Title: Auscultation of the lungs. Semiotics of the respiratory system diseases. The respiratory distress syndromes of and respiratory failure, general clinical symptoms
1Auscultation of the lungs. Semiotics of the
respiratory system diseases. The respiratory
distress syndromes of and respiratory failure,
general clinical symptoms
2Respiratory System
- Primary function is to obtain oxygen for use by
body's cells eliminate carbon dioxide that
cells produce - Includes respiratory airways leading into ( out
of) lungs plus the lungs themselves - Pathway of air nasal cavities (or oral cavity) gt
pharynx gt trachea gt primary bronchi (right
left) gt secondary bronchi gt tertiary bronchi gt
bronchioles gt alveoli (site of gas exchange)
helpusobi 1
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6- The excha nge of gases (O2 CO2) between the
alveoli the blood occurs by simple diffusion
O2 diffusing from the alveoli into the blood
CO2 from the blood into the alveoli. Diffusion
requires a concentration gradient. So, the
concentration (or pressure) of O2 in the alveoli
must be kept at a higher level than in the blood
the concentration (or pressure) of CO2 in the
alveoli must be kept at a lower lever than in the
blood. We do this, of course, by breathing -
continuously bringing fresh air (with lots of O2
little CO2) into the lungs the alveoli. - Breathing is an active process - requiring the
contraction of skeletal muscles. The primary
muscles of respiration include the external
intercostal muscles (located between the ribs)
and the diaphragm (a sheet of muscle located
between the thoracic abdominal cavities).
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8The external intercostals plus the diaphragm
contract to bring about inspiration
- Contraction of external intercostal muscles gt
elevation of ribs sternum gt increased front-
to-back dimension of thoracic cavity gt lowers air
pressure in lungs gt air moves into lungs
- Contrcnion of diaphragm
- diaphragm moves downward gt increases vertical
dimension of thoracic cavity gt lowers air
pressure in lungs gt air moves into lungs
9The mecanizm of breathing
10The mecanizm of breathing
11- The considerable differences in respiratory
physiology between infants and adults explain why
infants and young children have a higher
susceptibility to more severe manifestations of
respiratory diseases, and why respiratory failure
is common problem in neonatal and pediatric
intensive care units. The appreciation of the
peculiarities of pediatric respiratory physiology
is not only essential for correct assessment of
any ill child, but also for correct
interpretation of any pulmonary function test
performed in this population.
12Physiologicoanatomical peculiarities of the
respiratory system
The peculiarities of the nose at the neonate a)
The nose consists particular by of cartilage, b)
The nasal meatuses are narrow, c) There are not
inferior nasal meatuses (until 4 years), d)
Undeveloped submucosal membrane (until 8-9
years).
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14The peculiarities of sinuses in children
a) The maxillary sinus is usually present at
birth, b) The frontal sinuses begin to develop in
early infancy, c) The ethmoid and sphenoid
sinuses develop later in childhood.
15The peculiarities of the pharynx at the neonate
a) The pharynx is relatively small and
narrow, b) The auditory tubes are small, wide,
straight and horizontal
16The peculiarities of the larynx at the neonate
- a) The larynx is funnel-shaped (in the adult it
is relatively round), - b) It is relatively long,
- c) The cricoids cartilage descendents
17The peculiarities of the trachea at the neonate
- a) The length of the trachea is relatively larger
(about 4 cm (in the adult -7)) and wide, - b) It is composed of 15-17 cartilage rings (the
amount does not increase), - c) The bifurcation of the trachea lies opposite
the third thoracic vertebra in infant and
descends to a position opposite the fourth
vertebra in the adult, - d) Mucus membrane is soft, well-blood supplied,
but sometime dry, - f) It can collapse easily.
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24The peculiarities of the bronchi at the neonate
- a) In young children the bronchi are relatively
wide, - b) The right bronchus is a straight continuation
of the trachea, - c) The muscle and elastic fibers are undeveloped,
- d) The bronchi are well blood supplied,
- e) The lobules and segmental bronchus are narrow.
25The functions of the bronchus
- a) The ciliated of mucus membrane sweeps out
dust particles, - b) Transfer the gases into the lungs,
- c) Immunologic function
26The functions of the lung are
- a) The main function of the lungs is the exchange
of oxygen and carbon dioxide, - b) To produce surfactant
27The peculiarities of the lungs at the neonate
- a) Size of alveoli is smaller than in the adult
- b) Quantity of alveoli is relatively less than in
the adult.
28Physiological reasons for theincreased
susceptibility of infants forrespiratory
compromise in comparisonto adults
- Metabolism --------------------------------------
- - Risk of apnoea ----------------------------------
- Airway resistance
- Upper airway resistance -----------------
- Lower airway resistance -----------------
- Lung volume v-------------------------------------
- Efficiency of respiratory muscles v-----------
- Endurance of respiratory muscles v---------
- O2 consumption
- Immaturity of control of breathing
- Nose breathing Large tongue Airway size
vCollapsibility Pharyngeal muscle tone v - Compliance of upper airway structures
- Airway size v Collapsibility Airway wall
compliance Elastic recoil v - Numbers of alveoli v Lack of collateral
ventilation - Efficiency of diaphragm v Rib cage compliance
Horizontal insertion at the rib cage Efficiency
of intercostal muscles v Horizontal ribs - Respiratory rate Fatigue-resistant type I
muscle fibres v
29An average respiratory rate at rest of the child
of different age is
- newborn 40-35 per minute,
- infant at 6 months 35-30 per minute,
- at 1 year 30 per minute,
- 5 years 25 per minute,
- 10 years 20 per minute,
- 12-18 years 16-20 per minute.
30Disorders of the respiratory rate
- Tachypnea is the increase of the respiratory
rate. - Bradypnea is the decrease of the respiratory
rate. - Dyspnea is the distress during breathing.
- Apnea is the cessation of breathing
31Factors involved in increasing respiratory rate
- Chemoreceptors - located in aorta carotid
arteries (peripheral chemoreceptors) in the
medulla (central chemoreceptors) - Chemoreceptors (stimulated more by increased CO2
levels than by decreased O2 levels) gt stimulate
Rhythmicity Area gt Result increased rate of
respiration - Heavy exercise gt greatly increases respiratory
rate - Mechanism?
- NOT increased CO2
- Possible factors
- reflexes originating from body movements
(proprioceptors) - increase in body temperature
- epinephrine release (during exercise)
- impulses from the cerebral cortex (may
simultaneously stimulate rhythmicity area motor
neurons)
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33Form of thoraxNormostenic type
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35Disorders of the respiratory depth
- Hyperpnea is an increased depth.
- Hypoventilation is a decreased depth and
irregular rhythm. - Hyperventilation is an increased rate and depth.
36Pathological respiration
- Seesaw (paradoxic) respirations the chest falls
on inspiration and rises on expiration. It is
usually observed in respiratory failure of third
degree - Kussmausl breathing is hyperventilation,
gasping and labored respiration, usually seen in
diabetic coma or other states of respiratory
acidosis
37Decreased vocal fremitus in the upper airway may
indicate
- a) the obstruction of a major bronchus,
- b) pneumo-, hydro-, haemothorax,
- c) emphysema of lungs,
- d) adiposity can also be the cause of decreased
vocal fremitus.
38The voice of fremitus is increased
- a) in pneumonia,
- b) in abscess,
- b) in atelectasis,
- c) in cavern.
39The pathological dullness is heard in cause of
- pneumonia,
- hydro-, haemothorax,
- pulmonary edema,
- lung or mediastinal tumor
40The bandbox is heard in cause of
- emphysema of lungs,
- cavern of lung,
- abscess of lung,
- pneumothorax,
- bronchial asthma,
- asthmatic bronchitis.
- In topographic percussion the chest, the doctor
looks for the lungs borders.
41Auscultation
- Vesicular breath sounds are normally heard over
the entire surface of the lungs, with the
exception of the upper intrascapular area and the
area beneath the manubrium. Inspiration is
louder, longer, and higher-pitched than
expiration. Sometimes the expiratory phase seems
nearly absent in comparison to the long
inspiratory phase. The sound is a soft, swishing
noise.
42Bronchovesicular breath sounds
- Bronchovesicular breath sounds are normally
heard over the manubrium and in the upper
intrascapular regions where there are
bifurcations of large airways, such as the
trachea and bronchi. Inspiration is louder and
higher in pitch than that heard in vesicular
breathing
43Puerile breath sounds
- Puerile breath sounds are one of normal types
of breathing in children by three years old.
Puerile breath sounds have shot inspiration and
louder, a hollow expiratory phase, blowing
character
44Bronchial breath sounds
- They are almost the reverse of vesicular
sounds the inspiratory phase is short and the
expiratory phase is longer, louder, and of higher
pitch. They are usually louder than any of the
normal breath sounds and have a hollow, blowing
character.
45Rough breath sounds
- Have shot inspiration and louder expiratory
phase. Rough breath has hollow and blowing
character.
46Absent or diminished breath sounds
- are always an abnormal finding warranting
investigation. Fluid, air, or solid masses in the
pleural space all interfere with the conduction
of breath sounds (pneumonia, pneumo-, hydro-,
haemothorax, tumor of lung or mediastinal,
emphysema of lungs, atelectasis, airways
obstruction, a foreing body in the bronchus).
47Voice sounds
- Voice sounds are also part of auscultation of
the lungs. Normally voice sounds or vocal
resonance is heard, but the syllables are
indistinct. They are elicited in the same manner
as vocal fremitus, except that the doctor listens
with the stethoscope
48Whispered pectoriloquy,
- Whispered pectoriloquy, in which the child
whispers words and the nurse, hears the syllables
49Bronchophony,
- Bronchophony, in which the child speaks
words that are not distinguishable but the vocal
resonance is increased in intensity and clarity
50Egophony
- Egophony, in which the child says "ee," which
is heard as the nasal sound "ay" through the
stethoscope
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56Method of percussion
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66Rales
- Rales result from the passage of air through
fluid or moisture. They are more pronounced when
the child takes a deep breath. Even though the
sound may seem continuous, it is actually
composed of several discrete sounds, each
originating from the rupture of a small bubble.
The type of rales is determined by the size of
the passageway and the type of exudate the air
passes through. They are roughly divided into
three categories fine, medium, and coarse
67Fine rales
- Fine rales (sometimes called crepitant rales)
can be simulated by rubbing a few strands of hair
between the thumb and index finger close to the
ear or by slowly separating the thumb and index
finger after they have been moistened with
saliva. The result is a series of fine crackling
sounds. Fine rales are most prominent at the end
of inspiration and are not cleared by coughing.
They occur in the smallest passageways, the
alveoli and bronchioles
68Medium rales
- Medium rales are not as delicate as fine rales
and can be simulated by listening to the "fizz"
from recently opened carbonated drinks or by
rolling a dry cigar between the fingers. They are
prominent earlier during inspiration and occur in
the larger passages of the bronchioles and small
bronchi.
69Coarse rales
- Coarse rales are relatively loud, coarse,
bubbling, gurgling sounds that occur in the large
airways of the trachea, bronchi, and smaller
bronchi. Often they clear partially during
coughing. They are frequently heard in dying
patients because the cough reflex is depressed,
allowing thick secretions to accumulate in the
trachea and major bronchi. Because they are so
common when death is imminent, coarse rales are
often called "the death rattle."
70Rhonchi
- Rhonchi are sounds produced as air passes
through narrowed passageways, regardless of the
cause, such as exudate, inflammation, spasm, or
tumor. Rhonchi are continuous, since sound is
produced as long as air is being forced past an
obstruction. Although they are often more
prominent during expiration, they are usually
present during both phases of respiration.
Rhonchi are classified according to pitch as
sibilant or sonorous
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73Sibilant rhonchi
- Sibilant rhonchi are high pitched, musical,
wheezing, or squeaking in character. The wheezing
quality is often more pronounced on forced
expiration. Sibilant rhonchi are produced in the
smaller bronchi and bronchioles
74Sonorous rhonchi
- Sonorous rhonchi are low pitched and often
snoring or moaning in character. They are
produced in the large passages of the trachea and
bronchi. Like coarse rales, they can be partly
cleared by coughing
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79Respiratory system disorder syndromes
- Syndrome of consolidation or compression of the
lung tissue. - Syndrome of bronhoobstruction.
- Syndrome of respiratory failure.
- Syndrome of respiratory distress.
- Syndrome of atelectasis.
- Syndrome of pneumothorax.
- Syndrome of liquid in the plural cavity.
- Syndrome of laryngotracheitis.
- Syndrome of bronchitis.
- Syndrome of congenital stridor.
- Syndrome of cough.
80Croup Syndromes
- 1 Acute laryngotracheitis.
- Laryngotracheobronchitis.
- 2.Spasmodic croup (more abrupt onset, milder
course). - Etiology. Viral coup syndrome is caused by a
viral infection in the subglottic area of the
larynx transmitted. Most cases involve children
age 3 months to 3 years. Peak incidence of the
disease is in late autumn, early winter. - Clinical Findings
- Often occurring at nigh.
- Croupy (barky) cough.
- Inspiratory dyspnea.
- Hoarseness
- Coryza (catarrh).
- Fever.
- Intercostal, suprasternal, infrasternal
retractions. - Respiratory rate slightly increased
81Croup Syndromes
82Croup Syndromes
83Croup Syndromes
84Croup Syndromes
85Acute Epiglottitis
- Epiglottitis is an infection of the epiglottis
and supraglottic structures.The child may also
show intercostal retractions and perioral
cyanosis and sounds stridorous
86Acute Epiglottitis
- Do not attempt direct visualization of the
epiglottis by depressing the tongue as this may
cause reflex laryngospasm and obstruction, which
may lead to respiratory arrest
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88Foreign body aspiration
- Foreign body aspiration is occurred of aspiration
of small objects (seeds, nuts, toy parts,
buttons, pebbles) into laryngotracheal are or
main stem bronchus. Aspiration is frequent in
children between 7 months and 4 years. - Clinical Findings
- Signs and symptoms depend on degree of
obstruction and nature of the foreign body. - The parents describe in history of disease that
child was swallowing or playing with a small
object followed by sudden onset of cough, choking
or gagging or wheezing. - There may be a period of no symptoms following
initial episode. - Foreign body aspiration clinic depends on the
level of obstruction. Laryngeal foreign bodies
may completely obstruct airways and may elicit
stridor, high pitched wheezing, cough or aphonia
and cyanosis. - Tracheal foreign bodies usually elicit cough,
some stridor or wheezing and may produce "slap"
sound - Bronchial foreign bodies usually cause wheezing
or coughing and are frequently misdiagnosed as
asthma may present with decreased vocal
fremitis, impaired or hyperresonant percussion
note, and diminishes breath sounds distal to
foreign body.
89Diagnostic tests
- Upper airway foreign bodies may be visualized on
standard roentgenography. - Bronchoscopy is usually required for definitive
diagnosis of foreign bodies in the larynx and
trachea. - Treatment
- Establish airway if child is in obvious distress.
- Back blows, Heimlich maneuver.
- Removed by means of direct laryngoscopy or
bronchoscopy. - Prevention is most important aspect age
appropriate anticipatory guidance, including
siblings.
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91Thank you for attention