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 <expiration respiratory sound or inspiration=expiration expiration during inspiration and expiration 4.Determining of Vesicular breathing or Bronchial breathing Mixed (or the main its varieties: or its varieties: bronchovesicular) respiratory sound 1.Vesicular. 1. Bronchial. breathing 2.Weakened vesicular. 2. Amphoric Bronchovesicular 3.Strengthened vesicular. 4.Harsh. 5.Cogwheel Adventitious respiratory sounds In norm adventitious respiratory sound are not heard. In pathology of bronchi, trachea rales can be heard; pathological process at a level of alveoli can be accompanied by occurrence of crepitation; the inflammation and a roughness of pleural leaves quite often lead to occurrence of pleural friction sound or less often - to pleuropericardial friction murmur. Rales can be dry (bass, buzzing or treble, whistling) and moist (fine, medium, and coarse bubbling). On loudness of sounding sonorous (consonating) and not sonorous (not consonating) moist rales are distinguished. The mechanism of occurrence crepitation Сrepitation arises in alveoli in presence in them of parietally located liquid secretion (viscous exudation, blood or transsudate) and some collapse of alveoli keeping, however, relative airiness. Such conditions arise in patients with initial stages of lobar pneumonia (croupous pneumonia), in compressive atelectasis and a pulmonary infarction. Unlike normal working alveoli in the healthy person, in the listed pathological conditions during a greater part of inspiration alveoli are in collapsed condition; penetration into them of air occurs only at height of a deep inspiration that is accompanied by unsticking of alveolar walls and occurrence of the cracking sounds very resemble moist fine bubbling rales (crackles). The mechanism of occurrence of pleural friction sound Pleural friction sound arises at friction of rough surfaces of inflammatory changed pleural layers against one another during breathing and resembles a crunch of a snow, a scratch of leather, rustle of a paper. Differences of adventitious respiratory sounds DIFFERENCES ADVENTITIOUS RESPIRATORY SOUNDS Dry rales Moist rales Crepitation Pleural friction sound The relative to During During During the During phases of inspiration inspiration height of inspiration breathing and and inspiration and expiration expiration expiration After cough Are Are changed Is not Is not changed changed changed The acoustic Various Various Monotonous Various characteristic sounds sounds more sounds sounds more often often At pressing by a Aren’t Aren’t Isn’t Is intensified stethoscope intensified intensified intensified Adventitious respiratory sounds, their characteristics Adventitious Typical signs of adventitious respiratory sounds respiratory Acoustic characteristics Place of Conditions of Diseases and sounds appearance appearance syndromes Dry bass rales Low-pitched, hooting, Trachea, large Threats, Tracheitis, buzzing, long (wheezes), and medium