Sympoms in respiratory organs diseases based on the results of auscultation of lungs.

1
Sympoms in respiratory organs diseases based on
the results of auscultation of lungs.
2
Pulmonary auscultation has been a principal
feature of standard physical examinations for
many years and is a very useful initial
noninvasive test for lung diseases.
3
(No Transcript)
4
direct auscultation 
5
(No Transcript)
6
(No Transcript)
7
(No Transcript)
8
Before you begin, there are certain things that
you should keep in mind

• a) It is important that you try to create a quiet
  environment as much as possible.
• b) The patient should be in the proper position
  for auscultation.
• c) Your stethoscope should be touching the
  patients bare skin whenever possible or you may
• hear rubbing of the patients clothes
• against the stethoscope and
• misinterpret them as abnormal sounds.

9
d) Always ensure patient comfort. Be
considerate and warm the diaphragm of your
stethoscope with your hand before auscultation.
10
Remember - Don't examine thru clothing or "snake"
stethoscope down shirts/gowns
11
Good exam options
12
As you are auscultating your patient, please
keep in mind these 2 questions

• Are the breath sounds increased, normal or
  decreased?
• 2) Are there any abnormal
• or adventitious
• breath sounds?

13
Points and lobes of auscultation. Anterior view
14
(No Transcript)
15
Posterior view
16
(No Transcript)
17
categories of breath sounds

•  Normal
• Tracheal
• Vesicular
• Bronchial
• bronchovesicular

• Adventitious
• crackles (rales)
• wheeze
• Rhonchi
• Stridor
• pleural rub
• mediastinal crunch (Hamman's sign)

• Abnormal
• absent/decreased
• bronchial

18
Vesicular Breath Sound

• The vesicular breath sound is the major normal
  breath sound and is heard over most of the lungs.
  They sound soft and low-pitched. The inspiratory
  sounds are longer than the expiratory sounds.
  Vesicular breath sounds may be harsher and
  slightly longer if there is rapid deep
  ventilation (eg post-exercise) or in children who
  have thinner chest walls. As well, vesicular
  breath sounds may be softer if the patient is
  frail, elderly, obese, or very muscular.

19
The vesicular breath sound is the major normal
breath sound and is heard over most of the lungs.
The inspiratory sounds are longer than the
expiratory sounds.

• 
  
  

Expiration
Inspiration
heard only during the first third of the
expiration phase
20
Vesicular breathing
may be louder
or softer for both physiological
and pathological reasons.
1.Vesicular breath sounds
may be harsher and slightly
longer if there is rapid deep
ventilation or in children (
puerile respiration ).2.Vesicular breath sounds
may be softer if the patient is frail, elderly,
obese, or very muscular.!Physiological changes
in vesicular respiration always involve both
parts of the chest, and respiratory sounds are
equally intensified at the symmetrical points of
the chest.
21
Alterations in vesicular respiration in
pathology depend on ? the amount of intact
alveoli ? the properties of their walls ?
the amount of air contained in them ? the
length and strength of the expiration and
inspiration phases ? the conditions of sound
conduction from the vibrating elastic elements of
the pulmonary tissue to the surface of the chest.
22
Pathologically decreased vesicular respiration
can be due to a significantly diminished
number of the alveoli due to inflammation
and swelling of the alveoli walls in a part of
the lung decreased also in insufficient
delivery of air to the alveoli through the air
ways due to obstructed conduction of sound
waves from the source of vibration (alveolar
walls) to the chest surface.
23
1. Abnormally increased vesicular breathing
depends on obstruction to the air passage
through small bronchi or their contracted lumen
(increased expiration). 2. Harsh vesicular
breathing occurs in marked and nonuniform
narrowing of the lumen in small bronchi and
bronchioles due to inflammatory oedema of their
mucosa (the inspiration and expiration phases are
intensified).
24
3. Interrupted or cogwheel vesicular
respiration is characterized by short jerky
inspiration efforts interrupted by short pauses
between them the expiration is usually normal
(occurs in non-uniform contraction of the
respiratory muscles, when a patient is
auscultated in a cold room, or when he has
nervous trembling, or diseases of the respiratory
muscles, Interrupted breathing over a limited
part of the lung indicates pathology in fine
bronchi (their tuberculous infiltration)
25
Bronchial Breath Sound Respiratory sounds known
as bronchial or tubular breathing arise in the
larynx and the trachea as air passes through the
vocal slit. As air is inhaled, it passes through
the vocal slit to enter wider trachea where it
is set in vortex-type motion. Sound waves thus
generated propagate along the air column
throughout the entire bronchial tree. Sounds
generated by the vibration of these waves are
harsh. During expiration, air also passes through
the vocal slit to enter a wider spase of the
larynx where it is set in a vortex motion. But
since the vocal slit is narrower during
expiration, the respiratory sound becomes
longer, harsher and longer. This type of
breathing is called laryngotracheal
26
Respiratory sounds known as bronchial or tubular
breathing arise in the larynx and the trachea as
air passes through the vocal slit.

?xpiration
Inspiration
27
(No Transcript)
28
Bronchial breathing can be heard instead of
vesicular (or in addition to the vesicular
breathing) over the chest in pulmonary pathology.
This breathing is called pathological bronchial
respiration.
29
If these sounds are heard anywhere other than
over the manubrium, it is usually an indication
that an area of consolidation exists (i.e. space
that usually contains air now contains fluid or
solid lung tissue).
Bronchial breath sounds.
30
Amphoric respiration arises in the presence of a
smooth-wall cavity( non less than 5-6 cm in
diameter) communicated with a large bronchus
Metallic respiration differs from both
bronchial and amphoric. It is loud and high, and
resembles the sound produced when a piece of
metal is struck. Metallic respiration is heard in
open pneumothorax when the air of if pleural
cavity communicates with the external air.
Stenotic respiration is heard in cases with
narrowed trachea or a large bronchus (due to a
tumor) Bronchovesicular or mixed respiration
is heard in lobular pneumonia or infiltrative
tuberculosis, and also in pneumosclerosis, with
foci of consolidated tissue being seated deeply
in the pulmonary tissue and far from one another.
31
Bronchovesicular Breath Sound

• These are breath sounds of intermediate intensity
  and pitch. The inspiratory and expiratory sounds
  are equal in length. They are best heard in the
  1st and 2nd ICS (anterior chest) and between the
  scapulae (posterior chest) - ie over the mainstem
  bronchi. As with bronchial sounds, when these are
  heard anywhere other than over the mainstem
  bronchi, they usually indicate an area of
  consolidation.

32
Tracheal Breath Sound

• Tracheal breath sounds are very loud and
  relatively high-pitched. The inspiratory and
  expiratory sounds are more or less equal in
  length. They can be heard over the trachea which
  is not routinely auscultated.

33
Normal Breath Sounds

Feature Tracheal Bronchial Broncho vesicular Vesicular
Location Trachea Manubri um Mainstem bronchi Peripheral lung
Quality Loud, harsh, hollow Loud, less harsh, hollow Soft Softer
Pitch Highest Higher High Low
Duration /"\ -""\ \ /"
34
Adventitious sounds are rales, crepitation, and
pleural friction.
35
Rales arise in pathology of the trachea, bronchi,
or if a cavern is formed in the affected lung.
Rales are classified as dry (rhonchi) and moist
rales.
36
Dry rales can be due to (1) spasms of smooth
muscles of the bronchi during fits of bronchial
asthma (2) swelling of the bronchial mucosa
during its inflammation (3) accumulation of
viscous sputum in the bronchi which adheres to
the wall of the bronchus and narrows its lumen
(4) formation of fibrous tissue in the walls of
separate bronchi and in the pulmonary tissue with
subsequent alteration of their architectonics
(bronchiectasis, pneumosclerosis) (5) vibration
of viscous sputum in the lumen of large and
medium size bronchi during inspiration and
expiration being viscous, the sputum can be
drawn (by the air stream) into threads which
adhere to the opposite walls of the bronchi and
vibrate like strings.
37
Dry rales are heard during inspiration and
expiration and vary greatly in their loudness,
tone and pitch. According to the quality and
pitch of the sounds produced, dry rales are
divided into sibilant (high-pitched and
whistling sounds are produced when the lumen of
the small bronchi is narrowed) sonorous rales
(low-pitched and sonoring rales are generated
in stenosis of medium calibre and large calibre
bronchi or when viscous sputum is accumulated in
their lumen).
38
Moist rales are generated because of accumulation
of liquid secretion (sputum, oedematous fluid,
blood) in the bronchi through which air passes.
Air bubbles pass through the liquid secretion of
the bronchial lumen and collapse to produce the
specific cracking sound. Moist rales are heard
during both the inspiration and expiration, but
since the air velocity is higher during
inspiration, moist rales will be better heard at
this respiratory phase.
39
Depending on the calibre of bronchi where rales
are generated, moist rales are classified as
fine, medium and coarse bubbling rales. Fine
bubbling rales are generated in fine bronchi and
are percepted by the ear as short multiple
sounds Medium bubbling rales are produced in
bronchi of a medium size Coarse bubbling
rales in large calibre bronchi, in large
bronchiectases, and in pulmonary cavities
(abscess, cavern) containing liquid secretions
and communicating with the large bronchus.
40
Depending on the character of the pathology in
the lungs, moist rales are subdivided into
consonating or crackling, non-consonating or
bubbling rales. Consonating moist rales are
heard in the presence of liquid secretions in the
bronchi surrounded by airless (consolidated)
pulmonary tissue or in lung cavities with smooth
walls surrounded by consolidated pulmonary
tissue. The cavity itself acts as a resonator to
intensify moist rales.
41
Non-consonating rales are heard in inflammation
of bronchial mucosa (bronchitis) or acute oedema
of the lung due to the failure of the left
chambers of the heart. The sounds produced by
collapsing air bubbles in the bronchi are
dampened by the "air cushion" of the lungs as
they are conducted to the chest surface.
42
Crepitation originates in the alveoli.
Crepitation is a slight crackling sound that can
be imitated by rubbing a lock of hair. The main
condition for generation of crepitation is
accumulation of a small amount of liquid
secretion in the alveoli. During expiration, the
alveoli stick together, while during inspiration
the alveolar walls are separated with difficulty
and only at the end of the inspiratoryn movement.
Crepitation is therefore only heard during the
heighi of inspiration. In other words,
crepitation is the sound produced by many
alveoli during their simultaneous reinflation.
43
(No Transcript)
44
Pleural friction sound.Pleural friction sound
are heard during both inspiration and
expiration.The sounds are differentiated by
intensity, or loudness, length, and site over
which they are heard.
45
Pleural friction sounds can be differentiated
from fine bubbling rales and crepitation by the
following signs (1) the character of rales is
altered or rales can disappear for a short time
after coughing, while pleural frictionsounds does
not change in these conditions (2) when a
stethoscope is pressed tighter against the chest,
the pleural friction sound is intensified, while
rales do not change (3) crepitation is only
heard at the height of inspiration, while pleural
friction sound is heard during both inspiration
and expiration (4) if a patient moves his
diaphragm in and out while his mouth and nose are
closed, the sound produced by the friction of the
pleura due to the movement of the diaphragm can
be heard, while rales and crepitation cannot
because there is no air movement in the bronchi.
46
Common errors of auscultation_Auscultating one
entire lung, and then moving to the other
lung__Auscultating over a patients gown or
article of clothing __Beginning auscultation
inferiorly at the lower lung fields __Moving
your stethoscope before each exhalation is
complete __Examiner does not make the room quiet
enough to hear breath sounds.
47
????? ?? ?????