SMALL ANIMAL MEDICINE DIAGNOSTIC LECTURES Lectures for students, 6th semester Examination of the respiratory organs V. Percussion Percussion

Prof. Dr. Vörös, Károly Department of Internal Medicine Methods of cardiovascular examination

• Physical examination:

• Inspection (heart, vessels) • Palpation (heart, vessels) • Percussion (heart) • Auscultation (heart)

2 Thoracic percussion METHODS - finger to finger (in small animals) -with plessimeter and percussion hammer (in large animals)

INDICATIONS - determination the caudal borders of the lungs - estimation the gas content of the organs (increased or decreased) - comparative percussion (left and right side)

dog

- Examination should be performed anytime in proper order from the back to the front, and from up to down. - Regions of considerable size, lying superficially can be detected. The proper position and moving of the percussion hammer

Genesis/origin of the percussion sound

• C - Crackling sounds of tapping the hammer and the plessimeter; thoracic wall will resonate (1), resonance C from the location of percussion (2) spreading Heart further (3) and producing resonant sounds of gas- containing tissue (lung) or other organs • Components of the percussion sound (Marek) (repeated slide)

1. Crackling sound of tapping the hammer and the plessimeter 2. Sound of the thoracic wall or the wall of any organ 3. Resonant sound of gas-containing tissue (lung) or other organs • Main characteristics of the percussion sound volume/loudness vibrations amplitude: strong/sharp  weak/dull pitch/frequency number of vibration/min: high  low tone/resonance homogenous/non-homogenous sonorous/resonant  damped duration short  long PERCUSSION (repeated slide)

-Acoustic percussion: to obtain information about the condition of the surrounding tissues (create sound waves, resonancy) thorax, paranasal sinuses, abdominal cavity, subcutaneous emphysema • border estimation (lung border) • assessment of a tissue density to a depth of 7 cm • detect a lesion at least 5 cm in diameter

-Percussion to localize pain (pain percussion) percussion tone: -weak, superficial (to define the border line)

-strong, deep • Methods: – direct (finger to finger) – indirect (plessimeter and percussion hammer) PERCUSSION SOUNDS (repeated slide) Main percussion sounds: • sonorous/resonant: fairly low, strongly resonant (air containing organ, e.g. normal lungs) • damped/dull: short sound of low intensity (any organ not containing gas: liver, heart, muscle) • tympanic (stronger, longer, higher than sonorous, higher in pitch) (striking a hollow organ containing gas under pressure, e.g. gastric volvulus) The normal percussion sound of the thorax (lungs)

Medium-sized and large animals (40-500 bwkg): sharp, low, (non)sonorous (non)resonant and short percussion sound

Small animals (25-40 kg bwkg):

sharp, high or low, sonorous (resonant) and long percussion sound Other special sounds

- Metallic (steel-like) sound (high-pitched, sharp musical sound) - Cracked-pot sound (rasping, whizzing sound with additional noises) - Hollow sound (strong, high, long sound, can be tympanic or nontympanic Vörös, 1991 Lung borders in the dog, Budapest school

Cs Ü

Most reliable, V easy to detect.

Cs: külső csípőszöglet ventral border of tuber coxae Ü: ülőgumó tuber ischii = ischiadic tuber V: vállvonal point of shoulder Caudal lung borders of animals

Species No. of Back Tuber Ischiadic Point of ribs muscles coxae tuber Shoulder Horse 18 17 16 14 10

Cattle, 13 12 11 - 8 sheep, goat Swine 14 12 11 9 7

Dog, cat 13 12 11 10 8 Abnormal shift of lung borders

1. Displacement of the caudal border backwards and downwards: •alveolar and interstitial lung emphysema

2. Decrease of the percussion area of the lungs: abdominal distention due to

•distention of stomach or intestine •enlarged liver •pregnancy •ascites •large intraabdominal tumor

3. „Elevation” of the caudoventral border: • increase of the cardiac dullness (cardiomegaly or pericardial effusion) Altered percussion sounds within the lung borders

1.1 Relative or incomplete dullness (damping): weak, high, short, nonmusical sound

1.2. Absolute (complete) dullness: even weaker and shorter sound

Can be caused by:

thickened thoracic wall (edema, pleural adhesions, ++ conjective tissue decreased gas content of the lungs (pneumonia, edema, neoplasm) pleural effusion (horizontal dorsal border!) caused by hydrothorax, pleuritis, haemothorax or chylothorax atelectatic abdominal organs (full stomach, spleen, liver) atelectatic solid masses or masses filled with fluid within the thorax Pleural effusion (and free abdominal fluid, cat, FIP) FIP: feline infectious peritonitis Laterolateral radiographic image (standing position) Cause: dorsally Louder than normal sounds or bronchial-like displaced, sounds can be heard above the horizontal compressed lung, dullness. dyspnea.

Diernhofer Dreieck Horizontal (upper) border during percussion.

No sounds can be heard under the horizontal line (in region of the dullness): nil respiration = respiratio nulla. 16 The Diernhofer triangle

Vörös, K., Kisállatpraxis, 2010. 11. (1.) 2-10.

Lobus accessorius

A. B. Figure A. The enlarged cardiac dullness and behind it the Diernhofer triangle including an air-containing lung lobe between the diaphragm and the caudal border of the heart (arrow). In this area, the percussion sound of the thorax is normal in healthy animals and the Diernhofer triangle can be detected even in the case of cardiac enlargement. Figure B. The dark grey color indicates the location of the horizontal (upper) border of the dullness in the case of free pleural fluid accumulation. 17 Figure C. Anatomical image showing the caudal lung lobe between the heart and diaphragm. Altered percussion sounds within the lung borders

2. Tympanic sound (intensive and high resonancy sound)

Forms: - sharp (intensive) - weak (dull) - high - low Caused by:

- atelectatic parenchyma around the normal lung cavern in the lung open pneumothorax - eventrated abdominal organs filled with gas - ichorous pericarditis (fluid and gas in the pericardium) - emphysema localised subcutaneously Altered percussion sounds within the lung borders

3. Hollow (box) sound (low, more intensive, shorter and more nonmusical than the tympanic sound) - in wasted animals with thin chest and severe lung emphysema

4. Metallic sound (steel band effect) - pneumothorax - large cavern within the lung - prolapsed stomach or intestine in the thoracic cavity - subcutaneous emphysema

5. Cracked-pot sound

- if there is a cavern filled with gas and located under the chest wall which communicates with a bronchus - small subcutaneous emphysema Percussion findings of pleural effusion in a dog

Percussion still 242473 Luca with pleuritis, after emergency revealed free fluid in the ventral third of the thoracocentesis followed by thoracic drainage right hemithorax.20 Figure 6.18. Thoracocentesis in a dog under ultrasound guidance. Citology revealed adenocarcinoma.

From Vörös, K., 2019 Necessary literature

• Rijnberk, A.; van Sluijs, F.J. (2009): Medical history and physical examination in companion animals. 2nd ed. Elsevier. Amsterdam.

• Nelson, C.R., Couto, G. (2020): Small animal internal medicine. 6th ed. Elsevier, St. Luis.

22 Köszönöm a figyelmet. – Thank you for your attention.

Shukraan of your aihtimam  شكرا

Vörös, K. (ed.)Veterinary internal medicine. Diseases of dogs and cats. (in Hung.) Budapest, 2019.