Weakening of vocal tremors occurs when. The tasks of palpation of the chest include determining pain, elasticity of the chest and determining vocal tremor

Palpation of the chest. Listening to the lungs. Types of breathing.

V. Ya. Plotkin Department of Therapy, Faculty of Medicine, St. Petersburg State University

Palpation of the chest

Examination of the lungs in patients can be carried out with the patient standing, sitting or lying down, depending on the general condition of the patient.
In a bedridden patient, the anterior and lateral surfaces of the chest are examined while lying down, and the posterior surfaces are examined while sitting or on the side (the patient is in serious condition).
When palpating the lungs, the main attention should be paid to vocal tremor. Voice tremors are vibrations that occur in the larynx during conversation and are transmitted to the surface of the chest. The study of vocal tremor should be carried out using the palmar surface of the fingers of one or both hands, applied to symmetrical areas of the chest.
The patient is asked to loudly pronounce words containing the letter “r”: thirty-three; three four. It is better to determine vocal tremors after percussion of the lungs in order to get a complete understanding of the reasons for the dullness of percussion sound or the appearance of tympanic percussion sound over the lungs. Thus, dullness, accompanied by increased vocal tremors, indicates compaction of the lung tissue (pneumonia, pulmonary infarction, pulmonary tuberculosis). Dullness without increasing vocal tremors or with its weakening indicates fluid in the pleural cavity (less often, dense pleural moorings).

Percussion of the lungs
Percussion is one of the most important research methods, since its results are often decisive in the diagnosis of lung diseases. Therefore, let us recall once again the basic principles of percussion. You should not press the pessimeter finger tightly against the chest, since this method of application provides a larger plane of contact.
A percussion blow causes circular waves at all points of contact, the closed curve of which is a transverse ellipse in relation to the surface of the body. The results will be completely different if you press your finger lightly so that it touches the surface of the body with fewer points on its surface. Then the spheres of concussion take the form of elongated ellipses, directed deep into the organ. The width of the elongated ellipses is much smaller than the width of the transverse surface ellipses, which reduces the error in determining the boundaries of the organ. the second point concerns the actions of the percussing finger. More accurate results are achieved by percussion with the predominant participation of the metatarsophalangeal joint of the third finger, rather than the wrist joint. In this case, it is necessary to quickly lower the finger in order to develop the force necessary for percussion. After the blow, you should immediately remove the percussing finger from the pessimeter finger without lingering on it. In this case, too, predominantly narrow, long, deep-going ellipses appear. The more perfect the percussion is, if possible, the “point” touch of the pessimeter finger and the quick withdrawal of the hammer finger, after a short blow, necessary to achieve the same sound intensity, the more impeccable its data will be.

Let me remind you of the two “golden” universal rules of percussion for determining the boundaries of any organ:
1. The pessimeter finger is always placed parallel to the desired boundary. The direction of percussion is perpendicular to the desired boundary.
2. Percussion is carried out from clear sound to dull sound.

The nature of the percussion sound largely depends on the airiness of the lung tissue. A clear (pulmonary) percussion sound is heard over normal lung tissue, with increased airiness of the lung tissue (pulmonary emphysema) - a boxy percussion sound, with compaction (displacement of air) of the lung tissue (pneumonia, lung tumor, lung atelectasis) - dullness of sound or dull percussion sound . A dull percussion sound is also determined in the presence of fluid in the pleural cavity (exudative pleurisy, transudate in heart failure). When a large superficial cavity filled with air is formed in the lung (lung abscess, cavity due to tuberculosis), a tympanic percussion sound appears in a limited area of ​​the chest (reminiscent of the sound above the gas bubble of the stomach). Determination of a tympanic percussion sound over a large surface of the chest indicates air in the pleural cavity (pneumothorax).
In this section we will focus on comparative percussion of the lungs, since when performing it, the most “pitfalls” are encountered. During comparative percussion of the lungs, the percussion sound in symmetrical areas of the chest is compared. Percussion is most often carried out from top to bottom, the finger plessimeter is placed horizontally (parallel to the lower border of the lung). An exception may be a narrow interscapular space, in the area of ​​which the plessimeter finger can be placed vertically. When performing comparative percussion of the lungs from the front, certain difficulties can be created by the heart, which during percussion produces a dullness of the percussion sound. Therefore, you need to remember the borders of the heart on the left and percussion the lungs along the intercostal spaces, bypassing the borders of the heart. In this case, unpaired sections of the lung remain on the right in the IV and V intercostal spaces between the parasternal and midclavicular lines (middle lobe), which percussion (asymmetrically) after the end of percussion of the anterior surface of the chest. Thus, comparative percussion of the lungs from the front resembles a herringbone expanding downward in shape:
1 pair of points - above the collarbones (finger parallel to the collarbones);
2 pair of points - directly with a finger (without a pessimeter finger) on the collarbone. Percussion of the clavicles is very valuable for the diagnosis of apical tuberculosis;
3 pair of points - 1st intercostal space along the parasternal line;
4 pair of points - II intercostal space along the parasternal line;
5 pair of points - III intercostal space outward from the parasternal line;
6 pair of points - IV intercostal space along the midclavicular line.
Comparative percussion of the lateral surfaces of the chest is carried out with a horizontally located finger-pessimeter along the midaxillary line in the upper part (1 pair) at the border with the scalp, middle (2 pairs) and lower (3 pairs) parts of the axillary region. It should be noted that during percussion in the 3rd pair of points, the liver is located close to the right, which can dull the percussion sound, and on the left is the gas bubble of the stomach, which, in turn, gives a tympanic sound. Therefore, dullness in the lower left axilla indicates fluid in the pleural cavity, consolidation of the lung tissue, or an enlarged spleen, which can be confirmed or rejected using the definition of vocal tremors (weakened or absent with fluid in the pleural cavity, increased with consolidation, and unchanged with enlarged spleen).

When examining the posterior surface of the chest, percussion is carried out with a horizontally positioned pleximeter finger. The exception is the interscapular areas, where the finger is placed vertically in the middle of the distance between the spine and the edge of the scapula.
1 pair of points - above and inward from the upper inner edge of the scapula;
2 pair of points - the upper part of the interscapular areas (the patient is asked to cross his arms on the chest in front to expand the interscapular space);
3 pair of points - the lower part of the interscapular areas (the patient is asked to cross his arms on the chest in front to expand the interscapular space);
4 pair of points - below the angle of the scapula inward from the scapular line by 2-3 cm;
5 pair of points - below the angle of the scapula outward from the scapular line by 2-3 cm;
6 pair of dots - 3-4 cm below 4 pair of dots;
7 pair of dots - 3-4 cm below 5 pair of dots.

Listening to the lungs. Types of breathing

Listening to the lungs is perhaps more important than percussion in recognizing the activity of the process in the lungs. While percussion gives us an idea of ​​the extent of the lesion, auscultation answers the question of the activity and quality of the detected changes.
When listening to the lungs, it is necessary to first determine the types of breathing, and only then identify additional (side) noises in the lungs (wheezing, crepitus, pleural friction noise). This must be done because the patient’s breathing technique when listening to the nature of breathing and additional noise is different. In order to establish the type of breathing, the patient must breathe deeply through the nose, while to identify additional noises, it is recommended to breathe with an open mouth to increase the flow of air in the lumen of the bronchi. When listening to a patient, three types of breathing most often occur over the lungs: vesicular, bronchial and hard. The main importance for identifying the type of breathing should be given to the comparison of inhalation and exhalation: by the strength (loudness) of the sound - emphasis on inhalation or exhalation, and duration - the inhalation is longer, ramen or shorter than the exhalation. The assessment of the character of the sound complements the first basic criteria. Thus, with vesicular breathing, inhalation is perceived as the letter “f”, and a short exhalation lasting one third as the letter “v”.

Bronchial breathing corresponds to the letter “x” in both phases of breathing, and exhalation is lengthened and lasts as long (equal) or even longer than inhalation. As for the accent, with vesicular breathing the inhalation is heard louder, and with bronchial breathing the emphasis is on the exhalation.
Vesicular breathing occurs due to vibrations of the walls of the alveoli as they straighten during inhalation and vibrations of the afferent bronchioles and alveoli at the beginning of exhalation. During auscultation, the entire inhalation (letter “f”) and less loudly (letter “v”) one third of the exhalation can be heard. Vesicular breathing in a healthy person is heard over all pulmonary fields. Weakening of vesicular breathing over the entire surface of the lungs is observed with pulmonary emphysema, and significant weakening or absence in limited places where we usually hear vesicular breathing occurs with large effusions into the pleural cavity, closed pneumothorax, over tumors of the lungs and pleura, or with complete blockage of the adductor bronchus
Bronchial breathing occurs as a result of turbulence as air passes through the glottis and, to a lesser extent, through the region of the trachea bifurcation and the division of the main and lobar bronchi. The expansion of numerous alveoli during vesicular breathing prevents the conduction of bronchial breathing to the surface of the chest. For bronchial breathing to occur, pathological conditions must arise under which respiratory sounds generated in the glottis would be better conducted through the lung tissue to the surface of the chest. Such conditions arise, firstly, with large infiltrative processes in the lungs (lobar, segmental or confluent pneumonia, infiltrative pulmonary tuberculosis) and, secondly, with the formation of large superficial cavities in the lung (abscesses, cavities). The cavities are often surrounded by an inflammatory infiltrate, which also improves sound conduction. This is also facilitated by sound resonance (amplification) in the cavity itself, and in the case of a smooth-walled cavity, it makes bronchial breathing amphoric or blowing (reminiscent of blowing air through the neck of a bottle). As already indicated, bronchial breathing resembles the letter “x”, exhalation is louder than inhalation, and the duration is equal to or slightly longer than inhalation. The third type is hard breathing. Breathing noise loses its soft, blowing character and becomes harsh. Hard can be inhalation, exhalation, or both. Unlike vesicular breathing, exhalation lengthens and becomes approximately equal to inhalation. However, the inhalation is almost always louder than the exhalation, which makes it possible to differentiate hard breathing from bronchial breathing, in which the emphasis is on exhalation. When hard breathing is detected over all pulmonary fields, this is associated with bronchitis, in which inflammation with swelling, edema of the mucous membrane, the presence of sputum in the lumen and moderate spasm of the muscles of the bronchial wall leads to an increase in the speed of air flow and its friction against the walls. Listening to hard breathing over a limited surface of the chest occurs with inflammatory infiltration of the lung tissue around the bronchi (pneumonia). In this case, the alveoli do not participate in breathing, and the infiltrate conducts sound better. When listening, we hear vesicular inhalation due to the straightening of the alveoli of a normal lung, surrounding the pneumonic infiltrate, and bronchial exhalation due to respiratory sounds occurring when air passes through the glottis. A number of authors call such breathing bronchovesicular or indeterminate, since with it both a rough inhalation and a rough exhalation are heard without a significant predominance of one of them.
Hard breathing with prolonged exhalation, during which the inhalation is louder, has a certain diagnostic value. exhale, but the exhalation is longer than the inhalation. Extension of exhalation is associated with narrowing of the bronchi due to spasm of the bronchial muscles, swelling of the mucous membrane, and a decrease in the elastic tissue of the lung. Hard breathing with prolonged exhalation is observed in chronic obstructive pulmonary disease (chronic obstructive bronchitis, bronchial asthma).

The algorithm for listening to types of breathing is given in Table 3.

Table 3. Algorithm for listening to types of breathing.

Before an objective examination of the respiratory system, it is useful to remember the complaints that patients with respiratory diseases may present.

An objective examination of the respiratory system begins with an examination.

Chest examination carried out in 2 stages:

♦ static inspection - shape assessment;

♦ dynamic examination - assessment of respiratory movements (i.e. the function of the breathing apparatus).

Form chest is considered correct, If she:

♦ proportional,

♦ symmetrical,

♦ has no deformations,

♦ the lateral size prevails over the anteroposterior,

♦ supraclavicular fossae are quite pronounced;

The shape of the correct chest depends on the type of constitution. Belonging to one type or another is determined by the angle between the costal arches: >90° - asthenic, 90° - normosthenic, >90° - hypersthenic.

Pathological forms of the chest:

Emphysematous(syn. barrel-shaped) - increased anteroposterior size, horizontal arrangement of ribs, decreased intercostal spaces, smoothness and even bulging of the supraclavicular and subclavian fossae - in diseases with an increase in residual volume due to bronchial obstruction (bronchial asthma, COPD, etc.) or damage to the elastic framework of the lungs.

Paralytic- resembles asthenic. General cachexia. Observed in tuberculosis and other debilitating diseases.

Rachitic or keeled (deformation of the sternum in the form of a keel). It is a consequence of rickets suffered in childhood.

Funnel-shaped- congenital (deformation of the sternum in the form of a funnel). Caused by a hereditary skeletal abnormality.

Scaphoid- congenital (rook-shaped sternum deformity). Caused by a hereditary skeletal abnormality.

Kyphoscoliotic- deformed (a combination of kyphosis and scoliosis in the thoracic region). It is a consequence of tuberculosis or spinal injury suffered in childhood.

Examples

Pathological forms of the chest may have abnormalities in the propagation of sound and the location of organs. This will be reflected in the results of determining vocal tremors, percussion, and auscultation.

After assessing the structure of the respiratory apparatus, violations of its function are excluded. For this purpose they carry out dynamic inspection and define:

♦ type of breathing (thoracic, abdominal, mixed);

♦ symmetry of participation in the act of breathing of the halves of the chest;

♦ frequency of respiratory movements per minute (normally 12-20);

♦ verify pathological types of breathing if present:

Kussmaul (deep, noisy, constant);

Cheyne-Stokes (periods of increase and decrease in the depth of breathing, followed by a stop, after which a new cycle begins);

Grocco-Frugoni (reminiscent of the previous one, but without periods of apnea);

Biota (several alternation of a series of identical breaths with periods of apnea).

Why do pathological types of breathing appear?*

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*Read on pages 121-122 in the textbook Propaedeutics of Internal Diseases or page 63 in the textbook Basics of Semiotics of Diseases of Internal Organs.

After inspection is carried out chest palpation.

NB! Before performing palpation (and then percussion), evaluate the suitability of your manicure for the intended purpose. Nails should be short. If you have long nails, palpation and percussion is impossible. Have you ever tried to write with a capped pen?

In addition, long nails injure patients and also act as a safe pocket for storing secretions from skin glands, saliva, mucus and other patient secretions. Think about it, is it necessary for you to have the listed items with you at all times?

With the help of palpation they clarify form(ratio of lateral and anteroposterior dimensions), determine soreness, resistance chest, voice tremors, identify symptoms Stenberg and Potenger.

You will evaluate the shape, symmetry, and resistance in class.

detection of vocal tremors from the front

detection of voice tremors from behind

Sequence for determining vocal tremors:

Below the collarbones on the right left

Above the collarbones right left

Along the lines of medioclavicularis:

2nd intercostal space right left

III intercostal space right left

IV intercostal space right left

Along the lines of axillaris media:

V intercostal space right left

VII intercostal space right left

Above the shoulder blades right left

Between the shoulder blades right left

Under the angles of the shoulder blades from right to left

Diffuse weakening, local weakening, and local strengthening of voice tremors have diagnostic significance.

Diffuse(above all fields) weakening Voice tremors occur when the airiness of the lungs increases - emphysema. At the same time, the density of the lung tissue decreases and sound is transmitted worse. A second cause of diffuse weakening may be a massive chest wall.

Local(in a limited area) weakening vocal tremors are noted:

If there is a violation of the conduction of sound to this part of the chest from the glottis (impaired patency of the adductor bronchus);

If there is an obstacle to the propagation of sound in the pleural cavity (accumulation of fluid - hydrothorax, air - pneumothorax; formation of massive accumulations of connective tissue - fibrothorax).

When the lung tissue is compacted in this place

When resonance occurs due to the formation of a cavity in the lung (abscess, cavity).

Compaction of the lung tissue occurs when the alveoli are filled with exudate (for example, in pneumonia), transudate (for example, in heart failure with congestion in the pulmonary circle), when the lung is compressed from the outside (compressive atelectasis, which can form, for example, over a massive hydrothorax).

Definition muscular symptoms Stenberg and Potenger.

A positive Shtenberg sign is pain when pressing on the upper edge of the trapezius muscle. It indicates the current pathological process in the corresponding lung or pleura, without, however, revealing its nature.

A positive Potenger symptom is a decrease in muscle volume and thickening. It is a sign of a previous disease, during which, due to disruption of trophic innervation and prolonged spastic contraction, partial degeneration of muscle fibers occurred with their replacement by connective tissue.

The next research method is percussion of the lungs. The method is based on assessing the reflection and absorption of sound by structures of different densities.

When applying percussion blows using a special technique* over different structures, a sound of different volume and timbre is obtained. Percussion allows you to determine the boundaries of organs, their pathological changes, as well as the appearance of pathological formations.

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*Read about the percussion technique on pp. 50-53 in the textbook Propaedeutics of Internal Diseases or pp. 80-84 in the textbook Fundamentals of Semiotics of Diseases of Internal Organs.

Distinguish 4 options sound ( tones) formed during percussion:

Clear pulmonary(an example can be obtained by percussion in a healthy person in the 3rd intercostal space along the midclavicular line on the right).

Dull or dull (an example can be obtained by percussion of a large muscle mass, for example, the thigh, hence another synonym - femoral).

Tympanic sound arises abovecavity (percuss over a hollow organ - the stomach, for example).

Boxed soundoccurs when the airiness of the lungs increases - emphysema. This sound is accurately reproduced when percussing a feather pad.

Percussion is performed in a certain sequence. This allows you to avoid errors when assessing percussion tones.

First, comparative percussion is performed.

The sequence of comparative percussion of the lungs

Below the collarbones on the right left

Above the collarbones right left

Direct percussion on the collarbones on the right left

Along the lines of medioclavicularis

In the 2nd intercostal space on the right left

In the third intercostal space on the right left

In the IV intercostal space on the right left

Along the lines of axillaris media

In the 5th intercostal space on the right left

In the 7th intercostal space on the right left

Above the shoulder blades right left

Between the shoulder blades

At the base right left

At the corner on the right left

Along the lines of scapularis

In the 7th intercostal space (angle of the scapula) right left

Types of percussion sound and their diagnostic value.

An example of recording the results of comparative lung percussion.

With comparative percussion in symmetrical areas of the chest lung, the sound is clear, pulmonary. There are no focal changes in percussion sound.

Topographic percussion allows you to assess the size of the lungs and their changes during breathing.

Rules for topographic percussion:

Percussion is carried out from the organ giving a loud sound to the organ giving a dull sound, that is, from clear to dull;

The pessimeter finger is located parallel to the defined boundary;

The border of the organ is marked along the side of the pessimeter finger facing the organ that produces a clear pulmonary sound.

Topographic percussion sequence:

1. determination of the upper boundaries of the lungs (height of the apexes
lungs in front and behind, as well as their width - Krenig fields);

2. determination of the lower boundaries of the lungs;

3. determination of mobility of the lower edge of the lungs.

Normal boundaries of the lungs):

Upper borders of the lungs

Lower borders of the lungs

Mobility of the lower edge of the lungs

Reasons for changes in the boundaries of the lungs

Auscultation of the lungs completes a physical examination of the respiratory system. The method involves listening to the sounds produced when the breathing apparatus operates. Currently, listening is carried out with a stetho- or phonendoscope, which amplifies the perceived sound and allows one to determine the approximate location of its formation.

Using auscultation, the type of breathing, the presence of adverse respiratory sounds, bronchophony, and the localization of pathological changes, if any, are determined.

Basic respiratory sounds (types, types of breathing):

1. Vesicular respiration.
2. Bronchial breathing.
3. Hard breathing.

Vesicular(syn. alveolar) breathing - the noise of rapid expansion and tension of the walls of the alveoli as air enters them during inhalation.

Characteristics of vesicular respiration:

1. Reminds me of the sound "F".

2. Heard throughout inhalation and at the beginning of exhalation.
Diagnostic value of vesicular breathing: healthy lungs.

Bronchial(syn. laryngo-tracheal, pathological bronchial) breathing.

Characteristics of bronchial breathing:

1. Laryngo-tracheal breathing, which is carried out on the chest outside the zones of its normal localization under the following conditions:

• if the bronchi are passable and there is dense lung tissue around them;
• if there is a large cavity in the lung containing air and connected to the bronchus;
• if there is compression atelectasis. Reminds me of the sound "X".

Heard on inhalation and exhalation, exhalation is sharper. Diagnostic value of bronchial breathing: in pathological processes in the lungs with its compaction.

Zones of normal localization of laryngotracheal breathing(syn. normal bronchial breathing):

1. Above the larynx and at the manubrium of the sternum.
2. In the area of ​​the 7th cervical vertebra, where the projection of the larynx is located.
3. In the area of ​​3-4 thoracic vertebrae, where the projection of the tracheal bifurcation is located.

Hard breathing.

Characteristics of hard breathing:

■ equal duration of inhalation and exhalation.

Diagnostic value of hard breathing: heard during bronchitis, focal pneumonia, chronic stagnation of blood in the lungs.

Stridorosis(stenotic) breathing. Characteristics of stridor breathing:

1. Inhalation and exhalation are difficult.

2. Observed when the airways are narrowed at the level of the larynx, trachea, large bronchi:

■ foreign body;

■ enlarged lymph node;

■ swelling of the mucous membrane;

■ endobronchial tumor.

Additional (syn. side) breath sounds:

1. Wheezing (dry, wet).
2. Crepitus.
3. Pleural friction noise.

1. Dry wheezing- additional respiratory sounds that occur in places of narrowing of the bronchi, caused by swelling of the bronchial mucosa, local accumulation of viscous bronchial secretions, spasm of the circular muscles of the bronchi and are heard during inhalation and exhalation.

Dry buzzing (syn. bass, low) wheezing that occurs in the large bronchi.

Dry whistling (syn. treble, high) wheezing, occurring in the small and minute bronchi.

Diagnostic value of dry wheezing: characteristic of bronchitis and bronchial asthma.

Wet(syn. bubble) wheezes are additional respiratory sounds that occur in the bronchi when there is liquid bronchial secretion in them, accompanied by the sound of bubbles bursting as air passes through the layer of liquid secretion and heard during inhalation and exhalation.

Fine bubbles moist rales that form in the small bronchi.

Medium bubble moist rales formed in the middle bronchi.

Large-vesicular moist rales that form in the large bronchi.

Voiced (syn. sonorous, consonant) moist rales formed in the bronchi in the presence of compaction of the lung tissue, a cavity in the lung associated with the bronchus and containing liquid secretions.

Silent (syn. silent, non-consonant) moist rales formed in the bronchi in the absence of resonators in the lungs, their increased airiness and weakened vesicular breathing.

Diagnostic value of moist rales:

1. Always a lung pathology.
2. Voiced fine-bubble, medium-bubble rales in a limited area are a typical sign of pneumonia.
3. Silent wheezing, isolated scattered, intermittent - a sign of bronchitis.

2. Crepitus- additional respiratory noise that occurs when the alveoli come apart when air enters them and the presence of viscous secretion on their walls, reminiscent of the sound of hair rubbing in front of the ear,
heard in the middle and at the end of inspiration.

Diagnostic value of crepitus:

Inflammation:

■ stage of hyperemia and stage of resolution of lobar pneumonia;

■ alveolitis.

Other reasons:

■ Transudation of plasma into the alveoli during infarction and pulmonary edema.

■ Hypoventilation of the lungs, crepitus disappears after several
deep breaths.

3. Pleural friction rub- additional respiratory noise that occurs as a result of changes in its layers during inflammation, the application of fibrin, the replacement of the endothelium with connective tissue, characterized by the appearance of a dry, rustling sound of varying intensity, audible superficially under the ear, on inhalation and exhalation.

Diagnostic value of pleural friction rub: observed in pleurisy, pleuropneumonia, pulmonary infarction, pleural tumor, etc.

Main featurestypes of breathing, their possible changes andcauses

Reasons for weakened breathing over a limited area of ​​the chestcells.

1. Impaired conduction of sounds occurring in the lungs (liquid, gas in
   pleural cavity, massive pleural adhesions, pleural tumor).
2. Complete obstruction of the bronchus with cessation of air flow into the lower
   departments.

Bronchophonia (BF), diagnostic significance of its changes.

Bronchophony - listening to whispered speech on the chest.

The method for determining it is similar to assessing vocal tremor, differing in the use of a phonendoscope instead of palpation. To improve the identification of the strengthening or weakening of conducted sounds, the patient should pronounce the same words (three-four, thirty-three, etc.) quietly or in a whisper. BF complements vocal tremors.

1. FD is weakened on both sides: whispered speech is inaudible or almost inaudible (a sign of pulmonary emphysema).
2. BP is absent or weakened on one side (a sign of the presence of fluid or air in the pleural cavity, complete atelectasis).
3. BF is strengthened, the words “three-four” are recognizable through the phonendoscope of the lung.
   Increased BP is observed over the area of ​​pneumonia, compression atelectasis, over the cavity in the lung containing air and connected to the bronchus.

Didiagnosis of adverse breath sounds.

Scheme for assessing the results of a physical examination of the lungs.

The page is under development, we apologize for any inconsistencies. Missing information can be filled in from the recommended literature.

Pneumonia is a dangerous disease that causes inflammation of the lung tissue. Most often it is of infectious origin, but today the name “pneumonia” unites a whole group of diseases with different etiologies and clinical presentations.

Symptoms may vary significantly depending on the type of disease, but one of the main signs of inflammation of the lung tissue is increased vocal tremors.

What is voice tremors and its deviation from the norm

This phenomenon is nothing more than mechanical vibrations of the chest, which arise as a result of the passage of the sound of the voice through the airways. Thus, voice tremors represent the transition of sound waves into mechanical vibrations of the human chest.

1. Sufficient bronchial patency.
2. Healthy lung tissue.

Due to the fact that with pneumonia, violations of these conditions occur, identifying the disease by voice tremors is not a difficult task.

But if any pathologies appear in the patient’s bronchopulmonary system, then this is necessarily reflected in this phenomenon, which can either increase or decrease.

In particular, increased vocal tremors are observed with pneumonia. This disease provokes inflammation of the lung tissues, as a result of which they lose their softness. Compaction occurs, and dense areas are known to have good sound conductivity. But a prerequisite for this will be the preservation of bronchial conductivity. Therefore, increased vocal tremors indicate the presence of an inflammatory process in the lungs.

But in addition to pneumonia itself, this phenomenon may indicate a number of other, no less serious diseases, including:

For this reason, a deviation from the norm in this case is an alarming symptom that requires immediate detailed diagnosis.

Determination of voice tremors

The level of vocal tremors can be detected by palpation, comparing the vibrations of the chest resulting from vibrations of the vocal cords. There are several methods that allow you to accurately determine deviations from the norm.

At the beginning of the diagnosis, the specialist places his palms on the patient’s chest and asks him to repeat words with the sound “r”. You need to speak loudly and in a low voice.

At this time, the doctor checks the difference between the vibration in the right and left half of the patient’s chest. If the study revealed unequal severity of trembling, the doctor should switch hands and ask the patient to repeat the spoken words.

In healthy people, moderate vocal tremors are observed. It is the same for symmetrical areas of the chest. But, given the structural features of the right bronchus, a slight increase in sound vibrations in this area is considered normal.

Another technique used to identify abnormalities in vocal tremor is percussion. The percussion method, used in medicine for more than 250 years, allows the doctor to obtain accurate information about the condition of the lungs through the chest wall. When performing percussion, the density of tissues and the amount of air contained in them should be taken into account. Therefore, only a specialist can accurately determine the presence of an anomaly when using this technique.

The conditions for performing chest percussion are as follows:

Clinical picture of the disease

Since swelling of the tissues occurs during pneumonia, as a result they become denser, unable to fully perform their original functions. Inflamed lung tissue loses its elasticity and softness, and it is these changes in the lung structure that appear when examining vocal tremors.

As mentioned above, these changes are determined by palpation. Using this method, you can accurately identify changes in sound by comparing the right and left lungs. In the places where the spoken sounds will sound most clearly, there is a compaction, and accordingly, the inflammatory process occurs.

A technique similar to vocal tremors is bronchophony. Only in this case, to identify pathology, a special device is needed - a phonendoscope. During such a study, the patient should make hissing sounds. In all other respects, the technique is an analogue of the method described above.

Therapy methods

Since vocal trembling in itself is not a separate disease, but is only one of the symptoms of pneumonia, therapy in this case comes down to eliminating the root cause of the disease. Today, pneumonia has several forms and types, and therefore the treatment method in each specific case is determined strictly individually.

The easiest way to treat is typical pneumonia, which, regardless of the causative agent of the disease, has one development pattern, and predicting the stages of therapy in this case is not particularly difficult.

Pneumonia is most often caused by various viruses. But due to the high likelihood of developing a bacterial infection, adult patients must be prescribed antibiotics. In particularly severe cases of the disease, the doctor may prescribe two of these drugs at once.

The course of treatment is determined based on several factors, which include:

• type of pneumonia;
• the volume of tissue affected by the disease;
• the patient's age and condition;
• presence of concomitant diseases.

For example, if a patient has a diseased heart, kidneys or liver, then this must be taken into account when carrying out treatment.

Much more dangerous is atypical pneumonia, the symptoms and treatment features of which largely depend on the pathogen. Predicting the course of the disease in this case is very difficult, therefore most often treatment of atypical pneumonia is carried out in a hospital setting under the constant supervision of the attending physician.

Determining the condition of the lungs by vocal tremor is a technique that dates back hundreds of years and is widely used in world medical practice. Today, chest percussion is one of the first stages in the complex diagnosis of respiratory diseases. It is on the basis of this technique that the first ideas about the clinical picture of the disease are created and further stages of research are determined.

You can recognize the signs of inflammation using this method almost accurately, which allows you to begin prompt treatment of pneumonia and quickly get rid of the disease.

In pathological conditions of the respiratory system, vocal tremors may be increased or weakened, and even not detected at all. . An increase in vocal tremors is observed with compaction of the lung. The cause of compaction can be different: lobar pneumonia, tuberculosis, infiltration of the lung, compression of the lung as a result of accumulation of air or fluid in the pleural cavity. But a prerequisite for this is the free passage of air into the respiratory tract.

Accumulations in the pleural cavity of liquid or gas, which move the lung away from the chest and absorb sound vibrations spreading from the glottis along the bronchial tree;

When the lumen of the bronchi is completely blocked by a tumor;

In weak, exhausted patients, due to weakening of their breathing

With significant thickening of the chest wall (obesity) .

Semiotics of changes in percussion sound by the lungs.

1. Dullness (shortening) percussion sound over the lungs is based on a decrease in the air volume of the lung:

a) with exudation in the cavity of the alveoli and infiltration of the interalveolar septa (focal and, especially, confluent pneumonia);

b) with pneumosclerosis, fibrous pulmonary tuberculosis;

c) with atelectasis;

d) in the presence of pleural adhesions or obliteration of the pleural cavities;

e) with significant pulmonary edema, hemorrhage into the lung tissue;

f) when the lung tissue is compressed by pleural fluid above the level of the fluid, the floor of the Sokolov-Damoiso line;

g) with complete blockage of a large bronchus, a tumor.”

2. Dull ("femoral dullness") percussion sound is observed in the complete absence of air in an entire lobe or part of it (segment) in lobar pneumonia in the compaction stage, in the formation of a large cavity filled with inflammatory fluid in the lung, in an echinococcal cyst, a suppurating congenital cyst in a lung abscess, in the presence of fluid in the pleural cavities.

3. Tympanic a tint of percussion sound occurs when the airiness of the lungs increases and pathological cavities appear in them: emphysema, abscess, tuberculous cavity, with the disintegration of a tumor, bronchiectasis, pneumothorax.

4. Boxed percussion sound is a loud percussion sound
with a tympanic tint is detected when the airiness of the lung tissue increases and its elasticity decreases.

5. A metallic percussion sound is characteristic of large cavities in the lungs.

6. The sound of a “cracked pea” is a kind of quiet, rattling sound that is detected by percussion of a large superficial cavity, which communicates with the bronchus through a narrow slit-like opening.

Semiotics of respiratory changes noise

1, Physiological attenuation of respiratory noise is observed
with thickening of the chest wall due to excessive development of its muscles
or increased fat deposition in adipose tissue.

2. Pathological weakening of breathing may be caused by:
a) a significant decrease in the total number of alveoli in

as a result of atrophy and gradual death of interalveolar barriers
dock and the formation of larger bubbles that are unable to collapse
when exhaling, the elasticity of the lung tissue is lost (pulmonary emphysema);

b) swelling of the alveolar walls and a decrease in amplitude

their fluctuations during inspiration (in the initial stage and the stage of resolution of pneumonia, when there is a violation only of the elastic function of the alveoli, but there is no exudation and compaction;

c) a decrease in the flow of air into the alveoli through the airways (narrowing of the larynx, trachea, inflammation of the respiratory tract
muscles, intercostal nerves, rib fractures, severe general weakness)
adynamia of the patient;

d) insufficient air supply to the alveoli through the airways as a result of the formation of a mechanical obstacle in them (for example, when the lumen of large bronchi is narrowed by a tumor
or foreign body);

e) displacement of the lung by accumulation of fluid and air in the pleura;

e) thickening of the pleura.

3. Increased breathing can occur in the inhalation, exhalation or both phases of breathing. Increased exhalation depends on the difficulty of air passing through the small bronchi when their lumen narrows (inflammatory swelling of the mucous membrane or bronchospasm). Breathing, in which the inhalation and exhalation phases are intensified, is called hard breathing, and is observed with a sharp and uneven narrowing of the lumen of the small bronchi and bronchioles due to inflammatory swelling of the mucous membrane (bronchitis).

4. Bronchial breathing under physiological conditions is well audible above the larynx, trachea and in the places where the trachea bifurcation projects onto the chest. The main condition for carrying out bronchial breathing on the surface of the chest is compaction of the lung tissue: filling of the alveoli with inflammatory exudate, blood, compression of the alveoli when fluid or air accumulates in the pleural cavity and pressing the lung to its root, replacement of the airy lung tissue with connective tissue, pneumosclerosis, carnification of the lung lobe.

6. Amphoric breathing appears in the presence of a smooth-walled cavity with a diameter of 5-6 cm, communicating with a large bronchus (similar to noise if you blow strongly over the throat of an empty glass or clay vessel).

7. The metallic hue of breathing resembles the sound that occurs when hitting metal, which can be heard with open pneumothorax.

Semiotics additional driving noises

1. Dry (wheezing, buzzing) wheezing occurs due to narrowing of the lumen of the bronchi, caused by: a) spasm of the bronchial muscles; b) swelling of the bronchial mucosa during the development of inflammation in it; c) accumulation of viscous sputum in the lumen of the bronchi; d) proliferation of fibrous (connective) tissue in the walls of the bronchi; e) fluctuation of viscous sputum as it moves in the lumen of large and medium-sized bronchi during inhalation and exhalation (sputum due to its viscosity during air movement along the bronchi it can be pulled out in the form of threads that stick to the opposite walls of the bronchus and are stretched by the movement of air, oscillating like a string.Dry wheezing is heard both in the inhalation and exhalation phases.

Thus, dry whistling and buzzing rales are characteristic of bronchitis, especially obstructive bronchitis, in the initial phase of the inflammatory process, bronchial asthma, fibrosing bronchitis.

2................................................. ........................................................ ........ Moist rales are formed mainly as a result of the accumulation of liquid secretions (sputum, edema fluid, blood) in the lumen of the bronchi and the passage of air through this secretion with the formation of air bubbles of different diameters. These bubbles, penetrating through the layer of liquid secretion into the fluid-free lumen of the bronchus, burst and produce peculiar sounds in the form of a crackling sound. Moist rales are heard both in the inhalation and exhalation phases. But, since the speed of air movement through the bronchi in the inhalation phase is greater than in the exhalation phase, moist rales will be somewhat louder in the inhalation phase. Depending on the caliber of the bronchi in which they arise, moist rales are divided into small-bubble, medium-bubble and large-bubble

Moist rales, therefore, are characteristic of bronchitis in the phase of resolution of the inflammatory process, bronchiolitis, and pulmonary edema.

3. Crepitus, unlike wheezing, occurs in the alveoli, appears only at the height of inspiration in the form of a crackling sound and resembles the sound
which is obtained by rubbing a small tuft of hair over the ear.
The main condition for the formation of crepitus is the accumulation in
in the lumen of the alveoli a small amount of liquid secretion. Under this condition, in the exhalation phase the alveolar walls stick together, and in the phase of intense inhalation they come apart with a characteristic sound. Therefore, crepitus is heard only at the end of the inspiratory phase and is characteristic of pneumonia and pulmonary edema.

4. Pleural friction noise is characteristic of fibrous (dry) pleurisy.

It is also necessary to distinguish between wheezing that forms in the lung tissue and wire wheezing, the source of which is the upper respiratory tract. To differentiate, you can use the following properties of conductive rales: they are clearly audible over the nose and mouth, and are carried out on the shoulder blades and spinous processes of the thoracic vertebrae.