Height of the tops. Features of comparative and topographic percussion. Lower borders of the lungs

PERCUSSION (percussio tapping) is one of the main objective methods of examining a patient, consisting of tapping areas of the body and determining by the nature of the sound that arises physical properties organs and tissues located under the percussed area (mainly their density, airiness and elasticity).

Story

Attempts to use P. arose in ancient times. It is believed that Hippocrates, by tapping the abdomen, determined the accumulation of liquid or gases in it. P. as a method of physical diagnosis was developed by the Viennese physician L. Auenbrugger, who described it in 1761. The method became widespread only after J. Corvisart translated the work of A. Auenbrugger into French in 1808. language. In the 20s 19th century a plessimeter and a percussion hammer were proposed. J. Skoda (1831) developed scientific basis P., explained the origin and features of percussion sound, based on the laws of acoustics and physical condition percussed tissues. In Russia, P. began to be used at the end of the 18th century, and at the beginning of the 19th century. its implementation in extensive practice contributed to F. Uden (1817), P. A. Charukovsky (1825), K. K. Seydlitz (1836) and especially G. I. Sokolsky (1835), who contributed to the improvement of the method, as well as subsequently V. P. Obraztsov and F. G. Yanovsky.

Physical Basics of Percussion

When you tap on an area of ​​the body, vibrations of the underlying media occur. Some of these* oscillations have a frequency and amplitude sufficient for auditory perception sound. The attenuation of the induced oscillations is characterized by a certain duration and uniformity. The frequency of vibration determines the pitch of the sound; the higher the frequency, the higher the sound. Accordingly, high and low percussion sounds are distinguished. The pitch of the sound is directly proportional to the density of the underlying media. So, with P. areas of the chest at the site of adjoining low-density air lung tissue Low sounds are formed, and high sounds are formed in the area where the dense tissue of the heart is located. The strength, or volume, of the sound depends on the amplitude of the vibrations: the greater the amplitude, the louder the percussion sound. The amplitude of body oscillations, on the one hand, is determined by the force of the percussion blow, and on the other hand, it is inversely proportional to the density of the oscillating body (the lower the density of the percussed tissues, the greater the amplitude of their oscillations and the louder the percussion sound).

The duration of the percussion sound is characterized by the decay time of the vibrations, which is directly dependent on the initial amplitude of the vibrations and inversely on the density of the vibrating body: the denser the body, the shorter the percussion sound; the lower the density, the longer it is.

The nature of the percussion sound depends on the homogeneity of the medium. With P. of bodies of homogeneous composition, periodic oscillations of a certain frequency occur, which are perceived as a tone. When P. of a medium inhomogeneous in density, vibrations have different frequency, which is perceived as noise. Among the media of the human body, only the air contained in the cavities or hollow organs of the body has a homogeneous structure (stomach or intestinal loop filled with air or gas, accumulation of air in the pleural cavity). With P. of such organs and cavities, a harmonic musical sound arises, in which the fundamental tone dominates. This sound is similar to the sound of hitting a drum (Greek, tympanon drum), so it is called tympanite or tympanic percussion sound. Characteristic property tympanic sound - the ability to change the pitch of the fundamental tone with a change in the tension of the walls of the cavity or the air in it. This phenomenon observed when spontaneous pneumothorax: with an increase in pressure in the pleural cavity (with valvular pneumothorax), tympanitis disappears and the percussion sound first takes on a dull-tympanic and then non-tympanic character.

Fabrics human body heterogeneous in density. Bones, muscles, fluids in cavities, and organs such as the liver, heart, and spleen have greater density. P. in the area where these organs are located gives a quiet, short-lived or dull percussion sound. Low-density tissues or organs include those that contain a lot of air: lung tissue, hollow organs containing air (stomach, intestines). P. of the lungs with normal airiness gives a fairly long or clear and loud percussion sound. As the airiness of the lung tissue decreases (atelectasis, inflammatory infiltration), its density increases and the percussion sound becomes dull and quiet.

Thus, with P. of different parts of the body healthy person three main characteristics of percussion sound can be obtained: clear, dull and tympanic (Table 1).

Table 1. CHARACTERISTICS OF THE MAIN TYPES OF PERCUTORY SOUND BY STRENGTH, DURATION AND FREQUENCY

A clear percussion sound occurs when P. of normal lung tissue. A dull percussion sound (or dull) is observed in P. areas under which there are dense, airless organs and tissues - the heart, liver, spleen, massive muscle groups (on the thigh - “femoral dullness”). Tympanic sound occurs when P. areas to which air cavities are adjacent. In a healthy person, it is detected above the place where the stomach, filled with air, adheres to the chest (the so-called Traube space).

Percussion methods

Depending on the method of tapping, a distinction is made between direct or immediate and mediocre tapping. Direct tapping is performed by striking the fingertips on the surface of the body being examined; with mediocre tapping, strikes with a finger or a hammer are applied to another finger or plessimeter placed on the body (Greek: plexis blow + metreo measure, measure) - a special plate made of metal, wood, plastic or bone.

Among the methods direct P. the methods of Auenbrugger, Obraztsov, and Yanovsky are known. L. Auenbrugger covered the percussed area with a shirt or put a glove on his hand and tapped the chest with the tips of his outstretched fingers, delivering slow, gentle blows (Fig. 1). V.P. Obraztsov used the index finger of his right hand (nail phalanx) for P., and in order to increase the force of the blow, he secured the ulnar part to the radial surface of the middle finger and then when sliding index finger from the middle he struck them with a percussion blow. With the left hand they straighten skin folds percussed area and limit the propagation of sound (Fig. 2, a, b). F. G. Yanovsky used one-finger P., in which percussion blows were applied with minimal force with the flesh of the two terminal phalanges of the middle finger of the right hand. Direct P. is used to determine the boundaries of the liver, spleen, and absolute dullness of the heart, especially in pediatric practice and in debilitated patients.

Methods of mediocre P. include tapping with a finger on a plessimeter, with a hammer on a plessimeter, and the so-called. finger bimanual P. The priority of introducing the finger bimanual P. belongs to G.I. Sokolsky, who struck with the tips of two or three fingers of the right hand put together on one or two fingers of the left hand. Gerhardt (S. Gerhardt) offered P. a finger; she received universal recognition. The advantage of this method is that the doctor, along with sound perception Using a pessimeter finger, he receives a tactile sensation of the resistance force of the percussed tissues.

With finger-to-finger fingerprinting, the middle finger of the left hand (serves as a plessimeter) is placed flat firmly on the area being examined, the remaining fingers of this hand are spread apart and barely touch the surface of the body. The end phalanx of the middle finger of the right hand (acts as a hammer), bent at the first joint almost at a right angle, strikes the middle phalanx of the plessimeter finger (Fig. 3). To obtain a clear sound, apply uniform, abrupt, short blows directed vertically to the surface of the plessimeter finger. During P. right hand bent at the elbow joint at a right angle and brought by the shoulder to the lateral surface of the chest, it remains motionless in the shoulder and elbow joints and performs only flexion and extension at the wrist joint.

The method of auscultation P. consists of listening to the percussion sound with a stethoscope (see Auscultation), which is installed on the side of the chest opposite to the percussed organ (when examining the lungs) or above the percussed organ (when examining the liver, stomach, heart) in the place of its contact with the abdominal or chest wall. Weak percussion blows or dashed palpatory movements (auscultatory palpation) are applied across the body from the point of contact of the stethoscope with it towards the edge of the organ being examined. While percussion strikes are made within the organ, the percussion sound is heard clearly; as soon as P. goes beyond the organ, the sound is sharply muffled or disappears (Fig. 4.).

Depending on the force of the blow, a distinction is made between strong (loud, deep), weak (quiet, superficial) and medium P. Strong P. is determined by deeply located organs and tissues (seals or a cavity in the lung at a distance of 5-7 cm from chest wall). Average P. is used to determine the relative dullness of the heart and liver.

Silent P. is used to find the boundaries of absolute dullness of the heart and liver, lung and spleen, small pleural exudates and superficially located lung compactions. So-called the quietest (minimal), delimiting P. is produced with such weak blows that the sound that arises is in the “threshold of perception” by the ear - threshold P. It is used to more accurately determine the absolute dullness of the heart; in this case, tapping is performed in the direction from the heart to the lungs.

Clinical Applications of Percussion

The supraclavicular and subclavian areas are percussed according to Plesch: the plessimeter finger is bent at a right angle at the first interphalangeal joint and pressed against the skin only with the end of the nail phalanx, blows are applied with a hammer finger on the main phalanx (Fig. 5). Depending on the purpose, there are two types of P.: topographic (restrictive) and comparative. With topographic P., the boundaries and dimensions of an organ (heart, lungs, liver, spleen), the presence of a cavity or focus of compaction in the lungs, fluid or air - in abdominal cavity or pleural cavity. With its help, the boundary of the transition of one sound to another is established. Thus, the right relative border of the heart is judged by the transition of a clear pulmonary sound to a dull one, and the absolute border is judged by the transition of a dull sound to a dull one. With P., tapping is usually done from a clear percussion sound to a dull one, delivering weak or medium-strength blows.

Comparative P. is performed using percussion blows of varying strength depending on the location of the patol, the focus. A deep-located focus can be detected by strong P., and a superficial one - moderate or quiet. Percussion blows are applied to (strictly symmetrical areas. They must be equal in strength on both sides. For better perception, two blows are usually made at each point.

With percussion of the heart define its boundaries. There are boundaries of relative and absolute dullness of the heart (see). In the zone of relative dullness, a dull percussion sound is determined, and in the zone of absolute dullness - dull. True size The heart corresponds to the boundaries of relative dullness, and the part of the heart not covered by the lungs corresponds to the zone of absolute dullness.

The right, upper and left borders of the heart are distinguished (P. is performed in this order). First, the right border of relative cardiac dullness is determined. The border of hepatic dullness is first determined. To do this, the finger-pessimeter is installed horizontally and the P. is guided along the intercostal spaces from top to bottom along the right midclavicular line. The place where the percussion sound changes from clear to dull corresponds to the border of hepatic dullness; it is usually located on the VI rib. Next, the P. is carried out in the fourth intercostal space from right to left (the plessimeter finger is located vertically).

The right border of relative dullness of the heart is normally located along the right edge of the sternum, and absolute dullness is along the left edge of the sternum.

The upper border is percussed in the direction from top to bottom, slightly retreating from the left edge of the sternum (between the sternal and parasternal lines). The pessimeter finger is positioned obliquely, parallel to the desired boundary. The upper limit of relative dullness of the heart is on the third rib, absolute - on the fourth. When determining the left border of cardiac dullness, P. begins outward from its apical impulse. If the apical impulse is absent, then the fifth intercostal space is found on the left and percussed, starting from the anterior axillary line, inwardly. The pessimeter finger is positioned vertically, percussion blows are applied in the sagittal plane.

The left border of absolute dullness usually coincides with the border of relative cardiac dullness and is normally determined 1 - 1.5 cm medially from the left midclavicular line in the fifth intercostal space.

P. vascular bundle formed by the aorta and pulmonary artery, are carried out in the second intercostal space sequentially to the right and left of the sternum in the direction from the outside to the inside. The width of the vascular bundle (the zone of dullness of percussion sound) normally does not extend beyond the sternum.

Percussion of the lungs It is produced in those places of the chest where normally the lung tissue is directly adjacent to the chest wall and causes a clear pulmonary sound in P.

Comparative and topographical P. of the lungs are used (see). With comparative P., the presence of patols, changes in the lungs or pleura is established by comparing the percussion sound in symmetrical areas of the right and left halves of the chest. With topographic P., the borders of the lungs are found and the mobility of the lower pulmonary edge is determined. The study begins with comparative percussion. With P. of the lungs, the patient occupies a vertical or sitting position; when examining the anterior and lateral walls, the percussionist is in front of the patient, and with P. of the posterior surface, he is behind the patient. With P. on the front surface, the patient stands with his arms down, on the side surfaces - with his hands behind his head, on the back surface - with his head down, slightly bent forward, with his arms crossed, with his hands on his shoulders.

The finger-pessimeter in the supraclavicular areas is applied parallel to the clavicle, in front below the clavicle and in the axillary areas - in the intercostal spaces parallel to the ribs, in the suprascapular area - horizontally, in the interscapular spaces - vertically, parallel to the spine, and below the angle of the scapula - horizontally, parallel to the ribs. The same percussion blows are applied with a hammer finger, usually of medium strength.

Comparative P. is carried out in front in the supraclavicular fossae, directly along the clavicles, below the clavicles - in the first and second intercostal spaces (from the third intercostal space on the left, the dullness of percussion sound from the adjacent heart begins, therefore, in the third and lower intercostal spaces in front, comparative P. is not performed). In the lateral areas of the chest, they percussion in the axillary fossa and along the fourth and fifth intercostal spaces (lower on the right, dullness of sound begins from the adjacent liver, and on the left, the sound acquires a tympanic hue from the proximity of Traube’s space). Behind the P. they lead in the suprascapular areas, in the upper, middle and lower parts interscapular spaces and under the shoulder blades - in the eighth and ninth intercostal spaces.

Patol, changes in the lungs or in the pleural cavity are determined by changes in percussion sound. A dull sound occurs when fluid accumulates in the pleural cavity ( exudative pleurisy, hydrothorax, hemothorax, pyothorax), massive compaction of the lung tissue (lobar pneumonia, extensive atelectasis). Shortening and dulling of percussion sound indicates a decrease in the airiness of the lung tissue, which occurs when it is focally compacted.

If a decrease in the airiness of the lung tissue is combined with a decrease in its elastic tension, the percussion sound becomes dull-tympanic (fine-focal infiltration, initial stage lobar pneumonia, a small air cavity in the lung with lung tissue compacted around it, incomplete atelectasis of the lung).

A tympanic sound is detected when the airiness of the lung tissue is sharply increased, when there is a cavity filled with air (abscess, cavern, bronchiectasis) and when air accumulates in the pleural cavity (pneumothorax). A type of tympanic sound is a box percussion sound, which is determined by pulmonary emphysema, accompanied by an increase in airiness and a decrease in the elastic tension of the lung tissue. If there is a large, smooth-walled cavity adjacent to the chest wall, the tympanic sound acquires a metallic tint, and if the cavity is connected by a narrow slit-like opening to the bronchus, air during P. comes out jerkily through the narrow opening in several stages and a peculiar intermittent rattling noise occurs - the sound of a cracked pot, described by R. Laennec.

In the presence of a large cavity or other pathol, a cavity communicating with the bronchus, the height of the tympanic sound changes when opening the mouth (Wintrich's symptom), with deep breath and exhalation (Friedreich's symptom), and if the cavity is oval, then also when the body position changes (Gerhardt's phenomenon).

With topographic P., the boundaries of the lungs are first determined: a finger-pessimeter is placed in the intercostal spaces parallel to the ribs and, moving it from top to bottom, quiet percussion blows are applied. Then the mobility of the lower edge of the lungs and their upper border are determined.

The location of the lower border of the lungs in people of different builds is not entirely the same. In typical hypersthenics it is one rib higher, and in asthenics it is one rib lower. Table 2 shows the location of the lower lung boundaries in a normosthenic person.

Table 2. POSITION OF THE LOWER BOUNDAR OF THE LUNG IN A NORMOSTHENIC

The lower limits decrease with an increase in lung volume due to emphysema or acute bloating (an attack of bronchial asthma).

The lower border rises with the accumulation of fluid in the pleural cavity (effusion pleurisy, hydrothorax), with the development of pulmonary fibrosis, with standing tall diaphragm in patients with obesity, ascites, flatulence.

When studying the mobility of the lower edges of the lungs, the lower border is determined separately at the height of a deep inspiration and after a complete exhalation. The distance between the position of the lung edge during inhalation and exhalation characterizes the overall mobility of the pulmonary edge, which is normally 6-8 cm along the axillary lines. A decrease in the mobility of the pulmonary edges is observed with emphysema, inflammation and edema of the lungs, formation pleural adhesions, accumulation of air or fluid in the pleural cavity, dysfunction of the diaphragm.

With P., the upper border of the lungs determines the height of the apexes and their width - the so-called. Krenig fields (see Krenig fields).

Percussion of the abdomen used to determine the size of hepatic and splenic dullness, identify fluid and gas in the abdominal cavity, as well as to identify painful areas abdominal wall(see Belly). The latter are revealed by applying light jerky blows to different areas abdominal wall - in the epigastric region, near xiphoid process(projection of the cardiac part of the stomach), from the right from the midline to the right hypochondrium (projection duodenum and gallbladder), along the midline and in the left hypochondrium (ulcer of the lesser curvature of the stomach, damage to the pancreas). Pain that appears at the height of inspiration during P. in the area of ​​the gallbladder is characteristic of cholecystitis (Vasilenko’s symptom).

Bibliography: Dombrovskaya Yu. F., Lebedev D. D. and M o l c h a n o v V. I. Propaedeutics of childhood diseases, p. 230, M., 1970; Kurlov M. G. Percussion of the heart and its measurement, Tomsk, 1923; L and with t about in A.F. Fundamentals of percussion and its features in children, M. - L., 1940; Obraztsov V.P. Selected works, p. 119, Kyiv, 1950; Propaedeutics of internal diseases, ed. V. X. Vasilenko et al., p. 43 and others, M., 1974; Skoda J. The doctrine of tapping and listening as a means of recognizing diseases, trans. from German, M., 1852; H o 1 1 d a with k K. Lehrbuch der Auskultation und Perkussion, Stuttgart, 1974; P i about g g at P. A. Traite de plessimetrisme et d’organographisme, P., 1866.

G. I. Alekseev; V. P. Bisyarina (ped.).

Includes sequential determination of their lower border, mobility of the lower pulmonary edge, standing height and width of the apexes. The determination of each specified parameter is carried out first on one side, and then on the other. In all cases, the pessimeter finger is placed parallel to the determined border of the lung, and the middle phalanx of the finger should lie on the line along which percussion is carried out, in a direction perpendicular to it.

Using quiet percussion blows, they percussion from the area of ​​clear pulmonary sound to the place where it becomes dull (or dull), which corresponds to the border of the lung. Fix the found boundary with a pessimeter finger and determine its coordinates. In this case, the edge of the pessimeter finger facing the area of ​​​​clear pulmonary sound is taken as the border of the organ. In cases where it is necessary to take measurements, it is convenient to use the previously known length or width of the phalanges of your fingers.

The lower border of the lungs is determined by vertical identification lines. The determination begins along the anterior axillary lines, since along the right midclavicular line the lower border of the lung was already found earlier before percussion of the right border of the heart, and the heart is adjacent to the left anterior chest wall.

The doctor stands in front of the patient, asks him to raise his hands behind his head and sequentially percusses along the anterior, middle and posterior axillary lines. The pessimeter finger is placed in the axillary fossa parallel to the ribs and percusses along the ribs and intercostal spaces in the direction from top to bottom until the boundary of the transition of a clear pulmonary sound into a dull one is detected (Fig. 39a).

After this, the doctor stands behind the patient, asks him to lower his arms and similarly percusses along the scapular line, starting from the lower angle of the scapula (Fig. 39b), and then percusses along the paravertebral line from the same level.

It should be borne in mind that determining the lower border of the left lung along the anterior axillary line may be difficult due to the close location of the tympanic sound area in Traube's space.

To indicate the location of the found lower borders of the lungs, ribs (intercostal spaces) are used, which are counted from the collarbone (in men - from the nipple lying on the V rib), from the lower angle of the scapula (VII intercostal space) or from the lowest freely lying XII rib. In practice, it is possible, having determined the localization of the lower border of the lung along the anterior axillary line, to mark it with a dermograph and use this mark as a guide to determine the coordinates of the lower border of this lung along other lines.

The localization of the lower border of the lungs along the paravertebral lines is usually designated relative to the spinous processes of the vertebrae, since the back muscles interfere with palpation of the ribs. When counting the spinous processes of the vertebrae, they are guided by the fact that the line connecting the lower corners of the shoulder blades (with arms down) crosses the VII thoracic vertebra.

Normal location of the lower borders of the lungs in normosthenics

In hypersthenics, the lower borders of the lungs are located one rib higher than in normosthenics, and in asthenics - one rib lower. Uniform descent of the lower borders of both lungs is most often observed with emphysema, less often with pronounced pubescence of the abdominal organs (visceroptosis).

The prolapse of the lower borders of one lung can be caused by unilateral (vicarious) emphysema, which develops as a result of cicatricial wrinkling or resection of the other lung, the lower border of which, on the contrary, is shifted upward. A uniform upward displacement of the lower borders of both lungs is caused by cicatricial wrinkling of both lungs or an increase in intra-abdominal pressure, for example, with obesity, ascites, flatulence.

If fluid accumulates in the pleural cavity (exudate, transudate, blood), the lower border of the lung on the affected side also shifts upward. In this case, the effusion is distributed in the lower part of the pleural cavity in such a way that the boundary between the zone of dull percussion sound above the fluid and the overlying area of ​​​​clear pulmonary sound takes the form of an arcuate curve, the apex of which is located on the posterior axillary line, and the lowest points are located in front - at the sternum and behind - at the spine (Ellis-Damoizo-Sokolov line). The configuration of this line does not change when changing body position.

It is believed that a similar percussion picture appears if more than 500 ml of fluid accumulates in the pleural cavity. However, with the accumulation of even a small amount of fluid in the left costophrenic sinus above Traube's space, instead of tympanitis, a dull percussion sound is determined. With a very large pleural effusion, the upper limit of dullness is almost horizontal or continuous dullness is determined over the entire surface of the lung. Severe pleural effusion can lead to mediastinal displacement. In this case, on the side of the chest opposite to the effusion, in its posteroinferior section, percussion reveals an area of ​​dull sound shaped like right triangle, one of the legs of which is the spine, and the hypotenuse is the continuation of the Ellis-Damoiseau-Sokolov line to the healthy side (Rauchfuss-Grocco triangle).

It should be taken into account that unilateral pleural effusion in most cases is of inflammatory origin (exudative pleurisy), while effusion simultaneously into both pleural cavities most often occurs when transudate accumulates in them (hydrothorax).

Some pathological conditions are accompanied by simultaneous accumulation of fluid and air in the pleural cavity (hydropneumothorax). In this case, during percussion on the affected side, the boundary between the area of ​​boxed sound above the air and the area of ​​dull sound above the liquid defined below it has a horizontal direction. When the patient's position changes, the effusion quickly moves to the underlying part of the pleural cavity, so the boundary between air and liquid immediately changes, again acquiring a horizontal direction.

With pneumothorax, the lower border of the box sound on the corresponding side is located lower than the normal border of the lower pulmonary border. Massive compaction in the lower lobe of the lung, for example in lobar pneumonia, can, on the contrary, create a picture of an apparent upward displacement of the lower border of the lung.

The mobility of the lower pulmonary border is determined by the distance between the positions occupied by the lower border of the lung in a state of full exhalation and deep inhalation. In patients with pathology of the respiratory system, the study is carried out along the same vertical identification lines as when establishing the lower boundaries of the lungs. In other cases, we can limit ourselves to studying the mobility of the lower pulmonary edge on both sides only along the posterior axillary lines, where the excursion of the lungs is maximum. In practice, it is convenient to do this immediately after finding the lower boundaries of the lungs along the indicated lines.

The patient stands with his hands raised behind his head. The doctor places a pessimeter finger on the lateral surface of the chest approximately a palm width above the previously found lower border of the lung. In this case, the middle phalanx of the pessimeter finger should lie on the posterior axillary line in a direction perpendicular to it. The doctor asks the patient to first inhale, then exhale completely and hold his breath, after which he percusses along the ribs and intercostal spaces in the direction from top to bottom until the border between a clear pulmonary sound and a dull sound is detected. Marks the found border with a dermograph or fixes it with the finger of the left hand located above the pessimeter finger.

Next, he asks the patient to take a deep breath and hold his breath again. In this case, the lung descends and below the border found on exhalation, an area of ​​​​clear lung sound again appears. Continues to percuss from top to bottom until a dull sound appears and fixes this boundary with a pessimeter finger or makes a mark with a dermograph (Fig. 40).

By measuring the distance between the two boundaries found in this way, the amount of mobility of the lower pulmonary edge is found. Normally it is 6-8 cm.

Reduced mobility of the lower pulmonary border on both sides in combination with drooping of the lower borders is characteristic of pulmonary emphysema. In addition, a decrease in the mobility of the lower pulmonary edge can be caused by damage to the lung tissue of inflammatory, tumor or scar origin, pulmonary atelectasis, pleural adhesions, dysfunction of the diaphragm or increased intra-abdominal pressure. In the presence of pleural effusion lower edge of the folded lung fluid remains motionless while breathing. In patients with pneumothorax, the lower limit of the tympanic sound on the affected side during breathing also does not change.

The height of the apex of the lungs is determined first from the front and then from the back. The doctor stands in front of the patient and places a pessimeter finger in the supraclavicular fossa parallel to the collarbone. Percusses from the middle of the clavicle upward and medially towards the mastoid end of the sternocleidomastoid muscle, displacing the pessimeter finger by 0.5-1 cm after each pair of percussion blows and maintaining it horizontal position(Fig. 41a).

Having discovered the border between the transition of a clear pulmonary sound into a dull one, he fixes it with a pessimeter finger and measures the distance from its middle phalanx to the middle of the clavicle. Normally, this distance is 3-4 cm.

When determining the standing height of the apexes of the lungs from behind, the doctor stands behind the patient, places a pessimeter finger directly above the spine of the scapula and parallel to it. It percusses from the middle of the spine of the scapula upward and medially towards the mastoid end of the sternocleidomastoid muscle, displacing the pleximeter finger by 0.5-1 cm after each pair of percussion blows and maintaining its horizontal position (Fig. 41b). The found boundary of the transition of a clear pulmonary sound into a dull one is recorded with a pleximeter finger and the patient is asked to tilt his head forward so that the most posteriorly protruding spinous process of VII is clearly visible cervical vertebra. Normally, the apexes of the lungs behind should be at its level.

The width of the apexes of the lungs (Kroenig's fields) is determined by the slopes of the shoulder girdles. The doctor stands in front of the patient and places the pessimeter finger in the middle of the shoulder girdle so that the middle phalanx of the finger lies on the anterior edge of the trapezius muscle in a direction perpendicular to it. Maintaining this position of the finger-pessimeter, he first percusses towards the neck, shifting the finger-pessimeter by 0.5-1 cm after each pair of percussion blows. Having discovered the border between the transition of a clear pulmonary sound into a dull one, he marks it with a dermograph or fixes it with a finger of the left hand located more medially finger-pessimeter.

Then, in a similar way, he percusses from the starting point in the middle of the shoulder girdle to the lateral side until a dull sound appears and fixes the found border with a plessimeter finger (Fig. 42). By measuring the distance between the internal and external percussion boundaries determined in this way, one finds the width of Krenig’s fields, which is normally 5-8 cm.

An increase in the height of the apex is usually combined with an expansion of Kroenig's fields and is observed with pulmonary emphysema. On the contrary, the low standing of the apices and the narrowing of Kroenig's fields indicate a decrease in the volume of the upper lobe of the corresponding lung, for example, as a result of its scarring or resection. At pathological processes, leading to compaction of the apex of the lung, a dull sound is detected above it already with comparative percussion. In such cases, determining the height of the top and the width of the Krenig fields from this side is often impossible.

To determine the height of the apex, a finger-pessimeter is placed above the collarbone, parallel to the collarbone, and from its middle it is percussed (by quiet percussion) upward and slightly inward to the earlobe until a dull sound appears. The mark is placed on the side of the pessimeter finger that faces the clear pulmonary sound, i.e. to the collarbone. Normal: protrudes above the collarbones by 3-4 cm. The right apex is 1 cm below the left.

2. Krenig margin width– zone of clear pulmonary sound above the apices of the lungs.

To determine the width of Krenig's fields, a finger-pessimeter is installed in the middle of the upper edge of the trapezius muscle and quiet percussion is carried out to the shoulder until a dull sound appears, after which a mark is made on the side of the clear pulmonary sound. Next, percussion is carried out to the neck until a dull sound appears. The distance (in cm) between the two marks will correspond to the width of the Krenig field. Normally, the width of the Koenigas margins is 5-6 cm.

A decrease in the height of the tops and the width of the Krenig fields is observed when the tops wrinkle. This most often occurs with pulmonary tuberculosis.

An increase in the height of the apexes and the width of Krenig's fields is observed with emphysema and an attack of bronchial asthma.

Lower border of the lungs

The lower border of the lungs is determined by percussion along the intercostal spaces from top to bottom and is located at the site of the transition of a clear pulmonary sound to a dull one. The border is marked from the side of the clear pulmonary sound.

The location of the lower borders of the lungs is normal.

A downward displacement of the lower border of the lungs is observed in the following pathological conditions:

1. emphysema;

2. prolapse of the abdominal organs.

An upward displacement of the lower border of the lungs is often unilateral and is observed in the following pathological conditions:

1. accumulation of fluid in the pleural cavity (exudative pleurisy, hydrothorax, hemothorax);

2. shrinkage of the lung (pneumosclerosis, fibrosis);

3. enlarged liver or spleen;

4. increased pressure in the abdominal cavity (ascites, pregnancy, flatulence, significant obesity);

5. obstructive atelectasis.

Mobility of the lower pulmonary edge.

Determination of the mobility of the lower pulmonary edge is carried out on the right along three lines - midclavicular, middle axillary, scapular, and on the left along two lines - middle axillary and scapular.

Stages of determining the mobility of the lower pulmonary edge:

Find the lower border of the lung and mark it.

The patient takes a maximum breath and holds his breath. At the height of inspiration, percussion is continued down from the lower border of the lung until a dull sound appears, note from the side of a clear pulmonary sound.

After calm breathing, the patient exhales as much as possible and holds his breath. At the height of exhalation, percussion is carried out from top to bottom from the 2-3 intercostal space until a dull sound appears, note from the side of a clear pulmonary sound.

The distance between points 2 and 3 is the total mobility of the lower pulmonary edge.

The total mobility of the lower pulmonary border is normal:

Midclavicular line – 4-6 cm;

Mid-axillary line – 6-8 cm;

Scapular – 4-6 cm.

A decrease in the mobility of the lower edge of the lungs is observed in the following diseases:

– pulmonary emphysema;

– inflammatory infiltration;

– congestion in the lower parts of the lungs;

– exudative pleurisy;

– obliteration of pleural layers.

There are two types of lung percussion: topographic and comparative.

Topographic percussion of the lungs

Topographic percussion of the lungs includes the topography of the apexes of the lungs, the topography of the lower edge of the lungs and determination of the mobility of the lower pulmonary edge, as well as the topography of the lobes of the lung.

In front, percussion is carried out from the middle of the clavicle upward and medially towards the mastoid process. Normally, the apex of the lung is 3–5 cm above the collarbone. If there are well-defined supraclavicular fossae, percussion is performed along the nail phalanx. Behind the boundary is determined from the middle of the spine of the scapula towards the spinous process of the VIIth cervical vertebra, at the level of which it is normal.

Determining the width of the apexes of the lungs or Kroenig's fields also has diagnostic value. They are determined from both sides, since it is important to evaluate their symmetry. Percussion is carried out along the upper edge of the trapezius muscle from its middle - medially and laterally. Normally, their value is 4–8 cm. When the apex of the lung is affected by the tuberculosis process with the development of fibrosis, the size of the Kroenig field decreases on the affected side, and with pulmonary emphysema it increases on both sides. The standards for the lower limit of the lungs are given in Table 3.

Table 3

Standards for the lower limit of the lungs

In severe hypersthenics, the lower edge may be one rib higher, and in asthenics – one rib lower.

The mobility of the lower pulmonary edge is determined by percussion along each topographic line, always during inhalation and exhalation. First, the lower border of the lung is determined during quiet breathing, then the patient is asked to take a deep breath and, while holding his breath, he percusses further until the percussion sound becomes dull. Then the patient is asked to exhale completely and is also percussed from top to bottom until the sound becomes dull. The distance between the boundaries of the resulting dullness on inhalation and exhalation corresponds to the mobility of the pulmonary edge. Along the axillary lines, it is 6–8 cm. When assessing the mobility of the lower edges of the lungs, it is important to pay attention not only to their size, but also to their symmetry. Asymmetry is observed in unilateral inflammatory processes (pneumonia, pleurisy, in the presence of adhesions), and a bilateral decrease is characteristic of pulmonary emphysema,

Comparative percussion of the lungs

Comparative percussion of the lungs is carried out sequentially along the anterior, lateral and posterior surfaces of the lungs. When conducting comparative percussion, the following conditions must be observed:

a) perform percussion in strictly symmetrical areas;

b) observe the identical conditions, meaning the position of the pessimeter finger, pressure on the chest wall and the force of percussion blows. Percussion of medium strength is usually used, but when identifying a focus located deep in the lung, strong percussion blows are used.

In front, percussion begins from the supraclavicular fossa, with the pessimeter finger positioned parallel to the clavicle. Then the clavicle itself and the areas of the 1st and 2nd intercostal spaces are percussed along the midclavicular lines, while the pessimeter finger is located along the intercostal spaces.

On the lateral surfaces, comparative percussion is carried out along the anterior, middle and posterior axillary lines, with the patient’s arms raised. When percussing the posterior surface of the lungs, the patient is asked to cross his arms over his chest, while the shoulder blades diverge and the interscapular space increases. First, the suprascapular space is percussed (the plessimeter finger is placed parallel to the spine of the scapula). Then the interscapular space is sequentially percussed (the pessimeter finger is placed parallel to the spine). In the subscapular region, percussion is performed first paravertebrally, and then along the scapular lines, placing the pessimeter finger parallel to the ribs.

Normally, with comparative percussion, it is reproduced clear lung sound basically the same in symmetrical areas of the chest, although it should be remembered that on the right the percussion sound is more muffled than on the left, since the apex of the right lung is located below the left and the muscles of the shoulder girdle in most patients on the right are more developed than on the left and partially dampen the sound.

A dull or dull pulmonary sound is observed when the airiness of the lung decreases (infiltration of lung tissue), the accumulation of fluid in the pleural cavity, when the lung collapses (atelectasis), or when there is a cavity in the lung filled with liquid contents.

Tympanic percussion sound is determined by increased airiness of the lung tissue (acute and chronic emphysema), which is observed in various cavity formations: cavity, abscess, as well as accumulation of air in the pleural cavity (pneumothorax).

A dull tympanic sound occurs when the elasticity of the lung tissue decreases and its airiness increases. Similar conditions arise with pneumococcal (lobar) pneumonia (the stage of influx and the stage of resolution), in the area of ​​​​the Skoda strip with exudative pleurisy, with obstructive atelectasis.

Examination technique respiratory system in children

MINISTRY OF HEALTH OF UKRAINE

National Medical University

them. acad. A.A.Bogomolets

METHODOLOGICAL INSTRUCTIONS

FOR INDEPENDENT WORK OF STUDENTS IN PREPARATION FOR PRACTICAL LESSONS

Kyiv 2007

1. Relevance of the topic

Diseases respiratory system– most common pathology in children. Children under 3 years of age suffer from 2 to 12 acute illnesses every year. respiratory infections, at 3–7 years old children suffer from ARI on average 6 times a year, and at 7–17 years old – 3 times a year. On average, from birth to graduation, a child gets ARI about 60 times.

Thus, respiratory diseases in children occur more often and are more severe than in adults, with more rapid development respiratory failure, which is associated both with the anatomical and physiological characteristics of the respiratory organs, and with the characteristics of the reactivity of the child’s body.

2. Specific goals.

1. Be able to collect anamnesis from a patient with diseases of the respiratory system.

2. Conduct an objective examination taking into account age characteristics.

3. Be able to interpret the received data.

4. Analyze the main syndromes of damage to the respiratory system.

5. Be able to prescribe a complex of laboratory and instrumental examinations for diseases of the respiratory system.

3. Basic knowledge that is necessary to study the topic.

4. Assignments for independent work.

4.1. A list of basic terms, parameters, characteristics that the student must learn.

4.2. Questions for the lesson.

1. What are the stages of examination of the respiratory system in children?
2. What features are there when examining the respiratory system of a newborn?
3. What are the features when examining the respiratory system in children? younger age?
4. What features are there when examining the respiratory system in older children?
5. What is the reason general state patient with respiratory system diseases?
6. Features of collecting anamnesis in children with diseases of the respiratory system?

4.3. Practical tasks performed in class:

1. Taking anamnesis in children with diseases of the respiratory system.
2. Conversation with relatives of a sick child.
3. Collecting a family history from relatives of a sick child.
4. Collecting an allergy history from relatives of a sick child.
5. General inspection child, taking into account his age characteristics.
6. Practicing practical skills of palpation, percussion, auscultation of the respiratory system in a newborn.
7. Practicing practical skills of palpation, percussion, auscultation of the respiratory system in a young child.
8. Practicing practical skills of palpation, percussion, auscultation of the respiratory system in an older child.

The examination of the respiratory organs includes anamnesis, examination, palpation, percussion, auscultation, laboratory and instrumental methods research.

ANAMNESIS. You need to find out the following:

• The child has difficulty breathing through the nose, as well as the nature of the nasal discharge (serous, mucous, mucopurulent, purulent, bloody);
• Does the child suckle freely at the mother's breast?
• The presence and nature of the cough (the cough can be barking, hoarse, paroxysmal, dry or wet), as well as the time of day when the child predominantly coughs;
• The presence of sputum and its nature (mucous, purulent);
• Does vomiting occur during coughing?
• Presence of pain in the chest, abdomen, side;
• Have there been any episodes of difficulty breathing;
• Duration of illness, cough;
• What respiratory diseases has the child suffered from before?
• Was there any contact with acute patients? infectious diseases, patients with tuberculosis.

Family and allergy history is also important

INSPECTION. They begin by assessing the patient’s condition, state of consciousness, position in bed, and behavior. It is important to evaluate the color skin, coloring of the nasolabial triangle.

Zev The child is examined at the end of the study, because The child's anxiety may interfere with further examination.

Child's voice It has great importance in assessing the condition of the upper respiratory tract. A loud cry at birth indicates the first deep breath. A weak first cry or its absence indicates general weakness, or asphyxia of the newborn, or respiratory failure. A hoarse voice or its absence (aphonia) indicates acute laryngitis, as well as grade 2-3 croup.

Cough– it is necessary to find out its nature, frequency, time of occurrence. Information about cough should be collected from the mother, as well as during an objective examination. A cough can be caused by irritating the throat with a spatula.

Upon examination chest pay attention to its shape, the participation of muscles in breathing, the synchronicity of movement of both halves of the chest.

It is very important to evaluate depth of breathing, its frequency and rhythm. It is best to count the respiratory rate while the child is sleeping using a phonendoscope for at least 1 minute.

Breathing rate – important indicator, which may indicate shortness of breath. Respiratory rate changes with age. A newborn's breathing is shallow, gas exchange is more vigorous than in adults, which is compensated by more frequent breathing.

Normal breathing rate:

Newborn 40 – 60 per 1 min.

Child 1 year 30 – 35 per minute.

Child 5 – 6 years old 20 – 25 per minute.

Child 10 years old 18 – 20 per minute.

Adult 16 – 18 in 1 min.

Breathing rhythm variable in children. Rhythm instability and short (up to 5 s) pauses in breathing (apnea) can occur in healthy newborns. Before the age of 2 years, the breathing rhythm may be irregular, especially during sleep.

Type of breathing: observed in young children abdominal type breathing. In boys it persists, but in girls from 5 to 6 years of age the type of breathing becomes chest breathing.

PALPATION. Performed with both hands over symmetrical areas. By squeezing the chest from front to back and from the sides, its resistance is determined. Voice tremor is also determined by palpation, and the child must pronounce words that cause vibration of the voice (for example, “thirty-three”, “forty-four”). In young children, vocal tremor is examined during crying.

PERCUSSION. It is necessary to carry out with the child in a position that ensures the symmetry of the location of both halves of the chest. At incorrect position the child's percussion picture may be distorted.

You can percussion a child in a lying or sitting position. Small children must be held. A child who cannot hold his head up can be percussed by placing him on his stomach or holding him in his left hand.

Percussion can be direct or indirect.

When percussing healthy lungs, a clear pulmonary sound is detected. However, pulmonary sound is not the same everywhere. On the right in the lower sections, due to the proximity of the liver, the percussion sound is shortened; on the left, due to the proximity of the stomach, it takes on a tympanic hue (the so-called Traube space).

Upper limit of the lungs in children preschool age not determined, because the tops of their lungs do not extend beyond the collarbone. In older children, the apex of the lungs is determined by percussion above the collarbone along the outer edge of the sternocleidomastoid muscle until the sound shortens. Normally, this area is located at a distance of 2-4 cm from the middle of the collarbone. From behind, percussion is carried out from the spina scapulae towards the spinous process of the VII cervical vertebra. The shortening of the percussion sound normally occurs at the level of the spinous process of the VII cervical vertebra, where the height of the apexes of the lungs is located.

Lower borders of the lungs

Mobility (excursion) of the lower edge of the lungs.

Find the lower border of the lungs using lin. axillaris medium or by lin. axillaris posterior. Then the patient is asked to take a deep breath and hold his breath, while determining the position of the lower edge of the lung. The mark is made on the side of the finger that faces the clear percussion sound. The lower border of the lungs is also determined during exhalation, for which the patient is asked to exhale and hold his breath.

When determining the boundaries of the lungs by percussion, the boundary is located on the side of the finger that faces the clear percussion sound.

In various pathological conditions, the following changes in the percussion pattern are observed:

• shortening of percussion sound (with a decrease in the airiness of the lung tissue);
• tympanic shade (when cavities containing air appear in the lungs, or the elastic properties of the lung tissue decrease);
• box sound - a loud percutronic sound with a tympanic tint (with an increase in the airiness of the lung tissue).

AUSCULTATION. The patient's position during listening is the same as during percussion. Listen to symmetrical areas of both lungs.

In newborns and children aged 3–6 months. Somewhat weakened breathing can be heard, from 6 months to 5-7 years - puerile. Puerile breathing is a respiratory noise that is louder and longer in both phases of breathing. Its occurrence in children is explained by the structural features of the respiratory organs:

• a shorter distance from the glottis to the listening site due to the small size of the chest, which contributes to the admixture of laryngeal breathing;
• narrow lumen of the bronchi;
• greater elasticity and thin wall of the chest wall, which increases its vibration;
• significant development of interstitial tissue, reducing the airiness of the lung tissue.

In children over 7 years of age, breathing gradually becomes vesicular. In this case, the exhalation is still audible quite well before almost disappearing during vesicular breathing.

Bronchophony – conduction of a sound wave from the bronchi to the chest, determined by auscultation. The patient pronounces words containing the letters “sh” or “ch” (for example, “cup of tea”). Bronchophony is examined over symmetrical areas of the lungs.

The same words, spoken in a whisper, are heard along the spine from bottom to top to determine the lower limit of the enlarged lymph nodes mediastinum (D'Espin's sign)

In various pathological conditions, the following changes in the auscultation pattern are observed:

• bronchial breathing (with compaction of lung tissue). Bronchial breathing can be heard in a healthy person during auscultation over the trachea. Bronchial breathing in this place is due to the presence of dense anatomical structures (trachea, sternum);
• amphoric breathing (occurs above air cavities with smooth walls - cavity, pneumothorax);
• weakened breathing (occurs when air flow into the lungs decreases);
• increased breathing;
• hard breathing.

Pathological processes in the lungs are often accompanied by wheezing. There are wheezing dry(whistling and buzzing), wet(small bubbles, medium bubbles, large bubbles). Should be distinguished from wheezing crepitus. If the pleura is affected, you can hear pleural friction noise. With diseases of the respiratory system, the nature of bronchophony may change, and it may occur strengthening or weakening of bronchophony.

When studying the respiratory system, the following paraclinical methods are used:

• X-ray and radiological: radiography, tomography, bronchography (after the introduction of contrast into the bronchial tree), pulmonary arteriography, aortography, radiological scanning of the lungs;
• endoscopic research methods: laryngoscopy, bronchoscopy;
• microbiological methods: bacterioscopic, bacteriological research throat swabs. nose, sputum, bronchial secretions;
• allergy diagnostics: carrying out skin tests with various allergens, determination of general and specific Ig E;
• function study external respiration: determination of tidal volumes and speed indicators different phases exhalation;
• blood gases: determination of the partial voltage of O 2 and CO 2 in capillary blood.

Materials for self-control:

Task 1.

During an objective examination of a young child, 5th year students, after examining the skin, examined the pharynx, after which the child negatively perceived the young doctors and further examination became impossible. What did the 5th year students do wrong?

Answer: Examination of the pharynx in children should be carried out at the very end of the objective examination.

Task2 .

Doctor examining healthy 2 year old child. During percussion, the doctor hears a shortening of the percussion sound above lower sections lungs on the right. How can this phenomenon be explained?

Answer: Shortening of the percussion sound over the lower parts of the lungs on the right occurs due to the proximity of the liver.

Task 3.

The mother of an 8-year-old child who suffers from a severe form of bronchial asthma came to the clinic. Last days The child's seizures became more frequent. During percussion, the doctor hears a tympanic tone of the percussion sound above the lungs on both sides. How can this phenomenon be explained? What should the doctor do?

Answer: A tympanic tint of percussion sound over the lungs occurs when the airiness of the lung tissue increases. IN in this case this indicates increased edema and bronchospasm, such a condition of the child with bronchial asthma requires hospitalization.

Tests for self-control: