Your SlideShare is downloading. ×
  • Like
Dynamic auscultation
Upcoming SlideShare
Loading in...5

Thanks for flagging this SlideShare!

Oops! An error has occurred.


Now you can save presentations on your phone or tablet

Available for both IPhone and Android

Text the download link to your phone

Standard text messaging rates apply

Dynamic auscultation



Published in Health & Medicine
  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Be the first to comment
No Downloads


Total Views
On SlideShare
From Embeds
Number of Embeds



Embeds 0

No embeds

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

    No notes for slide


  • 2. • This is a technique of altering circulatory dynamics by means of a variety of physiological and pharmacological maneuvers and determining their effects on heart sounds and murmurs
  • 3. Interventions most commonly employed are • Respiration • Postural changes • Valsalva maneuver • Isometric exercise • Premature ventricular contractions • Vasoactive agents- amyl nitrite ,methoxamine ,phenylephrine
  • 4. RESPIRATION • History • Pontain in1866 was the first to note the normal respiratory variation in splitting of the second heart sound . • In 1954 leatham brought pontain’s observations to clinical attention through emphasis on their significance
  • 5. • Hemodynamics • On inspiration the intra thoracic pressure decreases and results in augmentation of right heart blood flow and decrease in left heart flow • Murmurs generated in the right heart there fore generally become louder on inspiration and those in left heart chambers decrease as a result of reduced left heart flow as well as increased insulation by the air filled lungs
  • 6. • Second heart sound • Respiration alters the splitting and loudness of second heart sound • In normal young adults in supine position inspiration S2 split increase expiration split narrows and s2 becomes single • Failure of S2 to fuse in EXP may occur in normal children and 15 to 20 % of young adults • In up to 50% of normal adults > 50 yr single audible S2 is seen in supine position both in INSP and EXP
  • 7. • During inspiration A2 becomes softer because 1. aortic pressure decreases 2. increased lung space between heart and chest wall • During ispiration P2 becomes soft in 2nd LICS and • Louder in lower LSB ( increased flow in the pulmonary artery has greater effect lesser deree of lung space interposed in this area )
  • 8. Heart sounds Accentuated during Inspiration • RVS3 and RVS4 • Tricuspid OS Expiration • LVS3 and LVS4 • mitral OS
  • 9. Pulmonary ejection click • Inspiration diminish intensity of valvular PEC • PA diastolic pressure is very low • Inspiration causes elevation of RV DP • RV late diastolic Pr almost equlises PA diastolic Pressure • Causes partial presystolic opening of PV • Less upward motion of valve during systole
  • 10. MURMURS • Respiration exerts more pronounced and consistent alterations on murmurs of right side than left side • Especially tricuspid murmurs 100% sensitivity, 88% specificity • Inspiration increases venous return to right side of heart • Expiration increases venous return to left side of heart
  • 11. Murmurs accentuated during Inspiration • TS • TR (Carvallo’s sign) • PR • Mild or moderate PS • Severe PS no further increase in gradient Expiration • MS • MR • AS • AR • VSD • Pericardial rub (AP diameter)
  • 12. MVP • MSC and systolic murmur occur earlier during systole in inspiration • Inspiratory reduction in LV size • Increased redundancy of MV • Increase valvular prolapse
  • 13. • IHSS murmur may decrease in loudness and intensity with inspiration • This is because of inspiratory increase in Lv transmural pressure, with resultant decrease in LVOT obstruction
  • 14. • In general it is best to assess respiratory variation during normal respiration. • Effects of inspiration on auscultatory findings may be accentuated by Muller maneuver • Converse of Valsalva Maneuver • Forced inspiration against closed glottis • Forcibly inspires while the nose is held closed and mouth is firmly sealed for about 10 sec.
  • 15. • Patients who have pulmonary hypertension and severe RVF may not demonstrate inspiratory augmentation of Rt heart murmurs and gallops • This is due to high Rt heart filling pressures that does not allow venous return to increase in inspiration • By requesting these patients to stand and by repeating cardiac ausculation we can appreciate the expected respiratory changes
  • 16. • Widens split S2 and augments murmur and filling sound originating in right side of the heart.
  • 17. POSTURAL CHANGE RAPID STANDING • Decrease in venous return, thus stroke volume and the ensuing reflex increses the cardiac rate and systemic vascular resistance immediately
  • 18. • Width of the splitting become reduced • No change in patients with true fixed split Decrease in intensity • RVS3 and RVS4 • LVS3 and LVS4
  • 19. Decrease in intensity • Semilunar valve stenosis • AV valve regurgitation murmurs • VSD • Most functional systolic murmurs
  • 20. • Since LV EDV is decreased Increase in murmurs • HOCM(95% sensitivity, 84% specificity) • Early MSC and murmur of MVP
  • 21. • Physiological changes that cause increase in obstruction in LVOT include a smaller ventricular size and reflex inotropic stimulus from increased catecholamines
  • 22. SQUATTING • Sudden change from standing to squatting position • Increase venous return and augmentation of peripheral resistance due to kinking of femoral arteries simultaneously • Squatting abruptly increases ventricular preload and afterload • Arterial pressure rise may cause transient reflex bradycardia
  • 23. Increase in stroke volume causes augmentation of • S3 and S4(of both ventricles) • Right sided systolic murmurs • AS • Diastolic murmur of MS augmented due to increase in CO with increased flow across mitral valve
  • 24. Elevation of arterial pressure • Increase in aortic reflux AR • Increase in MR volume • Increase in LT to RT shunt in VSD • Increase in blood flow through RVOT in TOF
  • 25. Combination of elevated arterial pressure and venous return • Increase LV size and reduce LVOT obstruction • Decrease murmur in HOCM(95% sensitivity, 85% specificity) • Click and murmur of MVP delayed
  • 26. LEFT LATERAL RECUMBENT POSITION Accentuate intensity of • S1 • LVS3 and LVS4 • OS of MS • Murmurs of MS and MR • Click and murmur of MVP • Austin Flint murmur
  • 27. SITTING AND LEANING FORWARD • Accentuate AR and PR murmur (mechanical)
  • 28. Lying flat or passive leg raising in supine position • Results in increase in venous return with sequential increase in right and then left ventricular end diastolic volumes, stroke volume, and ejection velocities
  • 29. • Augmented • Valvular AS/PS murmurs • TR murmur • S3 and S4 • Diminished • EDM of AR • Murmur of HOCM • MVP murmur and click are delayed
  • 30. ISOMETRIC EXERCISE • This can be carried out by using a calibrated handgrip device or a handball • Better to carryout bilaterally • Performed in supine posture • Should be sustained for 30 to 40 secs • Valsalva maneuver during the handgrip must be avoided • Contraindicated in patients with myocardial ischemia and ventricular arrhythmias, severe HTN, cerebral ischemia
  • 31. • Hemodynamic effects • Increases cardiac contractility cardiac output arterial pressure without significant change in ventricular chamber size
  • 32. Isometric exercise results in significant increase in • Systemic vascular resistance • Arterial pressure • Heart rate • COP • LV filling pressure • Heart size
  • 33. • Systolic murmur of AS diminished –reduction of pressure gradient across AV • Diastolic murmur of AR and systolic murmurs of rheumatic MR and VSD increases • LVS3 and LVS4 accentuated • Diastolic murmur MS becomes louder – increase in flow across valve
  • 34. Increase LV volume • Systolic murmur of HOCM decreased • Click and murmur of MVP delayed
  • 35. VALSALVA MANEUVER • Forced expiration against a closed glottis Standard test consists of asking the patient to blow against an aneroid manometer and maintain a pressure of 40mmhg for 30seconds
  • 36. • Relatively deep inspiration followed by forced exhalation against a closed glottis for 10 to 20 seconds • Physician has to keep flat of the hand on the abdomen to provide the patient a force to breathe against • Normal response has four phases
  • 37. PHASE I • Intrathoracic pressure rises • Transient increase in LV output and SBP
  • 38. PHASE II STRAINING PHASE • Systemic venous return decrease • Filling of right and then left side reduced • Stroke volume reduced • Mean arterial and pulse pressures falls • Reflex tachycardia
  • 39. Since LV volume is reduced • Murmur of HOCM increased(65% sensitivity, 95% specificity) • Systolic click and murmur of MVP commence earlier
  • 40. PHASEIII VALSALVA RELEASE • Brief sudden Decrease SBP • Due to sudden decrease in intra thoracic pressure
  • 41. • Phase IV • Over shoot of SBP due to increased venous return and reduced systemic vascular resistance • Followed by reflex bradycardia
  • 42. • PHASE IV OVERSHOOT PHASE • Murmurs and heart sounds transiently augmented
  • 43. Square wave response • Seen in • Severe LV dysfunction +_ Heart failure • MS with significant PAH • ASD with significant L to R shunt • Apparently normal persons aged above 55 yr
  • 44. • Phase I: Intra thoracic pressure rises with increase in sys and pul arterial pressures with no increase in CO • Phase II: ventricular filling is not decreased and venous return is maintained during continued straining. Arterial pressure remains mildly elevated with insignificant changes in PP , HR , LV SV , CO
  • 45. • Phase III/IV: post release phase pressures return to normal pre strain level • No transient increase invenous return,SV or over shoot BP rise or reflex brady cardia
  • 46. • The maneuver should be performed with patient in supine position or upper part of body elevated no more than 30 degrees • Strain phase to be limitied to 10 to 12 sec • Should not be performed in patients with active myocardial ischemia or cerebral ischemia and unstable cardiac rhythm
  • 47. Valsalva Maneuver I/T Pr = VR = BP sympathetic tone HR sudden return of peripherally pooled blood to the vaso-constricted arterial system (20 to the increased sympathetic tone) PHASE II PHASE IV MAXIMAL SYMPATHETIC ACTIVATION FLAT PART OF STARLING’S CURVE HEART FAILURE ASD MS
  • 48. • Valsalva maneuver is helpful in differentiating rt sided systolic murmurs from those of the left side and of considerable importance in identifying systolic murmur of HOCM
  • 49. • During strain phase Attenuation of • S3 and S4 • AS & PS • MR & TR • AR & PR • TS & MS • Most of the heart sounds and murmurs decrease in the strain phase of valsalva
  • 50. • Up on release of valsalva murmurs on the right side of the heart return to baseline intensity in 2 to 3 cardiac cycles where as left sided murmurs donot return to baseline intensity till 5 to 10 cardiac cycles
  • 51. • Second heart sound • Normal splitting of S2 narrows during the strain phase of valsalva and widens markedly immedaitely during the release phase • Paradoxical plitting of S2 widens during the strain phase and then becomes more narrow during the release phase
  • 52. POSTPREMATURE VENTRICULAR CONTRACTIONS Followed by a significant pause • Increase in ventricular filling • Augmentation of cardiac contractility- post extra systolic potentiation • Onset of LV ejection at a lower diastolic pressure
  • 53. During postpremature beat – augmented are • ESM of AS and PS volume contractility • HOCM contractility-increase dynamic LVOT obstruction increase volume decrease LVOT obstruction net increase gradient
  • 54. • PSM of MR and of VSD - not altered(relatively little further increase in mitral valve flow or change in the LV-LA gradient) (ventricle has has 2 openings aorta and LA in MR not in AS) • Systolic murmur of papillary muscle dysfunction diminish • Increase in LV size delays systolic click and murmur of MVP (depend mainly on volume)
  • 55. • Similar auscultatory changes follow prolonged diastolic pauses in AF • After a long R-R interval augmented unchanged AS/PS TOF IHSS VSD TR MR AR
  • 56. • PR interval variations • When PR interval becomes abnormal atrial contribution to ventricles decrease and the stroke volume falls • Varying atrial contribution will cause significant alteration in ESMs • S1 soft with long PR and loud with short PR
  • 57. PHARMACOLOGICAL AGENTS AMYL NITRITE INHALATION • Crush ampule in towel • take 3-4 deep breaths over 10 – 15 secs • First 30 secs– Systemic art pressure decrease • 30 to 60 secs– Reflex Tachycardia • > 60 secs - positive inotropic effect, SV, EF, CO,HR and Ejection Velocity • Significant increase in venous return
  • 58. • S1 augmented • A2 diminished • OS mitral and tricuspid valve become louder • A2 OS interval shortens • RVS3 and LVS3 augmented –rapidity of ventricular filling • LVS3 associated with MR diminished(MR reduced)
  • 59. Systolic murmurs accentuated are • HOCM • AS • PS • TR • Functional systolic murmurs Increased ventricular contractility and SV
  • 60. Due fall in systemic arterial pressure murmurs diminished are • PSM of MR • PSM of VSD • EDM of AR • Austin flint murmur • Continuous murmur of PDA • Continuous murmur of AVF
  • 61. Systolic ejection murmur of TOF diminished • Decrease in arterial pressure • Increase right to left shunt • Decrease blood flow in RVOT
  • 62. Reduction cardiac size leads to • Early appearance of click and murmur of MVP • Murmur intensity show variable response
  • 63. Amyl nitrate response useful in distinguishing • Systolic murmur of AS(^)and MR(v) • Systolic murmur of TR(^) and MR(v) • Systolic murmur of PS(^) and TOF(v) • Systolic murmur of PS(^) and VSD(v) • Diastolic murmur of MS(^) and Austin flint(v) • EDM of PR(^) and AR(v)
  • 64. • In HOCM there an additional and earlier( 5 to 10 after inhaltion) augmentation of murmur due to decrease in LV Vol and sys art pressure with resultant increase in LVOT obstruction • This earlier response helps in differentiating HOCM from valvular AS where murmur augmentation starts 15 to 20sec after inhalation
  • 65. METHOXAMINE AND PHENYL EPHRINE • Increase systemic arterial pressure • Reflex bradycardia and decreased contractility and COP • Contraindicated in CHF and HTN
  • 66. • Methoxamine 3-5 mg IV increase arterial pressure by 20-40 mm Hg with in 2-3 min lasting for 30 to 40 min • Phenylephrine 0.5mg IV elevates systolic pressure around 30mm Hg for 3-5min • Phenylephrine preferred due to shorter duration action
  • 67. • S1 reduced • A2 becomes louder • A2 OS prolonged • S3 and S4 response variable • Click of MVP occurs later and accentuated
  • 68. Increase in arterial pressures cause following murmurs louder • EDM of AR and Austin Flint murmur • PSM of MR • VSD • TOF • Continuous murmurs of PDA and AVF
  • 69. • Systolic murmur of HOCM softens(^ LV size) • Click and murmur of MVP delayed(^ LV size) Decrease in COP diminish • ESM of AS • Functional systolic murmurs • MDM of MS
  • 70. TRANSIENT ARTERIAL OCCLUSION • Transient external compression of both brachial arteries • By bilateral cuff inflation to 20 mm Hg greater than peak systolic pressure • Augments the murmurs of MR, VSD, and AR
  • 71. MS Inspiration, Sudden standing Dec pulmonary venous return, Reduces LAP • MDM reduced • OS softens • A2-OS gap widen • Three sequential sounds (A2, P2, and OS) may be audible • Exercise ,Squatting ,Amyl Nitrate, isometric hand grip MDM accentuated
  • 72. • Valsalva maneuver may show square wave response • A2 OS interval directly related to R-R interval
  • 73. MR • Varies little with respiration Decrease murmur • Sudden standing • Valsalva • Amyl Nitrate Augments the murmur • Squatting • Isometric Exercise
  • 74. AS Murmur increases on • Post PVC beat • squatting • Lying flat from standing Reduces AS murmur • Valsalva • Standing • Handgrip • Abnormal PR
  • 75. AR EDM increases on • Expiration • sitting up and leaning forward • Squatting • Isometric exercise • Vasopressors Decreases with • Amyl Nitrate • Valsalva
  • 76. MVP Murmur and click earlier(intensity decreases) LV Volume decrease • Standing • Valsalva Murmur and click later LV Volume increase • Squatting • Post ectopic • Isometric Exercise (intensity increases)
  • 77. HOCM Increase murmur in • Expiration • Valsalva strain • Standing • Post ectopic • Amyl nitrate Decrease murmur in • Inspiration • Sustained Handgrip • squatting • Methoxamine
  • 78. • Valsalva strain following amyl nitrate in HCM • In 20 to 30% of patients systolic murmur of HCM remains unchanged after valsalva strain • When valsalva strain is repeated after amyl nitrate inhalation most of these pts will now show augmentation • This maneuver increases the sensitivity of valsalva for diagnosing HOCM
  • 79. Dynamic auscultation helpful in • AS X HOCM squatting (^/v) valsalva/standing (v/^) • AS x MR handgrip (v/^) phenyl ephrine (v/^) post pvc (^/v) amyl nitrate (^/v)
  • 80. • MS X TS respiration • MR X TR respiration • MS X AUSTIN FLINT amyl nitrate(^/v) • PS X AS respiration • PS X Small VSD amyl nitrate (^/v) phynylephrine (v/^) respiration • PR X AR squatting (_/^) sus handgrip (-/^)
  • 81. •Thank you