Disease management pathology.

2.  The respiratory system consists of the
airways and the respiratory tract. The laying
and formation of the respiratory system
begins from the 3rd week of gestation from
the protrusion of the anterior intestinal wall
and by the 16th week the main structure of
the bronchial derev is formed. The fetus
performs respiratory movements from the
end of the first trimester of intrauterine
development. They are performed with the
glottis closed, which prevents the penetration
of amniotic fluid into the lungs.

3.  Surfactant (a surfactant - a tension factor that
provides the area of the respiratory surface and
prevents the collapse of the alveoli) matures at
35-36 weeks of gestation, so the lack of
surfactant in premature infants is the main cause
of the respiratory disorders syndrome.
 In violation of embryogenesis 3-7 week of fetal
development (at the time of formation of the
trachea, the main bronchi, the lobes and main
lobes of the lung, the pulmonary arteries), as a
result of damage can develop: atresia of the
larynx, tracheal stenosis, tracheoesophageal
atresia, fistula, pulmonary agenesis, congenital
pulmonary cysts (including bronchial).

4. Features Value
The softness of the ribs and the pliability of
the chest
Easier passage through the birth canal, but
prone to paradoxical breathing
The "expiratory" structure of the chest (the
ribs are located almost at right angles to the
spine)
Limited opportunities to increase respiratory
volume
Poor development of the respiratory muscles Limited ability to increase the respiratory
volume, overcome resistance during
obstruction, ease of occurrence of weakness
and exhaustion of the respiratory muscles
High standing of the diaphragm The diaphragmatic type of breathing, a
decrease in the respiratory volume with
bloating of the intestine
Narrow (up to 1 mm) and short nasal
passages
Difficulty in sucking with rhinitis,
deterioration of anti-infective protection,
warming, mechanical air purification when
breathing through the mouth

5. Incomplete development of the paranasal
sinuses
The rarity of the occurrence of sinusitis at an
early age
The cartilage of the larynx is tender and
pliable mucosa is rich in blood vessels and
lymphatic vessels, elastic tissue poorly
developed, fiber subglottic apparatus has
high porosity. 1 mm of edema of the mucosa
of the subclavian space leads to a decrease
in its lumen by 50-75% (in adults by 20%)
High frequency of occurrence and severe
course of laryngitis, often accompanied by
the development of laryngeal stenosis
The trachea is relatively short, has a funnel-
shaped shape, the tracheal mucosa is tender,
richly vascularized; 1/3 of the trachea is
represented by the membranous part(in
adults-1/5), which leads to a decrease in its
lumen by one third during the respiratory
cycle and when coughing
. More frequent than in adults, as an isolated
lesion of the trachea, and its involvement in
the inflammatory process in laryngitis and
bronchitis(laryngotracheitis and
tracheobronchitis)
The bronchi are narrow, the bronchioles of
the newborn are 0.1 mm in diameter (in
adults-0.5 mm), edema of the bronchial wall
by 1 mm increases the resistance in the
airways of the newborn by 16 times (in
adults-2-3 times); less elastic tissue,
underdevelopment and softness of cartilage;
absence (up to 8 years) "auxiliary" air flow
between adjacent bronchi; relatively thick,
loose, well-vascularized bronchial mucosa,
large concentration of mucous glands
The tendency to acute and recurrent
bronchial obstruction; the predominance of
components of hypersecretion and edema in
the bronchial obstruction; a greater tendency
to reduce the lumen of the respiratory tract
with external compression((for example, the
lumen of the mid-lobe bronchus with
enlarged lymph nodes); a greater tendency to
atelectasis, the occurrence of air traps

6. The right bronchus is wider and seems to be
a continuation of the trachea
A greater frequency of foreign body
penetration into the right bronchus
Lower lung extensibility (1/3 the size of an
adult)
Relatively large amount of work spent on
breathing, high energy costs, especially in
tachypnea and shortness of breath
The respiratory equivalent in an infant is 2
times greater than in an adult; three times
the minute volume of ventilation (0.4 l / kg
in a one-month-old child and 0.125 l/kg in a
14-year-old child), which provides greater
oxygen absorption (13.2 ml/kg per minute in
a newborn compared to 4.3 ml/kg per
minute in an adult)
The possibility of rapid development of
respiratory failure in diseases of the
respiratory system, because for the
assimilation of 1 liter of oxygen, the child
has to do 2 times more work
Greater resistance to hypoxia in newborns
and infants; reduced intensity of oxidative
processes
Good tolerance to short-term moderate
hypoxia compared to adults; poor tolerance
to chronic hypoxia
"Primitive" nature of acinus, poor collateral
ventilation, greater looseness of interalveolar
and interlobular connective tissue, rich lung
vascularization
Lower diffusion capacity with a lower
coefficient of oxygen utilization from the air
(in newborns, 1 ml of oxygen is absorbed
from 42 ml of air, and in adults-from 16 ml);
greater tendency to edema and
generalization of infection in the lungs, a
decrease in respiratory volume in any
tachypnea

7. The pleura is thin, tender; the elastic
network of the pleura is formed by the age
of 7; loose and pliable fiber surrounding the
mediastinum
Ease of displacement of the mediastinal
organs with the accumulation of fluid in the
pleural cavity
Slightly lower viscosity of bronchial mucus
compared to adults
Easier evacuation of sputum from the
airways
Greater mediastinal mobility The possibility of inflection of large major
vessels and compression of the lung during
mediastinal shift
A relatively weak cardiac sphincter of the
stomach in well-marked pyloric.
Tendency to gastroesophageal reflux,
regurgitation, regurgitation followed by
aspiration
Low overall and local immune response at
an early age
High frequency, tendency to relapse and
more severe course of infectious diseases of
the respiratory tract, bronchiolitis; easier
occurrence of sensitization to exogenous
non-infectious allergens

8.  Respiratory movements in the fetus occur at the 13th week
of intrauterine development, which occur when the glottis
is closed. During labor, the fetus significantly reduces the
partial pressure of oxygen (pO2), increases the pCO2, and
decreases the pH. In this regard, there is an impulse from
the aortic and carotid artery receptors to the respiratory
center and its excitation. Along with this, there are also
signals from the irritation of the skin receptors. After birth
and contraction of the diaphragm, a negative intra-
thoracic pressure is created, which facilitates the entry of
air into the airways and lungs, which are filled with a
viscous liquid. With normal expansion of the lung, with the
participation of a surfactant, the pulmonary fluid is quickly
absorbed by the lymphatic vessels and blood capillaries
and gas exchange begins. The regulation of respiration in
the future is carried out mainly by the respiratory center.

9.  When collecting anamnesis, you should pay attention to the most
frequent complaints:
 - difficulty breathing through the nose, the nature of the discharge from
it;-
 - cough its strength, frequency, duration, soreness, presence and nature
of sputum, etc.;
 - change of voice-hoarseness, aphonia;
 - shortness of breath (shortness of breath), to clarify its nature.
 Further specify:-
 - whether there was an increased body temperature;
 - were there any contacts with infectious patients in the family, in
children's institutions;
 - were there any diseases of the respiratory system that preceded the
present,
 - has he received treatment so far and what was the degree of recovery;
 - did the child have measles, whooping cough;
 - the presence of respiratory diseases in the family and in the next of
kin;-
 - allergic history (the presence of allergies in the child, in other family
members, in relatives).
 At the end of the history collection, the data is analyzed and a short
conclusion is made.

10. During the examination, attention is drawn to:
 1. Consciousness, position in bed, reaction to
others.
 2. The state of physical development.
 3. Color of the skin of the face and mucous
membranes.
 4. Whether the breath is free through the
nose, the nature of the discharge.
 5. The nature of cough, sputum.
 6. The child's voice.
 7. The shape and symmetry of the chest.
 8. Type of breathing.

11.  9. Rhythm, frequency, and depth of
breathing. It should be remembered about
the average parameters of the respiratory rate
in children of different ages:
Respiratory rate (per minute) in young children
Age sleep Waking up
0 –1 мес. 30 (29 –47) 50 (40 – 60)
1 – 6 мес. 35 (20 – 60) 65 (50 – 75)
6 –12 мес. 27 (22 – 32) 60 (55 – 75)
1 –4-года 20 (16 – 25) 33 (23 – 42)
4 –10 лет 18 (13 – 23) 23 (15 – 36)
10 –14 лет 16 (13 – 19) 21 (15 – 28)

12. 10. The presence of shortness of breath; what
is the ratio between inhaling and exhaling;
11. Bulging or sinking of the intercostal spaces
(especially one-sided). The symmetry of the
participation of both halves of the chest in
breathing.
12. Inflating the wings of the nose.
13. The ratio between the respiratory rate and
pulse.
14. The condition of the pharynx, posterior
pharyngeal wall and tonsils.

13. When palpating, pay attention to:
 - elasticity and resistance of the chest;
 - soreness;
 - voice tremor;
 - the symmetry of the participation of both halves of the
chest in breathing;
 - the thickness of the skin-subcutaneous fold on
symmetrically locatedareas of the chest.
When percussion, pay attention to:
 - the age of the children, the severity of the condition,
which will determine the position of the patient with
percussion;
 - symmetry of both halves of the chest;
 - features of percussion in young children (less impact
force – "quietest" percussion, direct percussion).
In comparative percussion, the nature of the percussion
sound and the presence of a pathological focus are
determined

14. In topographic percussion is determined:
 - height Vistana apices above the clavicles,
the margins of Kreniga (in children under 5
years the tops of the lungs do not act outside
of the clavicles, normally the upper bounds at
this age is not defined);
 - the lower borders of the lungs; the
projection of the lobes of the lungs on the
chest;
 - mobility of the lower edge of the lungs.

15.  The lower border of the lungs in children
Lines From Right To Left
Middle clavicle VI rib The lower border of the left
lung along the midclavicular
line differs in that it forms a
notch for the heart and
departs from the sternum at
the height of the IV rib and
steeply descends downwards
Middle axillary VII rib IX rib
Scapular IX-X rib X rib
Paravertebral At the level of the –»»» spinous process of the
XI thoracic vertebra

16. During auscultation, attention should be paid to:
 - asymmetry of the auscultative zones;
 - the nature of the main respiratory noise, for which you
need to determine the duration of inspiration and
exhalation, their strength and ratio;
 - places of the most frequent localization of pathological
foci – axillary areas, paravertebral spaces, supra-and sub-
scapular areas;-
 - the presence of pathological changes in the main
respiratory noise (weakening, strengthening, hard,
bronchial breathing, etc.);
 - the presence of pathological noises (wheezing, pleural
friction noise);
 - changes in bronchophony;- auscultatory signs of
improvement in bronchial lymph nodes (symptom D"
Espina).
 After completing the clinical examination of the patient,
you need to make a short conclusion about the changes
found and the severity of the condition according to the
degree of respiratory failure and signs of toxicosis.

17. Next, it is necessary to evaluate the results of
additional research methods:
 1. Acid-base state of blood gases, paying attention to
the decrease in PO2 and increase in PCO2.
 2. Sputum examination (bacteriological and
microscopic).
 3. Examination of the pleural punctate
(bacteriological, microscopic, protein content).
 4. X-ray data.
 5. Instrumental studies (bronchoscopy, etc.).
 6. Functional studies – spirography,
pneumotachometry, etc. results of functional tests.
 7. Scarification tests with the most common
allergens.
 8. Examination of the biopsy of the bronchial mucosa
and lung tissue.

18. Cough is one of the most characteristic signs of respiratory damage.
 Cough is especially typical in whooping cough:
 it occurs with paroxysms (paroxysmal) and with reprises (long, high
breath), and is also accompanied by redness of the face and often
vomiting.
 Cough paroxysms are usually observed at night.
 Cough with laryngeal lesions is usually dry, rough, and barking. It is so
characteristic that it makes it possible to suspect a lesion of the larynx
(laryngitis or croup) at a distance.
 Cough with tracheitis is rough (like in a barrel).With bronchitis, the
cough can be both dry (at the beginning of the disease) and wet, with
sputum separation - during the development of the disease and at the
end of it.
 With bronchial asthma, first the cough is dry, irritable, and then – wet,
when the viscous, viscous sputum begins to separate.
 With pneumonia, also in the first days of the disease, the cough is more
often dry, and in the following days it becomes wet.
 When the pleura is involved in the process, the cough is usually painful
(croup pneumonia, pleurisy).

19.  Bitonal cough - spasmodic cough, having a rough the
main tone and musical II high tone, arises from irritation
cough zone of bifurcation of the trachea by enlarged
lymph nodes (often with bronhoadenita tuberculosis) or
observed in lim-agranulocytose, lymphosarcoma,
leukemia, tumors of the mediastinum (thymoma, sarcoma,
etc.).
 Painful dry cough occurs in pharyngitis and
nasopharyngitis. If adult patients usually expectorate
sputum, then young children usually swallow it. Infants do
not know how to cough up phlegm at all.
 Therefore, to solve the question: dry or wet cough, it is
necessary to observe a small child, whether he swallows
sputum.
 Copious discharge of sputum (purulent) with a full mouth
in young children is observed when an abscess, or a
suppurated cyst of the lungs, is emptied into the bronchi.
Older children have a lot of sputum in chronic pneumonia,
when there are already bronchiectases.

20.  Inspection. On external examination, cyanosis should be noted,
which can be permanent, local or general. The greater the
respiratory failure and the lower the oxygen saturation of the
body, the stronger and more widespread the cyanosis. In young
children (up to 2-3 months of age), foamy discharge can be seen
in the corners of the mouth, under the tongue in bronchiolitis
and pneumonia. This is due to the penetration of inflammatory
exudate from the respiratory tract into the oral cavity.
 During the inspection of the nose may be noted discharge
(serous, mucous, Muco-purulent, sukrovichnye, bloody), and
difficulty breathing through the nose. Depending on the nature
of the discharge, rhinitis is distinguished: serous, mucous,
mucopurulent and hemorrhagic. Rhinitis is most often one of the
symptoms of an acute respiratory viral infection (adenovirus,
parainfluenza, or influenza), but it is also observed in measles.
Sukrovichnye nasal discharge is characteristic of diphtheria of
the nose or foreign body. For congenital syphilis, the so-called
snoring breath is characteristic.

21.  During the examination, pay attention to the
child's voice, which often changes when the
larynx and vocal cords are affected. Laryngitis is
clinically manifested by a rough barking cough
and a change in voice. Unlike adults, laryngitis in
children is often accompanied by difficulty
breathing-croup. Croup can be true or false. True
croup is observed in diphtheria of the larynx,
when there is a croup inflammation of the vocal
cords with the formation of a hard-to-separate
film.
 False croup- sublingual laryngitis, most often
occurs in acute respiratory viral infections (most
often with parainfluenza) and is caused by
swelling of the mucous membrane below the
vocal cords.

22.  False croup usually occurs suddenly and
usually in the evening and at night. Before
that, it is as if a healthy child suddenly wakes
up and begins to suffocate. True croup
usually develops gradually (within 1-3 days).
Unlike the false croup, with the true croup,
the voice disappears gradually (aphonia).

23.  A rough, low voice is one of the signs of
myxedema. Nasal tone of the voice occurs in
chronic rhinitis, adenoids, pharyngeal
abscess, etc. The appearance of nasal tone in
diphtheria of the pharynx and
encephalopathies indicates paresis of the
palatine curtain. In children of preschool and
school age with chronic adenoiditis, the face
acquires a characteristic appearance. It is
pale, puffy, with a slightly open mouth, raised
upper lip and upturned nose, often there is
an incorrect bite.

24.  The appearance of a frequently coughing
child is typical, especially in whooping cough
and chronic non-specific lung lesions. Such
children have a pale, pasty face and eyelids
(due to a violation of the outflow of lymph-
lymphostasis), cyanotic lip mucosa, swollen
skin veins, and may experience hemorrhages
in the conjunctiva and subcutaneous tissue.

25.  When examining the oral cavity, it is necessary to
pay attention to the condition of the pharynx and
tonsils. In children of the first year of life, the
tonsils, as a rule, do not extend beyond the front
arches. In preschool children, there is hyperplasia
of the lymphoid tissue, and the tonsils usually
extend beyond the front arches when examined.
They are dense and do not differ in color from
the mucous membrane of the pharynx.
 Children often have inflammatory processes of
the tonsils - angina, which are divided into
catarrhal, follicular, lacunar, as well as specific
infec-tions. Angina in scarlet fever differs from
the banal angina by sharply limited hyperemia,
and in moderate to severe forms-by necrosis of
the mucous membrane ("necrotic angina").

26.  Changes in the shape of the chest in children occur
with rickets, pneumothorax, pneumomediastinum,
bronchial asthma (barrel-shaped). In exudative
pleurisy, there is a swelling of the chest on the side
of the lesion, and in chronic pneumonia - a
depression. A significant retraction of the intercostal
spaces and the jugular fossa in the inhalation phase
is typical for stenotic breathing in croup.
 Restriction of the chest excursion is observed in
acute pulmonary distension, bronchial asthma,
pulmonary fibrosis, subdiaphragmal abscess,
intercostal neuralgia. There may be a change in the
rhythm of breathing.

27.  Rapid breathing (tachypnea) in healthy children
occurs with excitement, physical exercise, etc.
diseases of the respiratory system, diseases of
the cardiovascular system, blood diseases
(anemia), febrile diseases, pain, and distress
syndrome in newborns.
 Respiratory depression (bratipnea) is rarely
observed in children, indicates exhaustion of the
respiratory center and usually occurs in comatose
states (uremia), poisoning (for example, with
sleeping pills), increased intracranial pressure,
and in newborns - in the terminal stages of the
distress syndrome. Pathological types of
respiration: Kussmaul, Biot, Cheyne-Stokes,
reflect the severe degrees of his disorder.

28.  When examining the child, you should pay attention to the
participation in the breathing of auxiliary muscles (rectus
abdominis, sternocleidomastoid, thoracic, etc.), which
indicates difficulty breathing-shortness of breath. At the
same time, young children also experience swelling and
tension of the wings of the nose. Dyspnea occurs with
hypoxemia, hypercapnia, an excess of various under-
oxidized products that accumulate in the blood and brain
matter during acidosis

29.  Inspiratory dyspnea – difficulty in inhaling, observed with
obstruction or narrowing of the upper respiratory tract
(croup, foreign body, cysts and tumors, congenital
narrowing of the larynx, trachea, pharyngeal abscess, due
to a drop in intra-thoracic pressure much lower than
atmospheric). Clinically, it is manifested by the retraction
of the intercostal spaces, the jugular fossa, the
supraclavicular regions and the epigastric region.
 Expiratory dyspnea is characterized by difficulty in
inhaling, intra-thoracic pressure, on the contrary, exceeds
atmospheric pressure. The chest is raised up and almost
does not participate in the act of breathing, the rectus
abdominis muscles are tense, the intercostal spaces are
flattened. It is observed in bronchial asthma, bronchitis,
with compression of large bronchi (tuberculous
bronchoadenitis).

30.  * Mixed shortness of breath (expiratory-inspiratory), manifested
by chest swelling and retraction of compliant places. It is
observed in pneumonia, pulmonary edema, exudate
compression, heart disease, flatulence, ascites, in patients with
rickets.
 * Shortness of breath Chic-expiratory puffing, depends on the
compression of the bronchi by tuberculous infiltrate and lymph
nodes of the lung root in the lower part of the trachea and
bronchi, which freely pass air only when inhaled.
 *The complete absence of respiratory movements in a newly
born child is the main symptom of imaginary death - asphyxia of
the newborn.
 * Congenital stridor-a disease of early age, characterized by
inspiratory noise when breathing. The noise is whistling, ringing,
reminiscent of the cooing of pigeons, sometimes the purring of a
cat, the clucking of a chicken. The noise in stridor is constant,
the intensity of the noise decreases during sleep, when the child
is transferred from a cold room to a warm one. Stridor begins
after birth, decreases in the second half of the year, and is self-
cured by 2-3 years.

31.  Palpation in the diagnosis of respiratory
diseases can be used to assess chest
deformities, search for pain points and areas
(myalgia, intercostal neuralgia, rib fractures).
When determining the elasticity and
resistance of the chest, in sick children, there
is a great resistance to exudate in the pleural
cavity, with tumors and strong compaction of
the lung tissue. When palpating (feeling) the
chest, you can detect soreness. It is necessary
to distinguish between superficial soreness
(damage to muscles, nerves, bones) and deep
- pleural.

32. The first one is found:
1) with inflammatory processes in soft tissues;
2) when the intercostal muscles are affected;
3) when the ribs and sternum are affected;
4) for diseases of the intercostal nerves.
 Pleural (deep) pain usually increases when
inhaling and exhaling, often given to the
epigastric and subcostal areas, weaken if you
squeeze the chest, decrease when bending the
body in the affected direction.
 The palpation method determines the thickness
of the skin fold on the symmetrical areas of the
chest. Thickening of the skin fold is observed in
exudative pleurisy, less pronounced in
tuberculous bronchoadenitis on the affected side.

33.  Voice tremor. Its strengthening is associated
with the compaction of the lung tissue, the
presence of cavities in the lungs (the distance
from the glottis is shortened).
 Weakening - when the bronchus is blocked
(atelectasis of the lung), when the lung is
pushed away from the chest wall (exudate,
pnevmotorax, pleural tumor).Restriction of
the chest excursion is observed in acute
pulmonary distension, bronchial asthma,
subdiaphragmal abscess, intercostal
neuralgia.

34.  Features of percussion in young children: less
impact force, mainly direct percussion is
performed. In comparative percussion, the nature
of the percussion sound and the presence of a
pathological focus are determined.
 With topographic percussion, determine:
 the height of standing on the tops of the
clavicles, the margins of Kreniga;
 - the lower borders of the lungs, the projection
of the lobes of the lungs on the chest;
 - mobility of the lower edge of the lungs.

35. When the respiratory system is affected, there is a change in the
percussion sound of different intensity.
The shortening of the percussion sound is noted:
 1. When the lung becomes less airy when:
 - inflammation of the lungs (infiltration and edema of the alveoli
and interalveolar septa;
 - hemorrhages in the lung tissue (lung infarction);
 - significant pulmonary edema;
 - scarring of the lungs;
 - decline of the lung tissue - atelectasis, compression of the
lung tissue with pleural fluid, a greatly expanded heart, a tumor
in the chest cavity.
 2. In case of formation of other airless tissue in the lung cavity:
 - in case of tumors- with the formation of a cavity in the lungs
and the accumulation of fluid in it (sputum, pus, echinococcal
cyst), provided that this cavity is more or less filled with fluid

36.  3. When filling the pleural space:
 - exudate (exudative pleurisy) or transudate;
 - fibrinous overlays on the pleural leaves.In exudative pleurisy, if
the fluid does not fill the entire pleural space, it is possible to
determine the Elissa-Damoiseau-Sokolov line - the upper border
of dullness with the highest point in the posterior axillary line.
 From here it goes in and down. The line corresponds to the
maximum level of fluid standing and is formed due to the
displacement of the lungs to their root outlet. On the affected
side it is possible to define a shortened tympanitis, which is in
the form of a right triangle over exudate (triangle Garland). It
corresponds to the location of the compressed lung. Its
boundaries are: the hypotenuse-the Elissa-Damoiseau-Sokolov
line, the catheters - the spine and the line perpendicular to the
upper point of the Elissa-Damoiseau-Sokolov line on the spine.
Behind, on the healthy side, due to the movement of the
mediastinal organs, a section of blunting of the percussion
sound is formed, which has the shape of a right triangle, this is
the so-called Grokko-Rauchfus triangle. One of its catheters is
the line of the spine, the second is the lower edge of a healthy
lung, the hypotenuse is the continuation of the Damoiseau line
to the healthy side.

37. A tympanic tinge of percussive sound appears:
1. In the formation of pathological, air-containing
cavities:-
 in the lung tissue by destruction during inflammation
(cavities in pulmonary tuberculosis, abscess), tumors(
decay), cysts;
 - for diaphragmatic hernia and pneumatization of cysts;
 - in the pleura, in the form of an accumulation of gas or
air in the pleural cavity: pneumothorax (spontaneous
pneumothorax, artificial).
 2. With some relaxation of the lung tissue due to a
decrease in its elastic properties (emphysema), with
compression of the lungs above the location of the fluid
(exudative pleurisy and other forms of atelectasis).
 3. At a certain degree of filling of the alveoli with air with
the simultaneous presence of fluid in them-pulmonary
edema at the beginning of inflammation, with the dilution
of inflammatory exudate in the alveoli.

38.  Box sound-a loud percussive sound with a
tympanic tinge, appears when the elasticity of the
lung tissue is weakened, and its airiness is
increased (emphysema of the lungs), and is
observed in pneumothorax.
 The noise of a "cracked pot" is a kind of
intermittent, rattling sound, similar to the sound
when tapping on a cracked pot. It becomes
clearer when the patient opens his mouth. It is
often obtained by percussion on the chest during
screaming in children. In pathology, it occurs in
cavities that communicate with the bronchi by a
narrow slit.

39.  A decrease in the height of the standing of the
tops can be observed when they are wrinkled on
the soil of tuberculosis. Thus there is a reduction
in the width field of Kreniga.The lower borders of
the lungs are lowered either due to an increase in
the volume of the lungs (emphysema, acute
pulmonary bloating), or due to a low standing of
the diaphragm-with a sharp lowering of the
abdominal organs and a decrease in intra-
abdominal pressure, as well as paralysis of the
diaphragmatic nerve.

40. The lower borders of the lungs are raised when:
 reduction of the lungs, due to their shrinking (more often on
one side in chronic inflammatory processes);
 when pushed back by pleural fluid or lung gas;
 lifting of the diaphragm due to increased intra-abdominal
pressure or pressure of the diaphragm upward by an organ or
fluid (flatulence, ascites, enlargement of the liver or spleen,
abdominal tumor).
The decrease in the mobility of the pulmonary edges is caused by:
 loss of lung tissue elasticity (emphysema in bronchial asthma);
 wrinkling of the lung tissue;
 an inflammatory condition or edema of the lung tissue;
 the presence of adhesions between the pleural leaves.
The complete cessation of mobility occurs when:
 filling the pleural cavity with fluid (pleurisy, hydrothorax) or gas
(pneumothorax);
 complete overgrowth of the pleural cavity;
 paralysis of the diaphragm

41. Additional respiratory noises. The mechanism of their formation
 The weakening of vesicular respiration is noted when:
 • general weakening of the respiratory act with a decrease in
the intake of air into the alveoli (severe narrowing of the
larynx, trachea, sharp general weakness, diseases of the
respiratory muscles, etc.);
 • closing of air access to a certain part of the lobe or lobe as
a result of blockage or compression of the bronchus (foreign
body, tumor, etc., atelectasis);
 pushing away a part of the lung with something: when fluid
accumulates in the pleura (exudative pleurisy), air
(pneumothorax), the lung moves deeper, the alveoli spread
out when breathing;
 loss of lung tissue elasticity, stretching, i.e. rigidity (low
mobility) of the alveolar walls (emphysema);
 in the initial or final stage of the inflammatory process in the
lungs, when there is only a violation of the elastic function of
the pulmonary alveoli without infiltration and compaction;

42.  Increased breathing occurs when:
 narrowing of the small or minute bronchi
(strengthening is due to exhalation) with their
inflammation or spasm (asthma attack,
bronchiolitis);
 febrile diseases, with compensatory
strengthening on the healthy side in the case of
pathological processes on the other.
 Hard breathing is rough vesicular breathing with
an elongated exhalation.
 There are two options for hard breathing:
 inhale and exhale are heard equally well and are
the same in duration;
 the inhale and exhale are equally rough, but the
exhalation is somewhat longer.

43.  Hard breathing usually indicates the defeat of small
bronchi, occurs in bronchitis and bronchopneumonia. In
these diseases, inflammatory exudate reduces the lumen
of the bronchi, which creates conditions for the occurrence
of this type of breathing.
 Bronchial respiration is heard only in cases of compaction
of the lung tissue (tuberculosis, heart attacks, pneumonia)
or the formation of cavities communicating with the
bronchi. With bronchial breathing, the inhale and exhale
are heard equally well (the exhale is heard even better, the
timbre is changed - a rough “x”is heard).
 Bronchial respiration by the degree of strength can be
weakened (when the lung is compressed with exudate)"it
sounds like it's coming from far away." If the foci of
compaction are located deep in the lung tissue and are
normally closed by the lung tissue, a rougher and longer
exhalation is heard, approaching the bronchial one
(breathing with a bronchial tinge). Bronchial respiration
can be of the amphoric type (in smooth-walled cavities-
caverns, bronchiectasis, etc.).

44.  Wheezes are additional noises and are formed when
moving or oscillating in the air-bearing cavities of
secretions, blood, mucus, edematous fluid, etc.
 Dry wheezes: whistling - treble, high and bass, low. The
first are more common with narrowing of the bronchi,
especially small ones, the second are formed from
fluctuations in thick sputum, especially in large bronchi,
giving resonance.
 Dry wheezes are called them because the liquid does not
play a big role in their formation. In the mechanism of
formation of dry wheezes, the bronchial wall itself and the
air stream play a role. They are characterized by
impermanence and variability. They are found in laryngitis,
pharyngitis, bronchitis, emphysema, asthma. Laryngeal
and tracheal wheezes are characterized by the fact that
they are single-caliber and are heard as if under the ear.
Bronchial tubes are divided into large and medium-sized,
depending on the place of formation, and their audibility is
different, which is associated with the place of their
formation.

45.  Wet wheezes are formed from the passage of
air through the liquid. Depending on the
caliber of the bronchus, where they are
formed, they are small-bubble. It is important
to divide them into ringing and non-ringing
ones. Ringing sounds are heard when the
lung tissue lying next to the bronchus is
compacted, which is observed in
bronchiolitis, bronchitis, pulmonary edema,
atelectasis.

46. Pleural friction noise occurs when the visceral
and parietal pleural leaves are rubbed and is
heard:
 when the pleura is inflamed, when it is
covered with fibrin or infiltration foci are
formed on it, which leads to irregularities,
roughness of the pleural surface, combined
with pain;
 with the formation of pleural adhesions as a
result of inflammation;
 when the pleura is affected by a tumor;
 with severe dehydration of the body.

47. From small crepitating wheezes, the noise of pleural friction
differs in the following signs:
 1) the noise of pleural friction is heard in both phases of
breathing, and crepitation only at the height of inspiration,
when the air reaches the small bronchioles and alveoli;
 2) wheezing often disappears after coughing, while the
noise of pleural friction remains;
 3) wheezing during respiratory movements, with the
mouth and nose closed, due to insufficient air movement
in the bronchi-do not occur. and the noise of pleural
friction continues to be heard;
 4). pleural noises when the phonendoscope is pressed on
the chest are amplified, while crepitation remains
unchanged;
 5) pleural noises are heard more superficially than small-
bubble wheezes formed in the depth of the lung.

48.  Increased bronchophonia is noted with infiltrative compaction of
the lung (pnev-monia, tuberculosis), atelectasis. Above the
caverns and bronchiectatic cavities, if the adductor bronchus is
not blocked, the bronchophony is also loud and has a metallic
character. When the lung tissue is compacted, increased
bronchophony is due to better voice conduction, and in cavities -
resonance. For the same reason, bronchophonia may be
increased in a patient with an open pneumothorax.
 With an increase in the bronchial lymph nodes, a symptom of
D'espin appears - listening to whispered speech and bronchial
breathing below the I thoracic vertebra along the vertebra. In
infants, this symptom does not apply.
 They use the De la Campa symptom - a loud laryngotracheal
exhalation is heard above the V and VI thoracic vertebrae.
 You can identify a symptom of Smith: if you tilt the child's head
so that the face is horizontal, then a venous noise is heard near
the upper part of the chest. If you slowly lower the child's head
down, the noise increases. The intensity of venous noise (in the
absence of anemia) depends on the size of the enlarged
paratracheal lymph nodes.

49. It is necessary to evaluate the results of additional research
methods:
 1. Acid-base state of blood gases, paying attention to the
decrease in PO2 and increase in PCO2.
 2. Sputum examination (bacteriological and microscopic).
 3. Examination of the pleural punctate (bacteriological,
microscopic, protein content).
 4. Radiological data
 5. Instrumental studies (bronchoscopy, etc.).
 6. Functional studies: spirography, pneumotachometry, etc.
results of functional tests.
 7. Scarification tests with the most common allergens.
 8. Examination of the biopsy of the bronchial mucosa and lung
tissue. After the summary of the results of additional research
methods, a final conclusion is made about the level and severity
of the respiratory system damage, for which it is necessary to
bring the data of the anamnesis and clinical examination into
line and agree

50.  Obstruction of the airways above the main
bronchi. Such obstruction, arising, for
example, in the larynx or trachea due to true
(with diphtheria) or false croup, Quincke's
edema in the larynx or a foreign body at this
level, leads primarily to a violation of
inspiration and shortness of breath takes on
an inspiratory character. For shortness of
breath.

51.  Bronchial obstruction syndrome always indicates the
presence of bronchitis, which can be independent or enter
into the manifestations of bronchopneumonia, bronchial
asthma, foreign body aspiration. Most often, the cause of
obstruction is the combined effect of edema and
inflammatory infiltration of the bronchial wall, the
abundance of secreted mucus with its thickening and
stagnation in the lumen of the bronchi, and, finally, spasm
of the smooth muscle of the bronchial wall. From the
obstruction of the main bronchi and below, first of all, the
mechanisms of exhalation suffer, since it occurs under the
influence of the lung's own elastic traction, which is still
very weak in children. Therefore, one of the most
persistent symptoms of bronchial obstruction is the
expiratory nature of shortness of breath. In addition, you
can hear distant whistling wheezes. With a complete
blockage of the bronchi in a certain segment or lobe, the
wheezing completely disappears, the respiratory noises
weaken and the phenomenon of "silent lung" occurs.

52.  Respiratory failure (DN) is a condition in which either the normal gas composition
of the blood is not maintained, or the latter is achieved due to the abnormal
operation of the external respiratory apparatus, which leads to a decrease in the
functional capabilities of the body.
 There are 4 degrees of DN.
 Causes of respiratory failure:
 1. Reduced pO2 in the inhaled air - anoxemic hypoxemia.
 2. The defeat of respiratory muscles, impaired air passage through the respiratory
tract, obstruction, impaired diffusion of oxygen through the alveolar-capillary
membrane, impaired capillary blood flow as a result of distension of the alveoli
(emphysema of bronchial hialnyh asthma, etc.)
 3. Obstructive type of respiratory failure characteristic narrowing of the bronchi
and bronchioles, edema of mucosa with bronchiolitis and when Steno-ziruyuschih
laryngitis (cereals).
 4. Restrictive (restrictive) type occurs when the ability of the lungs to expand and
fall is limited (pneumosclerosis, exudative pleurisy, lesions of the ribs and
respiratory muscles).
 5. Mixed type - with the predominance of one or another form.
 6. Disorders of blood gas transport (severe forms of anemia or changes in the
structure of hemoglobin)
 7. Circulatory disorders - congestive hypoxemia. There is a large absorption of
oxygen due to the slowing of blood flow in organs and tissues. Improvement of
cardiac activity contributes to the elimination of DN.
 8. Damage to the enzyme systems of cells involved in the utilization of oxygen-
tissue hypoxia. It occurs in severe infections and poisoning.

53.  Symptoms of pneumonia. Lung inflammation is characterized by fever,
lack of appetite, weakness, pallor (symptoms of intoxication) in patients
with a history of a previous viral infection. In young children, cyanosis
around the mouth, swelling of the wings of the nose, and an increase in
shortness of breath of a mixed nature are characteristic. Percutaneous:
blunting over the area of probable pneumonic infiltration. Breathing
increases, exhalation lengthens, With concomitant bronchitis
characterized by dry wheezing. Fine-bubbly wet wheezes of high
sonority are possible. The presence of atelectasis can reduce the degree
of sonority of wet wheezes. The diagnosis is confirmed radiologically by
the presence of foci of compaction of the lung tissue.
 Symptoms of pleurisy. Inflammation of the pleura, most often
complicates the course of other diseases. Characteristic features: severe
intoxication, pronounced asymmetry of the respiratory excursions, dry
cough, chest pain that increases with breathing and cough. Dulling of
the percussive tone over the inflamed pleura. In case of effusive pleurisy,
the Ellis-Damoiseau-Sokolov line is outlined. Breathing, as well as
wheezing over the zone of dullness, is not listened to. You can
percutaneously determine the displacement of the heart in the healthy
direction. The diagnosis is confirmed radiographically and pleural
puccia.