We had this discussion the other morning at work. Intubated gentleman with difficult time vent weaning post abdominal surgery. He has bad COPD so his lungs are not exactly in the best shape. I gave report to an agency nurse and stated that his lungs were "clear and diminished" (which I have been saying for years with no issue), to which he replied that lungs are not clear if they are diminished. According to him, they cannot be both clear and diminished at the same time. I told him I disagree, because to me if they are absent of adventitious lung sounds (i.e. rhonchi, wheezes, etc) then they are clear, but certain pathophysiologies, poor lung compliance, body habitus, etc may make them sound diminished but clear with a good stethoscope. I told him that with bowel sounds, they can be present and hypoactive. Just because they are hypoactive doesn't mean they sound any different, so they are still present. He seemed annoyed that I was disagreeing with him, but I think he has a complex for wanting to always be right.
Anyway, what are your thoughts on this? I was always under the impression that lung sounds could be both clear and diminished, but his reaction got me thinking!
I agree with you that they can be clear and diminished. But I've had this same exact argument at work with other nurses who say that they can't be. I still chart it that way when I hear it like you did.
Yup, they can be clear sounding but not a lot of flow so diminished.
I get what you mean, but diminished breath sounds are abnormal breath sounds. Let's say a patient has clear lung sounds to the upper fields/lobes but diminished to the bases bilaterally, then that's what you would say clear to upper fields but diminished to bases. If the patient has diminished sounds to all fields, then the lung sounds are diminished. There's no need to say clear and diminished, I think. In the absence of any other adventitious sounds to the area/s in question, if the only issue is that there's less flow, then when you say diminished it implies that it is "clear" of any consolidation/fluid/bronchoconstriction since there's no rhonchi/crackles/wheezing but there's just decreased flow to the area.
This reminds me of a fairly common occurrence in asthma; when the patient's airways are so constricted that no wheezes are heard (in fact, almost nothing is heard--ie, breath sounds are extremely diminished), if appropriate treatment is rendered the air flow will increase and Voila! Squeaks and wheezies everywhere. And sometimes other stuff too.
I think your co-worker may be confusing 'clear' with 'normal.' Masses, scarring, atelectasis, mucus plugging, bronchoconstriction, hyperinflation, and reduced compliance may inhibit aeration without causing adventitious sounds, but the lack of adventitious sounds is not the same as 'normal.' Which is exactly what you are pointing out when you chart that breath sounds are diminished. You're charting correctly--you can't define and describe what you don't hear; until you have other news to report, 'diminished' is all you need to say.
Yes, they can be clear and diminished. They can have no abnormal sounds but just not loud and clear. I often say clear, BUT diminished.
It's also possible that if you're charting clear then you're basically charting that you are hearing clear lung sounds with adequate flow. I suspect the thinking of not charting "clear but diminished" and going with "diminished" instead is that if you're not charting "other" adventitious sounds (wheezing, etc) then by default you're charting clear lungs sounds that are simply "diminished."
IMHO both ways are correct and chart the same thing: clear lungs that are diminished. Potato Potahto.
Absolutely, for the exact reasons you described. Clear, implying no adventious sounds, diminished due to multiple pathologies.
I personally would say diminished with no adventitious sounds but I would understand clear and diminished as meaning the same thing.
So, basically the dude is a drippy little turd. Probably mansplaining.
Quote from ChryssyD
I think your co-worker may be confusing 'clear' with 'normal.'
This was exactly my thought. It's not like OP said "normal but abnormal."
I agree with ClauICU. When receiving/giving report handoff, the term clear and diminished typically refers to Clear in the upper lobes and Diminished in the bases OR a certain part of the lungs sound one way and a different area sounds another. Reasoning behind that is Clear is one type of breath sound and Diminished is another...both having distinct characteristics. When I first started as a Respiratory Therapist many years ago, this is how it was explained by a Pulmonologist.
Answer to your question is yes. I worked with a doc who insisted that there must be wheezing for a person to be having an asthma attack. I got him to listen to a patient in triage who had no wheezing. He failed to notice that the patient was barely moving air at all. After the first neb treatment, the patient was able to move enough air to wheeze. The doc conceded he was wrong. Anyway, the moral of the story is whatever you hear is what you chart. I'd charted breath sounds absent initially on the above patient.
A lot of docs will write, "lungs clear to auscultation bilaterally with good air movement in all fields" which differentiates between adventitious sounds (e.g. rales, etc) and air flow (diminished or not).
Lungs can certainly be clear but diminished
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