antibiotics. Thirty-one of 32 acutely ill, coughing patients with bronchitis, sinusitis, or pharyngitis were free of induced crackles in dependent lungs in lateral decubitus positions. However, placement of two other patients in these positions appeared to have elicited the inspiratory crackles of chronic pulmonary disease and early congestive heart failure. These observations suggest that placement of acutely ill, coughing patients into lateral decubitus positions for auscultation of the dependent lungs may be a valuable maneuver for diagnosis of pneumonia.

Adult↗

PubMed1988

Value and limits of "critical auscultation" of neck bruits.

Within a group of 2,000 patients evaluated, most of them with symptoms of cerebrovascular insufficiency, 441 had a monolateral or bilateral cervical bruit. The 627 sides with an audible bruit were divided into main groups (A) symptomatic (TIA and/or stroke homolateral to the bruit), (B) possibly symptomatic (non-side-related symptoms), (C) asymptomatic (C1, in totally asymptomatic patients; C2, in patients with symptoms dependent on the hemisphere contralateral to the cervical bruit). Each patient was studied by means of clinical (history, blood pressure in both upper limbs, phonoendoscopic auscultation at various levels) and noninvasive instrumental examinations (CW Doppler spectrum analysis). An apparently primitive cervical bruit corresponded to a lesion of the carotid bifurcation in 61% of the cases (positive predictive value) whereas a normal bifurcation was detected in 70% of the cases in which the cervical bruit was considered as secondary (negative predictive value); the diagnostic accuracy of the "critical auscultation" has a value therefore of 63%, with a sensitivity of 84% and a specificity of 40%. The results obtained in the different groups of patients (symptomatic or asymptomatic) were not significantly different (chi-square). Even though maintaining the value of a cervical bruit as a sign of carotid stenosis or occlusion and consequently confirming the importance of neck auscultation, the authors conclude that the critical auscultation as commonly performed is not capable of excluding the presence of a carotid lesion with sufficient reliability, even in totally asymptomatic patients.

Auscultation↗

PubMed2003

Counting respiratory rate in infants under 2 months: comparison between observation and auscultation.

The World Health Organization's global programme for the control of acute respiratory infections relies on counting respiratory rate (RR) by observing abdominal and chest movements in order to diagnose pneumonia. However, few studies on the reliability of the observation method have been published. We counted RR simultaneously by observation and auscultation in 100 healthy infants at 1, 2, 4, 6 and 8 weeks of age for 15, 30 and 60 sec, and compared RRs obtained by the two methods. In all the age groups studied, the co-efficients of variation for the RRs recorded by observation or auscultation were similar. The mean RR by observation was higher by 1-3 breaths/min than mean RR by auscultation (p < 0.001). The 95% confidence interval (+/-2 SD) for the difference between RR by the two methods ranged from +5 to -8 breaths/min for RR counted for 1 full minute. Our data support the assumption that observation is as reliable as auscultation for counting RR.

Age Factors↗

PubMed2005

Cardiac auscultation training of medical students: a comparison of electronic sensor-based and acoustic stethoscopes.

BACKGROUND: To determine whether the use of an electronic, sensor based stethoscope affects the cardiac auscultation skills of undergraduate medical students. METHODS: Forty eight third year medical students were randomized to use either an electronic stethoscope, or a conventional acoustic stethoscope during clinical auscultation training. After a training period of four months, cardiac auscultation skills were evaluated using four patients with different cardiac murmurs. Two experienced cardiologists determined correct answers. The students completed a questionnaire for each patient. The thirteen questions were weighted according to their relative importance, and a correct answer was credited from one to six points. RESULTS: No difference in mean score was found between the two groups (p = 0.65). Grading and characterisation of murmurs and, if present, report of non existing murmurs were also rated. None of these yielded any significant differences between the groups. CONCLUSION: Whether an electronic or a conventional stethoscope was used during training and testing did not affect the students' performance on a cardiac auscultation test.

Cardiology↗

PubMed1976

Clavicular Auscultation. Preferential clavicular transmission and amplification of aortic valve murmurs.

Clavicular transmission of aortic valve murmurs was investigated in 15 consecutive patients. In all patients, transmission to the clavicle of aortic systolic murmurs was detected both by auscultation and by phonocardiographic studies. Of seven patients with aortic diastolic murmurs, auscultation revealed clavicular transmission in six, but only four were recordable. There was increased murmur amplitude over the clavicle in 13 out of 15 cases. In contrast, murmurs were attenuated over the subclavian artery in eight out of nine and over the carotid artery in nine out of 11 patients. We conclude that clavicular auscultation regularly discloses aortic valve murmurs. The aortic systolic murmurs are consistently propagated to the clavicle, where they are usually conspicuously amplified. Aortic systolic murmurs are less frequently transmitted to the carotid and subclavian arteries, where they are usually considerably attenuated. Clavicular auscultation appears to be more rewarding than the traditional search for transmission of aortic murmurs to the carotid artery.

Aortic Valve Insufficiency↗

PubMed1986

Detection of aortic insufficiency by standard echocardiography, pulsed Doppler echocardiography, and auscultation. A comparison of accuracies.

To determine the relative sensitivity and specificity of noninvasive methods for detecting aortic insufficiency, we compared the accuracy of auscultation, echocardiography, and pulsed Doppler echocardiography in detecting aortic insufficiency in 106 patients in whom the presence or absence of the lesion was shown by supravalvular aortography. The sensitivity and specificity for the diagnosis of aortic regurgitation was 96% and 96% for pulsed Doppler echocardiography, 73% and 92% for auscultation, 43% and 91% for two-dimensional echocardiography, 46% and 81% for anterior mitral leaflet flutter, and 9% and 96% for ventricular septal flutter, respectively. Auscultation was more sensitive than either M-mode or two-dimensional echocardiography in the diagnosis of aortic insufficiency (p less than 0.01). Pulsed Doppler echocardiography was significantly more sensitive than auscultation (p less than 0.0001) and was positive in 19 patients in whom no murmur was found. Thus, pulsed Doppler echocardiography is the optimal noninvasive marker for aortic insufficiency.

Adolescent↗