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Auscultation of the lungs. Semiotics of the respiratory system diseases. The respiratory distress syndromes of and respiratory failure, general clinical symptoms

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Physiologicoanatomical peculiarities of the respiratory system The peculiarities of sinuses in children The peculiarities of the pharynx at the ... Heimlich maneuver. – PowerPoint PPT presentation

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Title: Auscultation of the lungs. Semiotics of the respiratory system diseases. The respiratory distress syndromes of and respiratory failure, general clinical symptoms


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Auscultation of the lungs. Semiotics of the
respiratory system diseases. The respiratory
distress syndromes of and respiratory failure,
general clinical symptoms
2
Respiratory 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)

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  • 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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The 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

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The mecanizm of breathing
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The mecanizm of breathing
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  • 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.

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Physiologicoanatomical 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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The 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.
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The 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
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The 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

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The 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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The 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.

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The functions of the bronchus
  • a) The ciliated of mucus membrane sweeps out
    dust particles,
  • b) Transfer the gases into the lungs,
  • c) Immunologic function

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The functions of the lung are
  • a) The main function of the lungs is the exchange
    of oxygen and carbon dioxide,
  • b) To produce surfactant

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The 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.

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Physiological 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

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An 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.

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Disorders 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

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Factors 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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Form of thoraxNormostenic type
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Disorders of the respiratory depth
  • Hyperpnea is an increased depth.
  • Hypoventilation is a decreased depth and
    irregular rhythm.
  • Hyperventilation is an increased rate and depth.

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Pathological 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

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Decreased 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.

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The voice of fremitus is increased
  • a) in pneumonia,
  • b) in abscess,
  • b) in atelectasis,
  • c) in cavern.

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The pathological dullness is heard in cause of
  • pneumonia,
  • hydro-, haemothorax,
  • pulmonary edema,
  • lung or mediastinal tumor

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The 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.

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Auscultation
  • 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.

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Bronchovesicular 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

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Puerile 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

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Bronchial 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.

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Rough breath sounds
  • Have shot inspiration and louder expiratory
    phase. Rough breath has hollow and blowing
    character.

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Absent 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).

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Voice 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

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Whispered pectoriloquy,
  • Whispered pectoriloquy, in which the child
    whispers words and the nurse, hears the syllables

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Bronchophony,
  • Bronchophony, in which the child speaks
    words that are not distinguishable but the vocal
    resonance is increased in intensity and clarity

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Egophony
  • Egophony, in which the child says "ee," which
    is heard as the nasal sound "ay" through the
    stethoscope

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Method of percussion
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Rales
  • 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

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Fine 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

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Medium 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.

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Coarse 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."

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Rhonchi
  • 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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Sibilant 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

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Sonorous 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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Respiratory 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.

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Croup 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

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Croup Syndromes
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Croup Syndromes
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Croup Syndromes
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Croup Syndromes
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Acute Epiglottitis
  • Epiglottitis is an infection of the epiglottis
    and supraglottic structures.The child may also
    show intercostal retractions and perioral
    cyanosis and sounds stridorous

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Acute 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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Foreign 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.

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Diagnostic 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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Thank you for attention
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