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AUSCULTATION
Auscultation (Latin auscultare to listen) - listening to the sounds inside the body. Mediate auscultation was 1st developed by the French physician Rene Theophile Hyacinthe Laennec in 1816.
1782-1826
Types of auscultation
Immediate (direct) auscultation when the examiner presses his ear to the patients body Mediate (indirect / instrumental) auscultation using of a) stethoscope b) phonendoscope Bronchophony auscultation of the voice sounds
Silence in the room Warm room Position: sitting / standing (in grave condition lying in bed)
Better to sit up on a chair with hands on the laps (deep breathing due to hyperventilation may cause vertigo - the patient may faint)
Use warm instrument for auscultation Auscultation in each point of 2-3 respiratory cycle Auscultation of the main sounds - breathing through the nose Auscultation of the additional sounds - breathing through the mouth Ask to cough, to make forced expiration (after cough and expectoration the sputum rales may disappear / change their properties) Use the accustomed instrument (to differentiate the sounds of a stethoscope itself or the sounds generated in the human body)
Anterior surface
Lateral surface
Posterior surface
Physical grounds
A stethoscope - closed acoustic system (air - transmitting medium for sounds) The human ear perceives vibrations: 16-20 20 000 Hz The highest sensitivity of the ear - 2 000 Hz The sensitivity decreases sharply with the decreasing frequency A weak sound is perceived difficultly after a loud sound Auscultation sounds are noises (a mixture of various frequencies sounds) Auscultation noises of the lungs are mostly vibrations 20 - 600 Hz: bronchial respiration 240 1 000 Hz friction sounds 75 - 500 Hz
The type of breathing (main) sound Presence any of adventitious (added) sounds Vocal resonance (bronchophony)
Vesicular Bronchial
Vesicular breathing
Turbulent airflow transmitted to the chest wall, filtered by normally inflated alveoli vesicles (result - loss of the higher frequency) Rustling noise, louder and more prolonged in inspiration than in expiration - ratio 3:1 (active inspiration due to the passage of air into the bronchi and alveoli followed without a pause by passive expiration due to elastic recoil of the alveoli - maximal in the early phase of short expiration) Soft intensity & relatively low pitch of expiratory sound
Normal vesicular breathing is better heard over the anterior surface of the chest below the 2nd rib laterally of the parasternal line, in the axillary region, below the scapular angles (the largest masses of the pulmonary tissue are located) Vesicular breathing is heard worse at the apices of the lungs and their lowermost parts (the masses of the pulmonary tissue are less abundant) Expiration sounds are louder and longer in the right lung (better conduction of the laryngeal sounds by the right main bronchus, which is shorter and wider). The sound may become bronchovesicular over the apex (more superficial and horizontal position of the right apical bronchus)
Weakening excessively developed muscles / subcutaneous fat Intensification undeveloped muscle / subcutaneous fat children with thin chest wall, good elasticity of alveoli and interalveolar septa -puerile respiration (Latin puer child) during exercise (respiratory movements become deeper and more frequent)
Physiological vesicular respiration always involve both parts of the chest, respiratory sounds are equally intensified / weakened at the symmetrical points of the chest
Pulmonary emphysema (alveoli loss elasticity, their walls become incapable of quick distension - insufficient vibrations) Lobar pneumonia - early & final stage (inflammation & swelling of the walls in a part of the lung, decrease amplitude of their vibration during inspiration) Tumor (insufficient delivery of air to the alveoli through the airways -mechanical obstruction) Inflammation of the respiratory muscle, intercostal nerves, rib fracture, extreme asthenia & adynamia (markedly weakened inspiration phase) Pleural layers thickening, pneumothorax, hydrothorax (obstructed conduction of sound waves from the source of vibration to the chest surface)
Obstructive breathing - increased expiration (obstruction to the air passage through small bronchi or their contracted lumen - inflammatory edema of the mucosa, bronchospasm) Harsh breathing - increased inspiration & expiration (marked & non-uniform narrowing of the lumen in small bronchi & bronchioles - inflammatory edema of the mucosa) In bronchial asthma, acute bronchitis, COPD
Short, jerky inspiration efforts interrupted by short pauses non-uniform contraction of respiratory muscles
Interrupted breathing over a limited part of the lung difficult passage of air from small bronchi to the alveoli & uneven unfolding of the alveoli (pathology in fine bronchi, more frequently at the apices of the lungs - tuberculous infiltration)
Arise in the larynx & trachea as air passes through the vocal slit during inhalation & exhalation Exhalation sound louder, harsher, longer (2:1) vocal slit more narrow during exhalation (intense turbulence of air through the vocal slit in vortex-type motion) Expiration and inspiration separated by pause
Loud, harsh, long sound (as H ) - hollow blowing quality Turbulence in the large airways without filtering by the alveoli Expiratory sound higher pitch & intensity than the inspiratory sound Inspiration/expiration ratio 1:2 Silent gap between inspiration & expiration
Anterior - over the manubrium sterni (junction point) Posterior - 3rd & 4th thoracic vertebrae in the interscapular space
Lung consolidation Compressive atelectasis Cavity in the lung communicated with bronchus
Soft & low-pitch sound, faint Resembles echo (far from the ear)
Amphoric Greek amphoreus - jar More intense & highpitch Musical character Imitated by blowing over the narrow neck of a bottle
Cavernous sound over the cavity Low-toned form of bronchial breathing (more hollow in quality) Imitated by breathing into a tumbler
If the cavity is well filled, no abnormal breath sounds will be heard, though breathing may be faint
Bronchovesicular respiration
F H
Bronchovesicular respiration
Mechanism - mixture of bronchial & vesicular: Weak bronchial breathing in small region of deeply located consolidation focus projection Vesicular breathing of near located unchanged alveoli
Inspiratory sounds last longer than expiratory ones. Inspiratory and expiratory sounds are about equal. Expiratory sounds lasts longer than inspiratory ones. Inspiratory and expiratory sounds are about equal
Soft
Relatively low
BRONCHOVESICULAR
Intermediate
Intermediate
BRONCHIAL
Loud
Relatively high
Over the manubrium, if heard at all. Over the trachea in the neck
TRACHEAL
Very loud
Relatively high
The thickness of the bars indicates intensity; the steeper their incline, the higher the pitch
1. 2.
Rales: Discontinuous (cracles) Continuous (wheezes, ronchi) Crepitation Pleural friction rub
2 subgroups (intensity, pitch and duration): Fine crackles (..) soft high-pitched very brief (5-10 msec)
Coarse & medium crackles (..) louder lower in pitch not quite so brief (20-30 msec)
Crackles
Places of appearance: Bronchial tree Lung cavity (communicated with the large bronchus) Mechanism: Liquid secretion (sputum, edematous fluid, blood) Time of appearance: Both respiratory phases (better audible on inspiration)
Crackles
Simulated by bubbling air through water using a fine tube
Crackles formation
1.
2.
3.
Crackles
In lung or pleural cavities with liquid pus & air Pus sticks to the surface of the cavity in changing patients position pus falls down in drops at the bottom (one by one)
Notably longer than as dashes in time (>250 msec) Not persist throughout the respiratory cycle Musical quality Audible in both respiratory phases (better on expiration)
Spasm of smooth muscles of the bronchi Inflammatory swelling of bronchial mucosa Accumulation of viscous sputum in bronchi with narrowing lumen Formation threads from the sputum (from wall to wall)
Alveoli
Places of appearance:
Mechanism: Small amount of liquid secretion in alveoli Time of appearance: End of inspiration Conditions: Lobar pneumonia (1st & 3rd stages) Infiltrative tuberculosis Lung infarction Cardiac asthma Imitated by rubbing a lock of hear
Splashing sound in hydropneumothorax (serous fluid & air in the pleural cavity)
The physician presses his ear against the chest and shakes the patient suddenly
Respiratory Sounds
Respiratory music
Bronchophony
1. 2.
Predominantly
TRANSMITED VOICE Spoken words SOUNDS muffled an indistinct Spoken ee heard as ee Whispered words faint and indistinct TACTILE FREMITUS Normal
Increased