Auscultation of the lung as the basic method for respiratory system examination. The main and additional respiratory sounds Lung auscultation is an auscultation of the acoustic phenomena arising in a thorax in connection with normal or pathological work of the lungs. During auscultation it is necessary to estimate the main respiratory sounds, adventitious (additional) respiratory sounds and bronchophony. The main rules of lungs auscultation 1. It should be silent and warmly in the room where auscultation is carried out. 2. If it is possible the patient should be in vertical position (if the condition of the patient allows), and striped. 3. A stethoscope should be pressed to the chest wall firmly and uniformly. 4. In each point of auscultation 3 respiratory cycles should be listened. Remember: Sounds of low frequency are better conducted in using of a stethoscope without a membrane, especially with wide funnel, and at weak press of a stethoscope to the skin. Sounds of high frequency are auscultated better by means of a phonendoscope with a membrane, at strong press to the skin, or by means of Technique of lung a stethoscope with narrow auscultation funnel. by means of phonendoscope During auscultation the phonendoscope is placed in strictly symmetrical sites of the right and left sides of the chest practically in the same zones as during carrying out of comparative percussion.
It is necessary to remember, that during carrying out of auscultation of the lungs in lateral parts of thorax hands of the patient must be raised and clamped at the back of the head.
During auscultation behind the patient should be asked to cross his arms on the chest and to lower his head slightly. For an estimation of the main respiratory sounds auscultation in the specified zones should be carried out at quiet nasal breathing of the patient. At presence of additional respiratory sounds physicians use special methods for specification of character of sounds: ask the patient to breathe deeply by means of a mouth, listen breathing on a background of the forced inspiration and expiration, after spitting, laying on a side or a back, more firmly having pressed a phonendoscope, simulate an inspiration, use also other diagnostic methods. Revealed changes of breathing and adventitious respiratory sounds describe, using universally topographical landmarks on a thorax: supraclavicular, subclavicular areas, axillary areas, over-, inter-, subscapular areas, a level of corresponding ribs, etc.). Physical characteristics of the main respiratory sounds 1-vesicular; 2- harsh; 3- bronchovesicular; 4- bronchial; 5- amphoric. F-f f F f H-h H-H The mechanism of occurrence of normal vesicular breathing The soft blowing noise reminding sound “F- f”, is caused by vibration of the elastic elements of the alveolar walls, that can be heard during the entire inspiration phase. Alveolar wall still vibrate at the initial expiration phase to give a shorter second phase of vesicular breathing, which is heard only during the 1/3 of the expiration phase. In the healthy person almost above all surface of lungs it is heard vesicular breathing. The mechanism of occurrence of laryngotracheal breathing Rough and loud respiratory noise of laryngotracheitic breathing, similar to a sound "H-H ", is caused by a turbulent air flow and the fluctuations of adjoining dense tissues connected with it. The turbulent air flow is formed in a larynx and the upper part of a trachea both during inspiration, and during all expiration. But since the vocal slit is narrower during expiration the respiratory sound becomes louder, harsher and longer. All other types of breathing as a matter of fact are derivative of two main respiratory sounds - vesicular and laryngotracheal breathing. Laryngotracheal breathing is heard only in places of a projection of a trachea, and also above a thyroid cartilage. In other places it is heard vesicular breathing. Changes The mechanism Syndromes or diseases Weake- ning 1) Syndromes of "barrier" -hydrothorax -pneumothorax -fibrothorax 2) Decrease of elasticity of -pulmonary emphysema alveoli -early stages of an pulmonary parenchyma inflammation -interstitial pulmonary edema 3) Obturation of large bronchi - obturative atelectasis Strengthening 1.Hyperthermia -not changed pulmonary tissue in 2.Hyperthyrosis hyperventilation conditions 3.Physical activity Harsh Narrowing of bronchi due to Bronchitis edema of mucosa, exudation in a bronchial lumen, a spasm of smooth muscles of fine bronchi Cogwheel Non-uniform narrowing of the -tubercular bronchiolitis smallest bronchi -infringements of breath due to a trauma of a thorax or a pathology of respiratory muscles and their regulation Pathological bronchial breathing is heard above lungs at occurrence of conditions for good conducting on a surface of a thorax of noise laryngotracheal breathing, arising mainly in a larynx: in presence of a cavity in a lung, communicated with the bronchus, in lobar inflammatory consolidation of a lung and in compressive atelectasis.
Pathological bronchial breathing has almost the same physical characteristics, as laryngotracheal breathing: it is rough, rather high-frequency, reminds a sound “H-H”, its expiration is longer than inspiration. The mechanism of occurrence of mixed (bronchovesicular) breathing in focal inflammatory consolidation of a lung (in focal pneumonia) is the following. In the area of a projection of a small site of the consolidated pulmonary tissue weak bronchial breathing is conducted to a surface of a lung. Little changed alveoli, surrounding this focus, induce noise of vesicular breathing. Mixture of two noise leads to occurrence so-called bronchovesicular breathing. Remember:
For the decision of a question on character of listened breathing it is necessary to estimate: 1) a timbre of breathing (the sound standard of bronchial breathing is above a larynx), 2) a correlation of duration of heard parts of inspiration and expiration, 3) amplitude of respiratory noise during inspiration and expiration. Estimation of the main respiratory sound (of type of respiration) (at deep breathing by nose) 1. Determining of Soft, low, look like Rough, high, look During expiration it timbre and sound “F-f” or “F-F” like sound “H-H” is softer, look like frequent sound “F” more, characteristic of during expiration - sound differently rougher, look like during inspiration sound “H” and expiration 2. Comparison Isn’t like Is like Looks like during with standard of expiration mainly laryngotracheal breathing (larynx) 3. Duration of Inspiration > expiration, Inspiration < Inspiration
Fine bubbling Various, some Fine bronchi, Liquid sputum Stagnant signs in moist deadened sounds, bronchioles in bronchial pulmonary rales ( non look like bursting lumen, circulation, sonorous) of fine air surrounding by bronchitis (rare) bubbles (cracles), little-changed are heard during pulmonary inspiration and tissue expiration
Fine bubbling Various, very Fine bronchi, Liquid sputum Bronchopneumonia moist loud sounds, look bronchioles in bronchial rales (sonorous) like bursting of lumen, fine air bubbles surrounding by (cracles), are consolidated heard during pulmonary inspiration and tissue expiration Crepitation Monotonous Alveoli Alveoli in Initial stages sounds, look collapsed state, of lobar like bursting of but its airiness is pneumonia fine air bubbles kept partly, (croupous (cracles), is presence of pneumonia), heard at height parietally compressive of deep located atelectasis, inspiration transsudate, pulmonary only exudates or infarction blood Pleural Various sounds Pleural Inflammation of Dry friction look like a layers pleural layers, pleurisy, sound crunch of a accumulation of pleuropneu snow, a scratch fibrin on them monia, of leather, adhesions rustle of a (rare) paper (rub), is heard during inspiration and expiration Bronchophony Bronchophony - is the voice conduction from the larynx to the chest, which is determined by auscultation. The patient whisper says the words containing sounds “ch”. In the healthy person said words are heard equally over symmetrical points of the lung, they are indiscernible and undecipherable. Strengthening bronchophony is observed in syndromes of consolidation of the lung tissue and cavities in the lung, thus the voice is conducted so precisely, that it is possible to disassemble separate words. Weakening bronchophony is observed in the patients with emphysema, presence of a small amount of a liquid in a pleural cavity, incomplete obturation of a large bronchial tube. In research bronchophony a sound is not conducted on a thorax in such syndromes, as hydro- and pneumothorax, complete obstruction of the bronchial lumen by a tumor. Being, in essence, the same phenomenon, as vocal fremitus, bronchophony has advantage when the patent is not capable to say loudly words or deeply to breathe, and also in detection the small centers of consolidation. The conclusion: In carrying out bronchophony illegible (undecipherable) whisper speech is heard over symmetrical points of the lung. Thus, auscultation is one of the main methods in diagnostics of diseases of respiratory organs. It allows to the physician to make representation about presence of possible changes in pleural cavity, pulmonary parenchyma, and lumen of tracheobronchial tree.
On the base of results of auscultation together with data of other methods examination of respiratory organs diagnostics of the main bronchopulmonary syndromes is carried out. Thank you for attention