Physical therapy, types, means, methods

1. Department of Internal Medicine
Auscultation of the lungs (main and
pathological respiratory sounds)
IV semester
Practical lesson № 4
Part 2

2. The structure of the respiratory system
1 - nasopharynx
2 - oropharynx
3 - larynx
4 - trachea
5 - pleural cavity
6 - parietal pleura
7 - visceral pleura
8 - chest wall
9 - the main bronchi
10 - mediastinum
11 - diaphragm

3. The structure of the bronchi (1)
1 - the main bronchi
2 - lobar bronchus
3 - segmental bronchi
4 - branching of segmental
bronchi
5 - lobular bronchi
6 - terminal bronchioles
7 - acini
8 - pulmonary lobules

4. The structure of the bronchi (2)
1 - respiratory bronchioles
2 - alveolar passages
3 - alveoli
4 - interalveolar septum
5 - message of the alveolar
sac with the alveolar course
6 - alveolar sacs
7 - acinus
8 - terminal bronchiole

5. The projection of the trachea and main bronchi on the
anterior (a) and posterior (b) surfaces of the chest

6. Right and left lung lobes
 III, IV, VI – rib
numbers in order

7. Projection of lung segments on the anterior (a)
and posterior (b) surfaces of the chest

8. Projection of lung segments on the lateral
surface of the chest

9. Auscultation of the lungs
 Auscultation of the lungs (from lat.
аuscultatio) is the listening of
acoustic phenomena that occur in the
chest in connection with the normal
or pathological work of organs

10. Basic rules for lung auscultation
 The room for auscultation should be quiet and warm.
 Auscultation of the lungs is best heard in the upright
position of the patient.
 The patient should be without clothes to the waist.
 A stethoscope is pressed firmly against the chest.
 Listen to 2-3 respiratory cycles at each auscultation
point.

11. The technique of using a phonendoscope or
stethoscope

12. Steps for auscultation of the anterior surface
of the lungs

13. The position of the patient with auscultation of the
lungs in the lateral sections
 During auscultation in
the lateral sections of
the chest, the patient's
hands should be
raised by the head

14. Steps for auscultation of the lateral surfaces
of the lungs

15. The position of the patient with auscultation
of the posterior surface of the lungs
 The patient's head
should be slightly
lowered, arms crossed
on the chest.

16. Steps for auscultation of the posterior surface
of the lungs

17. Note !
 During auscultation of the lungs, respiratory
sounds during inhalation and exhalation are
compared, their character, duration, sonority
(strength) at the symmetrical points of the
chest are assessed (comparative auscultation
of the lungs).

18. Classification of respiratory sounds
 The main respiratory sounds -
1) normal - vesicular and laryngotracheal
breathing;
2) with pathology – harsh (hard) vesicular,
bronchial and amphoric breathing.
 Pathological respiratory sounds -
wheezing, crepitus and pleural friction
noise - are heard only with pathology.

19. The main respiratory sounds
1 - vesicular breathing; 2 - harsh vesicular breathing;
3 - bronchovascular; 4 - bronchial; 5 – amphoric breathing

20. Note !
 To assess the main respiratory sounds,
auscultation is performed with calm breathing of the
patient through the nose.
 To identify pathological respiratory sounds, special
techniques are used to clarify the nature of the
sounds: the doctor asks the patient to breathe
deeply in their mouths, listen for breathing against
the background of forced inhalation and exhalation,
after coughing, lying on their sides or backs,
pressing the phonendoscope more tightly, imitate
inhalation, etc.

21. The main respiratory sounds.
Vesicular breathing

22. Note !
 Vesicular respiration occurs as a result of the
oscillation of the elastic elements of the alveolar
walls at the time of filling the alveoli with air in the
inspiration phase.
 In a healthy person, vesicular breathing is heard
almost over the entire surface of the lungs.
 Above the right apex, bronchovascular breathing
can be heard due to a more superficial and
horizontal arrangement of the right apical
bronchus.

23. Changes in vesicular breathing
 Physiological weakening - with a thickening of the
chest in athletes, with obesity, etc .;
 Physiological enhancement - in children, persons
of asthenic physique, in conditions of
hyperventilation (during physical activity);
 Pathological weakening - with emphysema,
pneumonia, hydrothorax, etc.
 Pathological enhancement - with hyperthermia,
thyrotoxicosis.

24. Causes of pathological weakening of the
Vesicular breathing (1)
A – norm; B - emphysema; C - pulmonary edema

25. Causes of pathological weakening of the
Vesicular breathing (2)
a - hydrothorax; b - pneumothorax

26. Causes of pathological weakening of the
Vesicular breathing (3)
1 - fibrothorax; 2 - obstructive atelectasis

27. Causes of pathological weakening of the
Vesicular breathing (4)
Pulmonary emphysema

28. Harsh vesicular breathing
 Vesicular breathing, in which the phases of
inspiration and expiration are intensified, is called
harsh vesicular breathing.
 Harsh vesicular breathing occurs due to
narrowing of the lumen of the small bronchi
(inflammatory edema or bronchospasm).
 Harsh vesicular breathing is more common with
bronchitis.

29. The mechanism of formation of harsh
vesicular breathing

30. Saccade breathing
 This is vesicular breathing, the inhalation phase
of which consists of separate short intermittent
breaths with insignificant pauses between them
(exhalation does not change).
 Saccade breathing is observed with an uneven
contraction of the respiratory muscles - in a cold
room, with pathology of the respiratory muscles,
nervous tremors and with tuberculous
bronchiolitis, etc.

31. The mechanism of formation
of saccade breathing

32. Изменения везикулярного дыхания

33. The main respiratory sounds.
Laryngotracheal breathing
 Laryngotracheal respiration is formed by a
turbulent flow of air in the larynx and upper part of
the trachea during inhalation and exhalation and
the associated oscillations of adjacent dense
tissues.
 The duration of the coarse and loud breathing
sound of laryngotracheal breathing on exhalation
is somewhat longer than on inspiration.
 Normally, laryngotracheal respiration is heard only
over the area of the projection of the trachea and
thyroid cartilage.

34. The mechanism of formation of the
Laryngotracheal breathing

35. Laryngotracheal respiration sites
in a healthy person

36. The main condition for the formation
of bronchial breathing
 1) compaction of the lung tissue as a result
of filling the lung alveoli with inflammatory
exudate (croupous pneumonia,
tuberculosis, etc.), blood (pulmonary
infarction);
 2) compaction of lung tissue with
compression atelectasis - as a result of
compression of the lung with hydrothorax
or pneumothorax.

37. Causes of pathological bronchial breathing (1)
A - cavity in the lung, communicating with the
bronchus.

38. Causes of pathological bronchial breathing (2)
 b - lobar inflammatory compaction of the lungs,
 c - compression atelectasis of the lungs

39. The mechanism of formation of the
Bronchovascular breathing
Bronchovascular
breathing
- formed in the
presence of focal
inflammatory
compaction of the
lung (for example,
with focal
pneumonia).

40. Pathological respiratory sounds
 Note!
Pathological breathing sounds
are heard during deep breathing
with a half-open mouth or using
special techniques.

41. Pathological respiratory sounds.
Wheezing. Classification
1. Dry wheezing:
- low, or bass, or buzzing;
- high, or treble, or wheezing
2. Wet wheezing:
a) depending on the size of the bronchi:
- small;
- medium;
- large.
b) soundness:
- sonorous, or consonant;
- not sonorous, or non-consonant.

42. The mechanism of formation of the
Dry bass wheezing
a - edema and viscous
sputum in large
bronchi;
b - vibration of the
threads of viscous
sputum during the
passage of air flow
Note!
Dry bass wheezing are
inconsistent.

43. The mechanism of formation of the
Dry high wheezing
a - edema of the mucous
membrane;
b - viscous sputum;
c - bronchospasm
Note!
The appearance or
intensification of dry high
wheezing during forced
expiration is a sign of
latent bronchial
obstruction of the small
airways.

44. The mechanism of formation of the
Wet wheezing
 Wet wheezing occur in the presence of parietal
fluid secretion in the trachea, bronchi or cavities
connected to the bronchi. The flow of air during
inhalation (to a lesser extent) and exhalation
foams the liquid secret, forming a crack.

45. Classification of wet wheezing depending on
the size of the bronchi
 The nature of
wet wheezing
depends on
the diameter
of those
sections of
the airways
in which
there is a wet
secret.

46. Causes of sonorous wet wheezing
a - cavity in the lung, communicating with the bronchus;
b - compaction of lung tissue

47. Wet wheezing. Clinical situations
 Pneumonia
 Chronic bronchitis
 Bronchiectasis
 Heart failure in the pulmonary circulation

48. Pathological respiratory sounds.
Crepitus
 Crepitus occurs in
the alveoli in the
presence of a near-
wall fluid secretion
and alveolar
collapse; in this
case, the alveoli
disintegrate only at
the height of a deep
breath.

49. Pathological respiratory sounds.
Pleural friction noise
 The pleural friction noise occurs when the
rough surfaces of inflammatory pleural sheets
are rubbed against each other during
breathing and resembles a crunch of snow,
creak of skin, and rustling of paper.
Usually, the pleural friction noise indicates the
presence of acute inflammation of the pleural
sheets in the absence of exudate in the pleural
cavity.

50. The mechanism of formation of the
Pleural friction noise

51. Отличия побочных дыхательных шумов
Отличия
Сухие
хрипы
Влажные
хрипы
Крепитация
Шум
трения
плевры
Отношение к
фазам дыхания
На вдохе и
выдохе
На вдохе и
выдохе
На высоте
вдоха
На вдохе и
выдохе
После кашля изменяются изменяются
Не
изменяется
Не
изменяется
Акустическая
характеристика
Чаще
разнообразные
звуки
Чаще
разнообраз-
ные звуки
Однообраз-
ные звуки
Разнообраз-
ные звуки
При
надавливании
стетоскопом
Не
усиливаются
Не
усиливаются
Не
усиливается
Усиливается
Имитация
дыхательных
движений
Не выслуши-
ваются
Не выслуши-
ваются
Не выслуши-
ваются
Выслушивает
ся

52. Bronchophony
 Bronchophonia is an auscultatory method for
assessing the conduct of voice from the larynx
along the air column of the bronchi to the surface
of the chest.
 The method of bronchophony is similar to the
method of determining vocal fremitus, but is
more sensitive in detecting pathology in
weakened individuals with a low and high voice.
 Normally, bronchophony over symmetrical
sections of the lungs is heard the same way.
 An increase in bronchophony indicates the
presence of compaction of the lung tissue or
cavity in the lung, resonating and amplifying
sounds.

53. Bronchophony method
 In a whisper, the patient pronounces words
containing hissing sounds (for example,
“ninety-nine”). In this case, the doctor puts a
phonendoscope on symmetrical sections of the
chest and compares the sounds heard.

54. Thanks for attention!