1. Palpation is carried out with the palms of both hands, which are placed on strictly
symmetrical areas of the chest in the supraclavicular areas.
2. The patient is asked to pronounce the word “thirty-three”, “tractor”.
3. Then the hands are placed in the subclavian areas and the patient also says the word
suprascapular, interscapular.
Step eight: Auscultation (auscultatio) - listening to sound phenomena that arise during the mechanical work of internal organs.
Auscultation of the lungs is carried out in a certain sequence with deep breathing: along the anterior surface of the chest in the supraclavicular areas, then in the subclavian and below; in the upper parts of the axillary region, gradually moving the stethoscope downwards; posteriorly above the spines of the scapulae, in the interscapular areas and above the lower parts of the lungs.
The sound phenomena heard during this process, arising in connection with the act of breathing, are called respiratory sounds (murmura respiratoria). There are 2 main 0 and 2 additional 0 or secondary respiratory sounds.
The main respiratory sounds are vesicular, bronchial and hard breathing. Additional symptoms include wheezing, crepitus, and pleural friction noise.
Vesicular respiration. Weakened vesicular breathing indicates insufficient air supply to the auscultated area of the lungs due to local hypoventilation (presence of fluid or air in pleural cavity, pneumosclerosis, bronchial obstruction) or with general hypoventilation (pulmonary emphysema). Vesicular respiration is also weakened by the thick layer of tissue in the chest wall in obesity.
Increased vesicular breathing indicates hyperventilation, both general (physical activity) and local (compensatory hyperventilation of some parts of the lung while hypoventilation of others).
Listening to bronchial breathing over the lungs becomes possible when a solid zone of compacted air appears between the large bronchus and the place of auscultation. lung tissue or a resonating cavity: lobar pneumonia, compression of the lung to the root with hydrothorax, lung abscess communicating with the bronchus. In the latter case, breathing may resemble the sound that is produced when blowing over the neck of an empty bottle. This type of breathing is called “amphoric”.
Hard breathing. - a pathological variant of the main respiratory noise, which occurs when the lumen of the bronchi narrows and the peribronchial tissue thickens. The narrowing of the small bronchi makes it difficult for air to escape from the alveoli, increases the vibrations of the bronchial walls, and the compaction of the peribronchial tissue makes it better to conduct these vibrations to the periphery. In this case, a rougher inhalation than with vesicular breathing is heard, and the entire exhalation is equal in volume to the inhalation. Hard breathing is observed in acute bronchiolitis, chronic bronchitis.
Wheezing (rhonchi). - additional respiratory sounds that occur in the trachea and bronchi during pathology. Based on the mechanism of formation and sound perception, wheezing is divided into wet and dry.
Wet wheezing are caused by the accumulation of liquid sputum in the bronchi or in the cavities communicating with them (for example, a lung abscess). During inhalation, air passes through this liquid, forming bubbles, as if foaming it. The sounds that occur when air bubbles burst are heard on auscultation as wheezing. Moist rales are heard mainly during inhalation, less often during exhalation. The size of the air bubbles formed depends on the caliber of the bronchi or the size of the cavity, therefore moist rales are divided into small, medium and large bubbles.
Fine bubble moist rales are most often heard during bronchopneumonia, pulmonary infarction, and in the initial phase of pulmonary edema. Medium-bubble rales are detected in hypersecretory bronchitis and bronchiectasis. Large-bubble local rales are heard over relatively large cavities containing fluid and communicating with the bronchus (cavern, lung abscess).
Large-bubbling widespread wheezing appears in the late phase of development of pulmonary edema against the background of abundant medium- and fine-bubble wheezing.
Moist rales may be loud or silent. Sonorous ones are heard when the lung tissue thickens (pneumonia, cavity). Silent moist rales are formed in the presence of liquid secretion in the lumen of the bronchi without compaction of the surrounding lung tissue (bronchitis, congestion in the pulmonary circulation).
Dry wheezing are formed in the bronchi and represent drawn-out sounds with a different musical timbre. They are divided into buzzing and whistling. Buzzing wheezing owes its appearance to the sound in the air flow of thread-like bridges from sputum formed in the lumen of large and medium-sized bronchi when they are inflamed.
Wheezing arise as a result of uneven narrowing of the small bronchi, caused by their spasm and swelling of the mucous membrane. They are most typical for an attack of bronchial asthma.
Crepitus. (crepitare - creaking, crunching) - an collateral respiratory noise that is formed when the walls of the alveoli are more moistened than usual and have lost their elasticity, and is heard exclusively at the height of inspiration as a short sound “flash” or “explosion”. It resembles the sound that occurs when kneading a tuft of hair near the ear with your fingers.
Crepitation is sometimes difficult to distinguish from fine bubbling moist rales. Unlike the latter, it is heard only at the very end of inspiration, and does not change after coughing. Typically, crepitus is a sign of lobar pneumonia, accompanying the phases of the appearance and resorption of exudate, and can occasionally be heard at the very beginning of the development of pulmonary edema.
Pleural friction rub. occurs with dry pleurisy, when the surface of the pleura becomes uneven, rough due to fibrin deposits, and during respiratory excursions of the pleural layers a characteristic sound occurs, reminiscent of the creaking of a bent piece of skin or the creaking of snow. Sometimes it sounds like crepitus or fine wheezing. In this case, it should be remembered that the pleural friction noise is heard in both phases of breathing, intensifies when pressing on the chest with a stethoscope and persists when simulating respiratory movements with the nose and mouth closed.
When auscultating the lungs in areas of dull percussion sound, bronchophony is determined. - listening to whispered speech on the chest when the patient pronounces words with hissing and whistling sounds, for example, “sixty-six”, “cup of tea”. Normally, bronchophony is negative. In the case of compaction of the lung tissue, the formation of a cavity in the lung, when the conduction of sound improves, it turns out to be positive, i.e. spoken words become audible. Essentially, bronchophony is the acoustic equivalent of vocal tremors, i.e. conducting sound vibrations from the larynx along the air column of the bronchi to the surface of the chest. Therefore, positive bronchophony is detected simultaneously with a dull percussion sound, increased vocal tremors, and also with the appearance of bronchial breathing.
LABORATORY RESEARCH METHODS
Sputum examination. When examining sputum, its total amount per day and its general appearance (serous, purulent, bloody, putrefactive) are determined. Morning sputum is taken for examination. Normally, microscopy in sputum reveals leukocytes, red blood cells, squamous epithelial cells and mucus strands.
Step one: Before taking a sample, you should rinse your mouth; samples are best collected early in the morning.
Step two: Patients who are unable to produce sufficient sputum can be helped by nebulizing hypertonic saline.
Step three: Sputum samples should contain more sputum than saliva. In young children, you can try to collect sputum for examination during a cough.
Step four: If the required amount of sputum cannot be obtained by these methods, then resort to gastric lavage or aspiration of its contents. During sleep, tracheobronchial contents continue to flow into the pharynx, from where they can be swallowed. Due to the reduced acidity of gastric juice during sleep, gastric aspirate obtained in the early morning hours contains frequent secretions from the tracheobronchial tree and is suitable for preparing smears and obtaining a culture of acid-resistant microflora. In this way, washing waters are examined for the content of tuberculosis bacilli that come from the lungs and bronchial tree. To test for tuberculosis, sputum is collected in a sterile bottle for 1-3 days. This can only be done with older children. The patient expectors the sputum and, spitting it into the bottle, immediately closes it with a sterile stopper.
Step five: Expectorated sputum is considered to be a secretion of the tracheobronchial tract, but this is not always the case. The presence of alveolar macrophages in it serves as evidence that it comes from the alveoli. Ciliated epithelial cells may be present in both nasopharyngeal and tracheobronchial discharge, although they are most often found in sputum. A large number of squamous epithelial cells are often detected in the contents of the nasopharynx and oral cavity. Sputum can contain both types of cells; They enter it from the oral cavity. With Wright's stain, large alveolar macrophages and mononuclear cells (sometimes multinucleated, but not polymorphonuclear) with rich cytoplasm stain blue. They are easily distinguished from scaly cells that have the appearance of a fried egg.
The absence of polymorphonuclear leukocytes in Wright-stained sputum smears and an adequate number of macrophages argues against the bacterial nature of the process in the lower respiratory tract and a reduction in neutrophil function. Detection of eosinophils allows us to think about the allergic nature of the disease. Using iron stains, hemosiderin granules can be seen in macrophages, suggesting the possibility of hemosiderosis.
Step six: Held bacteriological examination sputum for tuberculous mycobacteria, pneumococcus, streptococcus, staphylococcus, fungi. Gram-stained smears are examined for the presence of microflora. Bacteria located within or adjacent to macrophages and neutrophils are important for assessing the inflammatory process in the lungs. The appearance of intranuclear or cytoplasmic inclusions, which can be seen in Wright-stained smears, is typical of viral pneumonia. Fungal forms of infection are detected by Gram staining of sputum.
In some diseases of the respiratory system, a number of formations that have diagnostic value can be detected in the sputum. These are elastic fibers during the breakdown of lung tissue (tuberculosis, abscess), Charcot-Leyden crystals (colorless, pointed, shiny rhombuses, consisting of protein products released during the breakdown of eosinophils - in bronchial asthma), Kurschmann spirals (mucous spiral-shaped formations - in asthmatic bronchitis and bronchial asthma), tumor cells (large with large nuclei, resembling granular balls), actinomycete drusen (under a microscope they appear in the form of a central ball with diverging radiant shiny threads with flask-shaped thickenings at the end). Hematoidin crystals in the form of thin needles and brown-yellow rhombic plates may be found in sputum in cases where blood after pulmonary hemorrhage is not released with sputum immediately, but some time later. Diagnosis of pulmonary echinococcus is carried out by the presence of its elements in the sputum in the form of bubbles or hooks.
Pleural fluid examination (Pl). Normally, the pleural cavity contains a small volume of fluid (<15мл). Жидкость в плевральной полости может быть воспалительной (экссудат) и не воспалительной (транссудат). Эти формы выпота дифференцируют по различным критериям, в том числе по содержанию в жидкости белка: экссудаты - выше 30г/л, транссудаты -до 30 г/л. Другие характеристики экссудата включают: отношение белка плевральной жидкости к белку сыворотки >0.5, ratio of pleural fluid LDH to serum LDH >0.6, pleural fluid LDH >2/3 of the normal limit of serum LDH. The exudate is characterized by a specific gravity of more than 1015, a positive Rivalta reaction (turbidity of the liquid when adding a weak solution acetic acid). Cytologically, leukocytes, erythrocytes, and malignant cells are found in the exudate. The total number of leukocytes has a lower diagnostic value, however, it is believed that with a transudate of 1 liter there are less than 10 10 9 leukocytes, and with an exudate of 1 liter there are more than 10 10 9 leukocytes. The leukocyte formula is informative in two cases: the predominance of neutrophils (75%) indicates a primary inflammatory process, lymphocytes (>50%) - a chronic exudative effusion (tuberculosis, uremic or rheumatoid pleurisy, malignant neoplasms). Eosinophilic pleural effusion occurs with pulmonary infarction, periarteritis nodosa, as well as with parasitic and fungal diseases. The hemorrhagic nature of the liquid is given by the presence of more than 5-10 10 9 erythrocytes per liter (a bloody color of the liquid is observed when 1 ml of blood is added to it), observed in trauma (hemothorax), hemorrhagic diathesis, malignant neoplasms and pulmonary embolism. Chylothorax (accumulation of lymph in the pleural cavity) is caused by mechanical damage to the thoracic duct, lymphosarcoma, tumor metastases, tuberculosis posterior mediastinum, leiomyomatosis.
Determination of glucose content in pleural fluid is important to determine the cause of effusion. A ratio of pleural fluid glucose to blood sugar levels of less than 0.5 can be considered abnormal. Low glucose content in the pleural fluid narrows the differential diagnosis of the causes of exudative effusion to 6 pathological processes: parapneumonic effusion, and primarily empyema, in which the glucose content is almost always low, rheumatoid pleural effusion, tuberculous pleural effusion (<1,65 ммоль/л), волчаночный плеврит, разрыв пищевода, при котором низкое содержание глюкозы связано с наличием эмпиемы. Содержание амилазы в плевральной жидкости повышается (>160 units per 100 ml) in cases of combination of pleural effusion with acute or chronic pancreatitis, with esophageal rupture (significant increase due to salivary amylase) and with malignant tumors. The pH value of pleural fluid usually correlates with glucose levels. A low pH value (below 7.0) is found in pleural empyema, collagenosis and esophageal rupture. In a patient with pneumonia complicated by pleural effusion, such a pH value of the pleural fluid indicates the purulent nature of the process. A more specific method for examining pleural fluid is testing for LE cells (for lupus pleurisy) and rheumatoid factor (for rheumatoid effusion). In these diseases, low levels of complement are also found in the effusion. In milky pleural fluid, the fat content is examined. Cultural studies of pleural fluid are carried out when it is purulent or putrefactive in nature in order to isolate aerobic or anaerobic microorganisms (a syringe with 20 ml of fluid is immediately capped and sent to the laboratory for anerobic cultivation). With tuberculous pleurisy, isolation of a pure culture is observed in 30% of cases.
Assessment of external respiratory function in respiratory failure.
The study of external respiration function (PEF), along with the study of the composition of arterial blood, makes it possible to assess the severity and sometimes the nature of the pathological process.
Pulmonary volume and capacity. When studying pulmonary volumes and capacities, the most important is to evaluate the following indicators (their normal values are usually in the range of 80-120% of the proper values):
1. Total lung capacity - the volume of air in the lungs after completing the deepest possible breath.
2. Residual lung volume - The volume of air in the lungs after maximum deep exhalation.
3. Vital capacity lungs - the volume of exhaled air, the value of which is determined by the difference between the total lung capacity and the value residual volume lungs.
4. Functional residual capacity of the lungs – the volume of air in the lungs at rest, i.e. upon completion of a quiet exhalation.
Vital capacity of the lungs can be measured using a spirometer (“Pneumoscreen”, “Vincotest”): the patient completely exhales the air after a maximum deep breath. Due to the fact that other volumes and capacities include part of the air that remains in the lungs even after maximum deep exhalation, more complex methods are used to evaluate them, in particular the helium dilution method, the method of general plethysmography.
Air flow speed. Air flow velocity is usually measured when performing a forced expiration maneuver, i.e. exhale with the maximum possible force and speed from the level of the total lung capacity to the residual lung volume.
The volume of air completely exhaled during this maneuver is called forced expiratory capacity (FVC), and the volume of air exhaled in the first second of exhalation is called forced expiratory volume in 1 second. (FVC 1). To assess the air flow rate, the ratio of these two indicators (FVC 1\FVC) is usually examined, the value of which is in the presence of bronchial obstruction and a slowdown in the volumetric expiratory flow rate (normally, this ratio should be below 95% of the proper value).
Diffusion capacity of the lungs. This reflects the rate of gas transfer from the alveoli to the capillary bed of the lungs, depending on the partial tension (pressure) of the gas on both sides of the alveolar-capillary membrane.
To assess the diffusion capacity of the lungs, the ratio of the rate of passage of CO through the alveolar-capillary membrane to the gradient of the alveolar-capillary tension of this gas is studied. Determining the difference in CO concentrations in inhaled and exhaled air makes it possible to calculate the rate of its absorption, and the alveolar concentration of CO is calculated based on determining its concentration in exhaled air at the end of exhalation (the value of CO concentration in the plasma of the pulmonary capillaries is usually neglected). Carbon monoxide binds relatively quickly and easily to hemoglobin in the blood (210 times more active than oxygen), therefore, when inhaling, its transition from the air of the alveoli to the pulmonary capillaries will be determined not only by its movement through the alveolar-capillary membrane, but also by the hemoglobin content in the blood.
The diffusion capacity of the lungs is impaired during pathological processes leading to a decrease in the total area of gas exchange and/or a decrease in blood volume in the capillary bed of the lungs, for example, with emphysema, interstitial lung diseases (pneumonia, infiltrative tuberculosis, etc.), as well as pathology of the pulmonary vessels. In diseases of the respiratory tract without involvement of the pulmonary patenchyma (for example, bronchial asthma, chronic bronchitis), the diffusion capacity of the lungs, as a rule, does not change.
When analyzing changes in physical activity indicators, two main options (or a combination of them) are distinguished: obstructive variant, characterized by a decrease in air flow velocity due to airway obstruction and restrictive variant characterized by limitation of pulmonary volumes.
With obstructive variant violation of respiratory function is characterized by a decrease in the volumetric expiratory flow rate. In this case, an increase in the residual lung volume and the RV\TLC ratio (more than 33%) is possible due to early expiratory closure (collapse) of the airways.
The main sign of impaired respiratory function according to the restrictive type of respiratory function is a decrease in lung volumes and capacities, mainly TLC VC.
Various forms of damage to the parenchyma of the lungs and chest, as well as neuromuscular pathology, are manifested by a restrictive variant of impaired respiratory function. A decrease in diffusion capacity is more often observed in interstitial lung diseases, and high RV values can be observed with weakness of the respiratory muscles or severe abnormalities (deformations) of the chest
Physical methods include postural drainage, vibration massage And physiotherapy. Postural drainage helps improve the outflow of mucus from the affected areas, which is ensured by placing the patient in special positions (Quincke position, etc.). Postural drainage is indicated for all patients with chronic pneumonia, even if there is only slight sputum production.
Postural drainage is a change in body position to facilitate the outflow of mucus and phlegm. (A) Drainage of the apical segments of the right lung. (B) Drainage of the medial and lateral segments of the right lung. (B) Drainage of the apical segments of the left lung. (D) Drainage of the basal segments and trachea. The last method is especially important in postoperative period, but, unfortunately, often impossible
The effectiveness of postural drainage increases when combined with vibration massage. The vibration massage technique for young children consists of applying rhythmic blows to the chest with the fingertips of one hand or to the finger of the researcher’s other hand, placed along the intercostal space. In older children, vibration massage is carried out by rhythmically patting the chest above the affected area with a palm folded in the shape of a boat.
FUNCTIONAL RESEARCH METHODS
RADIOGRAPHY
Fluorography- a method of x-ray examination with photographing on film with a special attachment. It is convenient for mass examinations during medical examinations.
Main indications for x-ray examination of the respiratory organs:
1) clinically justified suspicions of pneumonia and other bronchopulmonary and pleural processes that require radiological clarification of their presence and nature;
2) anamnestic indications of a previously suffered bronchopulmonary process, the exacerbation or consequences of which may cause the symptoms of the present disease;
3) changes clinical manifestations developed bronchopulmonary disease (acute or chronic), which may require changes in treatment tactics);
4) cases of clinical suspicion of sinusitis and all cases of recurrent, protracted and chronic bronchopulmonary processes, regardless of whether there was prior consultation with an otolaryngologist (radiography of the paranasal sinuses);
5) sudden changes in condition in patients with lung diseases.
Sequence of use and possibilities of x-ray examination of the lungs. Fluoroscopy and radiography of the lungs do not require special preparation of the patient and can be performed using almost any X-ray diagnostic equipment. Each of these methods has its own resolution and capabilities. The methods are not equivalent in terms of radiation exposure to the body. Chest radiography is associated with the lowest level of radiation. With fluoroscopy, the integral absorbed dose is 10-15 times higher than the dose with a single radiography.
The diagnostic capabilities of these methods are also different.. The most information can be obtained from radiography.
Such a radiograph allows :
1) assess the constitutional features of the chest and its symmetry, the degree of airiness of the lung tissue as a whole and in individual parts of the lungs, the nature of the pulmonary pattern, including its small elements, the structure of the roots of the lungs, the size of the lobes and approximately segments of the lungs, the position, size and configuration of the mediastinal organs, the width of the lumen of the trachea and main bronchi and their position, the condition and position of the domes of the diaphragm and the condition of the costophrenic and cardiophrenic sinuses;
2) identify: inflammatory processes in the lungs and their approximate localization and prevalence, pleural changes, changes in the lymph nodes, changes in the mediastinal organs that cause certain respiratory symptoms or are associated with them;
3) clarify the need for further research and develop a plan for it. In most cases, one radiograph is sufficient to make the correct diagnosis. In isolated cases, it becomes necessary to identify a number of functional symptoms: mobility of the domes of the diaphragm, displacement of the mediastinum during breathing, etc., information about which can be obtained using transillumination.
Step one: Chest X-ray is one of the most accessible and frequently performed tests for pulmonary diseases. The X-ray method allows for dynamic monitoring of the course of the disease. To accessible and informative diagnostic methods includes chest radiography. To minimize harmful radiation exposure, it is necessary to place the patient in an appropriate position and use protective devices. In most cases, radiography is usually taken in posteroanterior and lateral projections with the patient in an upright position and taking a deep breath. If effusion into the pleural cavity is suspected, the examination is carried out with the patient lying down. Radiographs in this case are difficult to decipher if free fluid is located both in the pleural cavity and behind it. Oblique views can help assess the condition lung root and the zone located behind the heart, while the apex of the lung is more clearly visible in the lordotic position of the patient.
On an x-ray, small bronchi are visible only when their walls are compacted. At focal pneumonia areas of darkening are blurred, vague, and small in size; with confluent pneumonia, the foci are large. A significant decrease in the transparency of the lungs in the form of a continuous uniform darkening is observed with lobar pneumonia of a lobe (usually on one side) or several segments of the lung (segmental pneumonia). Congestion and pulmonary edema are radiographically characterized by uniform darkening of the pulmonary fields and increased pulmonary pattern. The roots of the lungs are sharply defined and sometimes pulsate. Massive lesions (more than 5 cm in diameter) may be caused by interlobar effusion, pulmonary abscess, pulmonary infarction, cyst, secondary deposits. The presence of well-defined nodes with a diameter of more than 0.5-1 cm is more often found in the following cases: tuberculosis, sarcoidosis, fungal infections, multiple abscesses, multiple metastatic lesions, hydatid cysts, rheumatoid nodes, Kaplan syndrome, Wegener's granulomatosis, arteriovenous malformations. Numerous and too small (less than 5 mm) nodes (such lesions also include interstitial structures, defined as honeycombs or reticular structures) are most often observed in allergic or fibrosing alveolitis, sarcoidosis, miliary tuberculosis, bronchopneumonia, pneumoconiosis, histoplasmosis, idiopathic hemosidero -ze lungs, metastatic deposits, histiocytosis X. A clear, well-defined, rounded clearing indicates focal bullous emphysema, a cavity, an emptied abscess. The latter is also characterized by the presence of a horizontal liquid level and denser walls. Cavities and cysts are observed in the following cases: tuberculosis, cavernous pneumonia (especially staphylococcal and caused by Klebsiella), abscesses (aspiration, septic emboli), bronchogenic or sequestered cyst, cystic bronchiectasis, hydatid cysts, cavernous infarctions, tumors. Increased diffuse transparency in both pulmonary fields is observed when they are highly filled with air in asthma and emphysema. Unilateral increase in transparency is observed in MacLeod syndrome, when suffered in early childhood viral infection leads to underdevelopment of the airways and vasculature in one lobe or lung. In pneumothorax, the area occupied by a gas bubble is determined by the bright clearing of the pulmonary field and the absence of a pulmonary pattern. The compressed lung (distinguished by the comparative density of the shadow and the absence of a pulmonary pattern) and the mediastinal organs are shifted to the healthy side due to positive intrathoracic pressure on the diseased side. Alveolar opacities - soft, “fluffy” opacities are more often observed with pulmonary edema of cardiogenic or other origin. They are observed in respiratory weakness syndrome and in a number of other conditions: pulmonary edema, alveolar hemorrhage, alveolar proteinosis, pneumonia (pneumocystis, viruses), alveolar cell carcinoma, the appearance of fluid in the pleural cavity, depending on its amount, leads to a decrease in the transparency of the lung. A large amount of it sharply reduces the transparency of the lung and pushes the mediastinal organs to the healthy side.
Electroradiography. The electroradiography method is based on obtaining an X-ray image on a selenium plate (instead of X-ray film) with the possibility of its repeated use and image transfer. onto plain paper for documentation purposes. The advantages of the method are the speed of obtaining information, cost-effectiveness, and the possibility of a more structural identification of the main details of the pulmonary pattern and the roots of the lungs (the image becomes, as it were, retouched). However, in assessing the condition of the lung tissue, an electroradiogram is inferior to a conventional photograph.
There is no general experience of using electroradiography in pediatric pulmonology yet. It can be assumed that this method will find recognition in cases of rapid diagnosis, largely replacing fluoroscopy, as well as in assessing the main stages of the dynamics of the immediate postoperative period.
CT SCAN
Tomography. The essence of the method is a clearer identification of a certain layer of organs and tissues on the film due to the projection immobility of the selected layer in relation to the film and blurring of the image of the layers lying in front and behind it. The indications are to clarify the topography and structure of the pathological area found on the x-ray.
Step one: Most x-ray diagnostic devices equipped with a tomography attachment allow examination with the patient in a horizontal position on his back or on his side. This position meets the purpose of the study in the vast majority of cases.
Step two: In some cases, for example, to isolate the axial layer of the middle lobe or lingular segments, oblique projections of tomograms are used.
Step three : To produce tomograms in a vertical position, specially designed tomographs are used.
Step four: The need to restrain the child arises when studying small and restless children. The device described in the “Radiography” section also meets these goals. In its absence, the help of clinic staff or parents is necessary.
Step five: In order for small children to get used to the situation and not be frightened by the movement of the tube and noise, it is recommended to make one or two idle movements.
In order to reduce patient exposure and simultaneously obtain images of several layers, a special Simultan cassette is used. The image obtained on the first film of such a cassette corresponds to the level set on the tomograph scale. The layer located 1 cm below is displayed on the second film, etc. It should be remembered that some Simultan cassettes, for example those made in the Czech Republic, have an interval between films of 1.2 cm.
Before producing a tomogram, it is necessary to consider the reality of obtaining a quality product. The fact is that children who do not hold their breath (usually children under 3 years old) manage to make 1-2 respiratory cycles during the exposure, which sharply worsens the clarity of the image.
Tomography should never be used as a search method of research, i.e., if there is no area suspicious for pathology on the radiographs. The lack of clarity of the character of the shadow on the x-ray is often due to the poor quality of the latter. It is not recommended to resort to tomography until a good quality image has been obtained. If, upon evaluation of clinical data and conventional imaging, it becomes clear that bronchography will be required, it should be performed first, after which the need for tomography may no longer be necessary.
The computed tomography method can help in a detailed study of the structures of internal organs and their relationships. However, it is expensive and requires longer exposure times. CT allows you to examine in detail the condition of the mediastinal organs, tissues of the root of the lung, visualize the tracheobronchial tree (see abnormalities in the structure of the bronchi and bronchiectasis). CT is also indicated for the formation of a cavity, detection of calcification of a lesion, identification of bullae, foreign bodies, localization and determination of the boundaries of lesions, detection of intrapulmonary metastases, assessment of intrapulmonary vessels, anomalies of the aorta.
Step one: It must be remembered that tomograms are performed with the patient in the supine position, therefore, the direction of pleural fluid, fluid levels and outlines change and do not necessarily repeat those on a direct image.
Some indications for CT scanning in ore cell diseases: preoperative assessment of mediastinal and hilar nodes; screening for distant metastases in the liver, adrenal glands and brain; search for multiple nodular thickenings of the lungs; identification of complicated pleural lesions; determination of mediastinal masses; study of vascular lesions of the lungs and mediastinum (with contrast); assessment of emphysema prevalence; determination of the location and size of bronchiectasis; diagnosis of changes in the interstitium of the lungs, bronchiolitis obliterans and cystic fibrosis, pulmonary edema, pulmonary hemorrhages.
Nuclear magnetic resonance imaging (NMR). The indications for the method are the same as for CT. The advantage of the NMR method is the absence radiation exposure, which is especially important in pediatric practice. When using NMR, a detailed study of the tissue structures of the trachea and large bronchi, mediastinum, root of the lungs, and the condition of the chest is carried out. Large vessels, their sizes and anatomical relationships with the respiratory tract are also visualized. NMR helps differentiate between the inflammatory process and fibrosis.
BRONCHOGRAPHY.
Obtaining bronchograms involves introducing into Airways radiopaque substance. Currently, bronchography is performed less frequently than before, which is due to a decrease in the frequency of bronchiectasis and their surgical treatment due to the development of fiber-optic bronchoscopy.
Step one: Bronchography is carried out by introducing a radiopaque substance through the channel of a fiber-optic bronchoscope or through a catheter placed in the same way as a bronchoscope.
The main indications for bronchography are as follows::
– Chronic or protracted inflammatory process in the bronchopulmonary system in the presence of signs of organic damage to the bronchi and pulmonary parenchema;
– Recurrent or chronic inflammatory process in certain areas
At pathological conditions respiratory organs, vocal tremors can be increased or weakened, and even not detected at all . An increase in vocal tremors is observed with compaction of the lung. The cause of compaction can be different: lobar pneumonia, tuberculosis, infiltration of the lung, compression of the lung as a result of accumulation of air or fluid in the pleural cavity. But a prerequisite for this is the free passage of air into the respiratory tract.
Accumulations in the pleural cavity of liquid or gas, which move the lung away from the chest and absorb sound vibrations spreading from the glottis along the bronchial tree;
When the lumen of the bronchi is completely blocked by a tumor;
In weak, exhausted patients, due to weakening of their breathing
With significant thickening of the chest wall (obesity) .
Semiotics of changes in percussion sound by the lungs.
1. Dullness (shortening) percussion sound over the lungs is based on a decrease in the air volume of the lung:
a) with exudation in the cavity of the alveoli and infiltration of the interalveolar septa (focal and, especially, confluent pneumonia);
b) with pneumosclerosis, fibrous pulmonary tuberculosis;
c) with atelectasis;
d) in the presence of pleural adhesions or obliteration of the pleural cavities;
e) with significant pulmonary edema, hemorrhage into the lung tissue;
f) when the lung tissue is compressed by pleural fluid above the level of the fluid, the floor of the Sokolov-Damoiso line;
g) with complete blockage of a large bronchus, a tumor.”
2. Dull ("femoral dullness") percussion sound is observed in the complete absence of air in an entire lobe or part of it (segment) in lobar pneumonia in the compaction stage, in the formation of a large cavity filled with inflammatory fluid in the lung, in an echinococcal cyst, a suppurating congenital cyst in a lung abscess, in the presence of fluid in the pleural cavities.
3. Tympanic a tint of percussion sound occurs when the airiness of the lungs increases and pathological cavities appear in them: emphysema, abscess, tuberculous cavity, with the disintegration of a tumor, bronchiectasis, pneumothorax.
4. Boxed percussion sound is a loud percussion sound
with a tympanic tint is detected when the airiness of the lung tissue increases and its elasticity decreases.
5. A metallic percussion sound is characteristic of large cavities in the lungs.
6. The sound of a “cracked pea” is a kind of quiet, rattling sound that is detected by percussion of a large superficial cavity, which communicates with the bronchus through a narrow slit-like opening.
Semiotics of respiratory changes noise
1, Physiological attenuation of respiratory noise is observed
with thickening of the chest wall due to excessive development of its muscles
or increased fat deposition in adipose tissue.
2. Pathological weakening of breathing may be caused by:
a) a significant decrease in the total number of alveoli in
as a result of atrophy and gradual death of interalveolar barriers
dock and the formation of larger bubbles that are unable to collapse
when exhaling, the elasticity of the lung tissue is lost (pulmonary emphysema);
b) swelling of the alveolar walls and a decrease in amplitude
their fluctuations during inspiration (in initial stage and the stage of resolution of pneumonia, when there is a violation only of the elastic function of the alveoli, but there is no exudation and compaction;
c) a decrease in the flow of air into the alveoli through the airways (narrowing of the larynx, trachea, inflammation of the respiratory tract
muscles, intercostal nerves, rib fractures, severe general weakness)
adynamia of the patient;
d) insufficient air supply to the alveoli through the airways as a result of the formation of a mechanical obstacle in them (for example, when the lumen of large bronchi is narrowed by a tumor
or foreign body);
e) displacement of the lung by accumulation of fluid and air in the pleura;
e) thickening of the pleura.
3. Increased breathing can occur in the inhalation, exhalation or both phases of breathing. Increased exhalation depends on the difficulty of air passing through the small bronchi when their lumen narrows (inflammatory swelling of the mucous membrane or bronchospasm). Breathing, in which the inhalation and exhalation phases are intensified, is called hard breathing, and is observed with a sharp and uneven narrowing of the lumen of the small bronchi and bronchioles due to inflammatory swelling of the mucous membrane (bronchitis).
4. Bronchial breathing under physiological conditions is well audible above the larynx, trachea and in the places where the trachea bifurcation projects onto the chest. The main condition for carrying out bronchial breathing on the surface of the chest is compaction of the lung tissue: filling of the alveoli with inflammatory exudate, blood, compression of the alveoli when liquid or air accumulates in the pleural cavity and pressing the lung to its root, replacement of the airy lung tissue with connective tissue, pneumosclerosis, carnification of the lung lobe.
6. Amphoric breathing appears in the presence of a smooth-walled cavity with a diameter of 5-6 cm, communicating with a large bronchus (similar to noise if you blow strongly over the throat of an empty glass or clay vessel).
7. The metallic hue of breathing resembles the sound that occurs when hitting metal, which can be heard with open pneumothorax.
Semiotics additional driving noises
1. Dry (wheezing, buzzing) wheezing occurs due to narrowing of the lumen of the bronchi, caused by: a) spasm of the bronchial muscles; b) swelling of the bronchial mucosa during the development of inflammation in it; c) accumulation of viscous sputum in the lumen of the bronchi; d) proliferation of fibrous (connective) tissue in the walls of the bronchi; e) fluctuation of viscous sputum as it moves in the lumen of large and medium-sized bronchi during inhalation and exhalation (sputum due to its viscosity during air movement along the bronchi it can be pulled out in the form of threads that stick to the opposite walls of the bronchus and are stretched by the movement of air, oscillating like a string.Dry wheezing is heard both in the inhalation and exhalation phases.
Thus, dry whistling and buzzing rales are characteristic of bronchitis, especially obstructive bronchitis, in the initial phase of the inflammatory process, bronchial asthma, fibrosing bronchitis.
2................................................. ........................................................ ........ Moist rales are formed mainly as a result of the accumulation of liquid secretions (sputum, edema fluid, blood) in the lumen of the bronchi and the passage of air through this secretion with the formation of air bubbles of different diameters. These bubbles, penetrating through the layer of liquid secretion into the fluid-free lumen of the bronchus, burst and produce peculiar sounds in the form of a crackling sound. Moist rales are heard both in the inhalation and exhalation phases. But, since the speed of air movement through the bronchi in the inhalation phase is greater than in the exhalation phase, moist rales will be somewhat louder in the inhalation phase. Depending on the caliber of the bronchi in which they arise, moist rales are divided into small-bubble, medium-bubble and large-bubble
Moist rales, therefore, are characteristic of bronchitis in the phase of resolution of the inflammatory process, bronchiolitis, and pulmonary edema.
3. Crepitus, unlike wheezing, occurs in the alveoli, appears only at the height of inspiration in the form of a crackling sound and resembles the sound
which is obtained by rubbing a small tuft of hair over the ear.
The main condition for the formation of crepitus is the accumulation in
in the lumen of the alveoli a small amount of liquid secretion. Under this condition, in the exhalation phase the alveolar walls stick together, and in the phase of intense inhalation they come apart with a characteristic sound. Therefore, crepitus is heard only at the end of the inspiratory phase and is characteristic of pneumonia and pulmonary edema.
4. Pleural friction noise is characteristic of fibrous (dry) pleurisy.
It is also necessary to distinguish between wheezing that forms in the lung tissue and wire wheezing, the source of which is the upper respiratory tract. To differentiate, you can use the following properties of conductive rales: they are clearly audible over the nose and mouth, and are carried out on the shoulder blades and spinous processes of the thoracic vertebrae.
Palpation
A method of research using touch, temperature sensation with palpating fingers.
Defined:
1. Temperature, density, humidity and tissue vibration (pulsation);
2. Sensitivity (pain) of body parts;
3. Physical properties of internal organs or pathological formations (location, size, boundaries, shape, surface, mobility or displacement).
Conditions: position depending on the organ being palpated, the paramedic is to the right of the patient facing him, the muscle layer should be as relaxed as possible, the examiner’s hands should be warm, the nails should be short-cut, movements should be careful.
Kinds: -superficial– indicative view – performed with the palm placed flat on the body or limb.
Deep- performed only with fingers using significant pressure. Types of deep palpation:
Penetrating: one or two fingers are pressed into any point of the body to determine pain points;
Bimanual – with both hands (kidneys);
Push-like - to determine the balloting of dense bodies - liver, spleen - they produce tremors;
Sliding, according to Obraztsov - the fingertips penetrate deeper gradually, during the relaxation of the muscle layer that occurs with each exhalation, and, having reached the depth on exhalation, slide in a direction transverse to the axis of the organ being examined. The organ is pressed to the back surface abdominal wall.
Percussion.
Tapping - tapping areas of the body and determining the physical properties of the percussed organs and tissues by the nature of the sounds that arise.
· Direct - tapping with the middle or index finger on the ribs of the chest in young children - produces unclear, imprecise sounds.
· Indirect – tapping a finger on a finger.
· Comparative – comparison of the sounds of organs located symmetrically on the right and left sides.
· Topographical – determination of boundaries, dimensions, configuration.
Percussion sounds of 3 types:
Clear - intense, distinct, clearly distinguishable - over tissues containing a certain amount of air - lungs;
Tympanic (drum) – loud and continuous, organs containing a significant amount of air - intestines
Dull, dull, weak, quiet - when percussing airless soft organs and tissues - the liver.
Dullness of percussion sound (shortening) is an intermediate position between clear and dull.
The plessimeter finger is pressed along its entire length to the surface being percussed, without touching adjacent fingers. Used as a hammer middle finger right hand, bent at a right angle. Percusses from clear to dull sound. The plessimeter finger is installed parallel to the border of expected dullness. The border of the organ is marked along the outer edge of the finger - the plessimeter, facing the organ that produces a clear sound.
Loud percussion – determines deeply located organs and tissues.
Quiet when the sound of impacts is barely audible. When determining the boundaries of absolute dullness of the heart, determining the boundaries of the lungs, etc.
Auscultation (listening)
Assessment of sound phenomena occurring in organs and vessels during their functioning. Widely used in the study of lungs and ss.
1. Direct - listening to a part of the body by applying the ear.
2. Indirect - using a stethoscope, phonendoscope, stethophonendoscope.
Conditions:
2. Silence.
3. Stripped to the waist.
4. Lightly moisten the abundant hair and shave.
Must be performed in a standing or sitting position. The heart is additionally listened to in the supine position, on the left side, at an angle of 45, after physical activity;
The head of the phonendoscope fits tightly to the surface. The stethoscope should not be placed on the ribs, shoulder blades or other bone formations.
The patient’s clothing and hands should not touch the bell;
Listening with the same instrument.
Lymph nodes are determined mainly by palpation. When palpating, pay attention to the size, pain, consistency, adhesion between each other and the skin. Using the fingers of the entire hand, pressing them to the bones. Submandibular, chin, anterior and posterior parotid, occipital, anterior and posterior cervical, supraclavicular, subclavian, axillary, ulnar, inguinal, popliteal. Normally they are not palpable. Increased in infections, blood diseases, tumors.
Determination of peripheral edema and ascites.
The palms are placed on symmetrical areas of the chest, and then the patient is asked to loudly pronounce several words that contain the letter “r”.
Supradorsal areas, interscapular, below the angles of the scapula, along the axillary lines from top to bottom, in front - supraclavicular, areas of the pectoralis major muscles, inferolateral sections.
Percussion of the lungs
The patient's position is vertical.
Topographical – determination of the boundaries of the lungs, the width of the apexes (Krenig's field), the mobility of the lower edge of the lungs.
First, the lower boundaries are determined. From top to bottom along symmetrical topographic lines. On the left it is not determined by 2 lines - periosternal and midclavicular.
the finger is placed parallel to the intercostal spaces.
Parasternal – V m/r
Midclavicular – VI r
Anterior axillary – VII r
Middle axillary – VIII r
Posterior axillary – IX r
Scapular – X r
Paravertebral – XI gr. vertebra
The height of the apexes in the front, the finger-pessimeter is installed parallel to the clavicles in the supraclavicular fossae, shifted upward and medially. Normally 3-4 cm above the collarbones.
The height of the apexes at the back - the finger-pessimeter is installed parallel to the spines of the shoulder blades, percussed upwards and inwards.
Kroenig fields - a plessimeter finger is installed in the middle of the trapezius muscle along its anterior edge, then percussed inward and outward until dullness. Normally 5-6 cm.
Mobility - the lower limit on deep inspiration and deep exhalation is determined by 3 lines - midclavicular, middle axillary, scapular. On the right, 2. Mobility along the midclavicular and scapular lines is 4-6 cm, along the middle axillary lines – 6-8 cm.
Comparative percussion. Normally, there is the same clear lung sound over symmetrical areas on the right and left. Anteriorly, in the third m/r and below, comparative percussion is not performed. Next it is carried out in the lateral areas and behind (in the suprascapular, interscapular and subscapular areas
Auscultation of the lungs
Listened standing or sitting. Auscultation should also be comparative. Listening is carried out by area (supraclavicular, area of the pectoralis major muscles, inferolateral sections of the anterior surface of the chest, axillary areas (hands behind the head), lateral surfaces of the chest). On the posterior surface - supraspinous areas, interscapular (cross your arms over your chest), below the angles of the shoulder blades and inferolateral areas.
Basic breath sounds:
· Vesicular breathing - the sound “f”, if you slightly draw in air, it is heard normally.
· Bronchial breathing - the sound “x”, maybe in the area of the manubrium of the sternum, the upper part of the interscapular space. In other areas it is not normally heard.
Bronchophony.
Bronchophony is a research method that involves listening to the voice, which is carried out on the chest, and its audibility is assessed by auscultation. Words with hissing sounds are used - a cup of tea.
Over the unchanged lungs, only individual sounds are heard in fragments under normal conditions. The phrase in compaction syndrome can be heard in full.
Auscultation of the heart
The sounds that occur when the heart contracts and vibrates its structures are called heart sounds.
Auscultation is carried out with the patient standing and lying down, if necessary - on the left, right side, after physical activity. The first sound occurs at the beginning of systole, which is why it is called systolic. The second sound occurs at the beginning of diastole, which is why it is called diastolic.
Heart valves are heard in in descending order of frequency of their damage
· . The mitral valve is the apex of the heart.
· Aortic valve – in the 2nd intercostal space at the right edge of the sternum.
· Pulmonary valve - in the 2nd intercostal space at the left edge of the sternum.
· Tricuspid valve - at the base of the xiphoid process.
· Botkin suggested the 5th point for listening to the aortic valve - the 3rd intercostal space on the left at the edge of the sternum.
In addition to sounds, additional sounds called murmurs may be heard during auscultation of the heart. . There are noises organic (associated with damage to the valves, heart muscle, narrowing of the orifices) and functional (not associated, more often in young children, changeable, not always audible, do not lead to disruption of intracardiac hemodynamics and general circulation).
· By phase cardiac cycle:
· Systolic – occur in systole between the 1st and 2nd sounds.
· Diastolic – occur in diastole between the 2nd and 1st sounds.
· Murmurs can be extracardiac: pericardial friction noise, etc.
RESPIRATORY ORGANS STUDY
INSPECTION
The purpose of the examination is to determine the static and dynamic characteristics of the chest, as well as external indicators of breathing. To characterize the chest, determine: 1) the shape of the chest (regular or irregular), 2) the type of chest (normosthenic, hypersthenic, asthenic, emphysematous, paralytic, rachitic, funnel-shaped, scaphoid), 3) the symmetry of both halves of the chest, 4) symmetry of respiratory excursions of both halves of the chest, 5) curvature of the spine (kyphosis, lordosis, scoliosis, kyphoscoliosis), 6) respiratory excursion of the chest at the level of the IV rib.
In addition, the following breathing indicators are assessed: 1) whether the patient breathes through the nose or mouth, 2) type of breathing: thoracic (costal), abdominal (diaphragmatic or mixed), 3) rhythm (rhythmic or arrhythmic), 4) depth (superficial, medium depth, deep), 5) frequency (number of breaths per 1 minute).
PALPATION
The purpose of the study is to determine: 1) chest pain, 2) chest resistance, 3) vocal tremor.
Determination of chest pain.
It is performed with the patient sitting or standing. More often, palpation is carried out with both hands at the same time, placing the fingertips of both hands on symmetrical areas of the chest. Thus, the supraclavicular areas, clavicles, subclavian areas, sternum, ribs and intercostal spaces are palpated sequentially, then the lateral parts of the chest and then the supra-, inter- and subscapular areas. When an area of pain is identified, it is palpated in more detail, if necessary with both hands (to identify crunching of rib fragments, crepitus), and a change in pain is noted at the height of inhalation, exhalation, and bending of the torso to the painful and healthy sides. To differentiate pain caused by damage to the muscles of the chest, the muscles are captured in the fold between the large and index fingers.
When determining the soreness of the spinous processes and paravertebral areas, it is better to use the thumb of the right hand.
Determination of chest resistance.
The resistance of the chest when compressed is determined. In this case, the patient stands or sits, and the doctor is to the right of the patient.
The examiner (doctor) places the right hand with the palmar surface on the anterior chest wall transversely at the level of the body of the sternum, and the left hand on the posterior chest wall, parallel to the right hand and at the same level.
Next, the chest is compressed. When determining the resistance of the chest in its lateral parts, the hands are located on the right and left axillary areas on symmetrical areas. If the examiner notices that the chest is easily compressed, then the elasticity (compliance) of the chest is stated. If the chest is not compressed, then its rigidity (resistance to compression) is stated. The chest, when compressed in the lateral parts, is more pliable than when compressed from front to back.
Trembling of the chest over the projection of the lungs is determined when the patient pronounces words with the sound r. Trembling of the chest is checked simultaneously with both hands over symmetrical areas of the chest, successively in front and behind. When determining vocal tremor from the front, the patient is in a standing or sitting position. The doctor is positioned in front of the patient, facing him.
The examiner places both hands with the palmar surfaces straightened and closed on symmetrical sections of the anterior chest wall longitudinally so that the fingertips are in the supraclavicular fossae. The fingertips should be lightly pressed against the chest. The patient is asked to say loudly thirty-three. In this case, the doctor, focusing on the sensation in the fingers, must obtain vibration (tremor) under them and determine whether the trembling is the same under both hands. Then the doctor changes the position of the hands, putting the right hand in place of the left, and the left hand in place of the right, offering to say thirty-three loudly again. He again determines the sensation under his hands and compares the degree of shaking under both hands. On the basis of such a double study, it is finally determined whether the vocal tremor is the same over both apexes or whether it predominates over one of them. The position of the hands is changed in order to eliminate the influence of asymmetry in the sensitivity of the hands on the result of the study. In the same way, vocal tremor is checked in the front in the subclavian areas, lateral sections, and behind in the supra-, inter- and subscapular areas.
This research method allows palpation to determine the conduction of sound vibrations to the surface of the chest. In a healthy person, vocal tremor in symmetrical areas of the chest is the same, but in pathological conditions, asymmetry (intensification or weakening) of it is revealed.
PERCUSSION
The purpose of percussion is to determine: 1) foci
Percussion is divided into comparative and topographical.
Comparative percussion.
By applying percussion blows of the same average force sequentially to symmetrical areas of the chest above the projection of the lungs, the physical characteristics of the percussion sound (loudness, duration, height) above them are assessed and compared. In cases where it is possible to roughly localize the side of the lesion (right or left lung) based on complaints and examination data, comparative percussion should begin with healthy side. Comparative percussion of each new symmetrical area should begin on the same side. In this case, the patient’s position is sitting or standing, and the doctor’s position is standing.
Percussion of the chest over the lungs is carried out in a certain sequence: in front, in the sides, in the back.
● Front: the patient’s arms should be lowered, the doctor stands in front to the right of the patient. Start percussion with upper sections chest. The pessimeter finger is placed in the supraclavicular fossa parallel to the clavicle, the midclavicular line should cross the middle middle phalanx finger-pessimeter. Using a hammer finger, strikes of medium force are applied to the pessimeter finger. The pessimeter finger is moved into the symmetrical supraclavicular fossa in the same position and blows of the same force are applied. Percussion sound is assessed at each percussion point and sounds at symmetrical points are compared. Then, using a hammer finger, blows of the same force are applied to the middle of the clavicles (in this case, the clavicles are natural plessimeters). The study is then continued by percussing at the level of the 1st intercostal space, 2nd intercostal space, and 3rd intercostal space. In this case, the pessimeter finger is placed on the intercostal space, its direction runs parallel to the ribs. The middle of the middle phalanx is intersected by the midclavicular line, the pessimeter finger is slightly pressed into the intercostal space.
● In the lateral sections: The patient’s hands should be clasped and raised on his head. The doctor stands in front of the patient, facing him. The pessimeter finger is placed on the chest in the armpit (intercostal space). The finger is directed parallel to the ribs, the middle of the middle phalanx is crossed by the middle axillary line. Then percussion is performed on the symmetrical lateral areas of the chest at the level of the intercostal spaces (up to VII-VIII inclusive).
● Behind: The patient should cross his arms over his chest. At the same time, the shoulder blades diverge, expanding the interscapular space. Percussion begins in the suprascapular areas. The pessimeter finger is placed parallel to the spine of the scapula. Then they percussion in the interscapular space. The pessimeter finger is placed on the chest parallel to the line of the spine at the edge of the shoulder blades. After percussion of the interscapular space, the chest is percussed under the shoulder blades at the level of the VII, VIII, and IX intercostal spaces (the pessimeter finger is placed on the intercostal space parallel to the ribs). At the end of the comparative percussion, a conclusion is made about the homogeneity of the percussion sound over symmetrical areas of the lungs and its physical characteristics (clear, pulmonary, dull, tympanic, dull-tympanic, dull, boxy). If a pathological focus is detected in the lungs, by changing the force of the percussion blow, you can determine the depth of its location. A percussion strike with quiet percussion penetrates to a depth of 2-3 cm, of medium strength - up to 4-5 cm, and loud percussion - up to 6-7 cm.
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