Examination of the thorax

The examination of the chest from the point of view of a pneumologist includes an examination from the point of view, where we notice mainly abnormal chest shapes and the type of breathing. Furthermore, palpation examination, where we examine chest tremors and pleural friction. By tapping, where we compare the symmetry of the tapping (we find out pathological darkening or hypersonic tapping) and the topographic delimitation of the lungs. We also examine the chest by listening, where we evaluate atrial and tubular respiration - we focus mainly on the intensity of respiratory murmurs, the ratio of inspiration and expiration, and the presence of secondary respiratory murmurs. By listening, we further examine the chest voice.

View
During the examination, we notice the shape, deformities, respiratory movements and soft parts. The shape of the chest changes during growth and adolescence. The normal chest is symmetrical on both sides.

Shape

 * We recognize these shapes:
 * Barrel (emphysematous) - found with obstructive lung disease, which is difficult exspirium a chest located in the inspiratory position. All diameters enlarged (mainly anteroposterior), arched sternum , kyphotic spine.
 * Pectus carinatum (bird's) - chest flattened from the sides, enlarged anteroposterior dimension, sternum extended forward, eg in rickets .Pectus carinatum
 * Pectus infundibuliforme, pectus excavatum (funnel) - 2 forms: inverted lower sternum (funnel) or inverted whole sternum (shuttle).Pectus excavatum
 * Kyphoscoliotic - kyphosis and scoliosis of the thoracic spine.
 * Deformities - most often the consequences of lung or pleural disease (adhesions after inflammation). Significant deformity can be observed in patients with congenital heart disease or defect in early childhood. The arched heart puts pressure on the chest wall, which creates a mound, also called a voussûr.

Breathing Movements
For respiratory movements, we monitor the type of respiration, symmetry and respiratory rate (physiologically 16–20 breaths / min). During normal eupnoea respiration, both halves of the chest participate at the same time and equally. In men we observe a more abdominal type of breathing (mainly diaphragmatic movements), in women we observe bone breathing (raising and lowering of the ribs).

Respiratory rate may be affected by lung, heart, CNS, anemia or toxic and metabolic influences.

Accelerated breathing is called tachypnoea. It occurs when agitated, increased body temperature, or increased exertion. Deep breathing is called hyperpnea. Slow breathing ( bradypnoea ) is found in patients with depression, in patients under the influence of certain drugs, or in patients with increased intracranial pressure. As dyspnoea is called dyspnea. Temporary respiratory arrest is called apnea.


 * Cheyne-Stokes breathing

We find it in heart failure, uremia , severe pneumonia , increased intracranial pressure (eg CMP ).


 * Sighing

Typical of neurocirculatory asthenia, deepened breath with often prolonged expiration. The patient feels that he cannot breathe.


 * Kussmaul's breathing (acidotic)

Tachypnoea and hyperpnea are present. It is most often encountered in diabetic coma (increased amount of ketone bodies ) and metabolic acidosis.

Typical of neurocirculatory asthenia, deepened breath with often prolonged expiration. The patient feels that he cannot breathe.


 * Orthopedics

Forced breathing position. It is most often found in patients with lung or heart disease. It is a sitting or semi-sitting position, the hands rest on the mat, the legs are lowered. In cardiac patients, venous return to the right atrium is reduced.


 * Biot's breathing
 * In meningitis and encephalitis, when the irritability of the respiratory center is reduce
 * Prolonged expiratory breathing
 * Typical of patients with asthma, chronic bronchitis and obstructive pulmonary disease . Additional attention should be paid to tumors arising from soft tissues or cartilage and bone . We also pay attention to breast examinations , where cancer can develop (especially in women, but also in men!).

Palpation
During palpation, we monitor resistance, soreness, chest tremors, pleural friction ( pleurisy ).


 * Fremitus pectoralis

There were no chest tremors. We examine with the help of both palms, which we place on symmetrical places on the chest, which we compare. We ask the patient to say out loud numbers, for example (1, 2, 3)


 * We feel the amplification over the infiltrated tissue, such as pneumonia.
 * Weakening or even disappearance is usually during pleural effusion, pneumothorax, adhesions, and when the bronchus is blocked by a tumor or a foreign body with subsequent atelectasis.


 * Pleural friction

Occurs in pleurisy. If it is present, we can touch it in inspiration and expiration. The most palpable is pleural friction at the lower edge of the lungs and in the axillary surfaces.

Percussion
'' The stroke is full, clear, comparable on both sides of the chest in healthy people. ''

We perform the tapping at the back and front of the chest, preferably while sitting, or we can shoot a lying patient appropriately.

We recognize several types of taps:
 * Comparative tap

Knocking out the same places on each side. Healthy tap - is clear, towards the bases is less clear.


 * Anterior comparison - we knock out and mutually compare the area of ​​the superclavicular wells, the parasternal area, the medioclavicular area, the middle axillary area, usually from top to bottom.
 * At the back - we tap paravertebrally from the seventh cervical vertebra (C7), then in the scapular line and in the middle axillary line, again downwards.
 * Topographic percussion

Defining a percussion change - for example, percussion dimming, we proceed perpendicular to the expected area of ​​percussion dimming. Topographic determination of the lower limits of the lungs - in the front and on the sides we orient ourselves according to the ribs and intercostal spaces, at the back according to the vertebral spines.

Physiological limits lung
Ventrally - parasternally - 6th rib, in the medioclavicular line - 6th intercostal space, in the middle axillary line - 8th rib,

Dorsally - in the scapular line 10th rib, paravertebrally - the thorn of the 10th thoracic vertebra on the right (Th10 P) and the thorn of the 11th thoracic vertebra on the left (Th11 L).

Diaphragm knock
The diaphragm is in the range of 4-8 cm Wrong quote: The opening mark is wrong or has a bad name depending on the breath phase. Bilateral reduction of the diaphragm shift occurs in emphysema, ascites , increased diaphragm in pregnancy , and pleuropulmonary adhesions. Unilateral reduction of diaphragmatic displacement can be knocked out in the presence of unilateral thoracic pleural effusion, in pneumothorax, in pleuropulmonary adhesions, in atelectasis of the lower lobe of the lung, in paralysis of the phrenic nerve, etc.

Percussion change

 * Hypersonoric - in the air lungs, in emphysema, in the presence of air - pneumothorax.
 * Drum - with a lot of air.
 * Darkened to dark - with reduced lung airiness; in the thickening of lung tissue - pneumonia, tumor, pulmonary infarction, atelectasis; in pleural thickening; in the presence of fluid in the pleural cavity - fluidothorax (percussion varies according to the amount of effusion).

Listening to
'' Under physiological circumstances, respiration above the lungs is ventricular, clean, with no side effects. Tubular breathing is only audible above the jugula, upper sternum and between the shoulder blades. ''

We recognize:


 * Straight - placing the ear on the chest.


 * Indirect - using a stethoscope.

By listening, we compare both sides, the patient breathes deeply with his mouth open, if not loud.

Basic types of breathing

 * Cellar respiration

As with exhalation through the mouth set to the letter f, we hear a murmur throughout the inspiration, but in the expiration only at the beginning - the inspiration / exspirium ratio = 3: 1.


 * Tubular breathing

As with exhalation through the mouth set to the letter ch, physiological respiration for the larynx and trachea, the expiratory component is greater than the inspiratory.

Changes in breathing

 * Enhanced atrial respiration

With increased ventilation - eg Kussmaul's breathing. It is important in a unilateral finding in a healthy lung (hyperventilated), when the other lung is affected by, for example, pneumonia or in pneumothorax and inflammatory exudate of the other lung.


 * Weakened atrial respiration:

Physiologically, it occurs in obese people. Pathologically, we find decreased atrial respiration in:


 * reduction of respiratory excursions that may occur in chest injuries or dry pleurisy ;
 * extensive pleuropulmonary adhesions;
 * effusion, pneumothorax;
 * pulmonary emphysema (reduction of the alveoli) when ventilation is reduced;
 * in obstructive atelectasis.




 * Deaf breathing

In pneumothorax, increased effusion, or obstructive atelectasis, a large part of the lungs is usually affected.


 * Cellar respiration with prolonged expiration

We cultivate in bronchial asthma, bronchitis and bronchioles (resistance in these ways) - spasm, swelling, secretion and emphysema (loss of elasticity).

Tubular respiration where not normally present. For example, when the alveoli are removed from the respiration, but when the main bronchus is patrolled.
 * Pathological tube respiration


 * Exclusion of alveolar function:
 * alveolar filling - inflammatory infiltrate in pneumonia, blood in pulmonary infarction, tumor tissue;
 * pressing the cellars from the outside - during effusion.
 * Compressive breathing (bronchosicular) - audible above the upper limit of medium and large effusions; is caused by effusion pressure. It is a combination of atrial and tubular (audible mainly in the expiration) breathing.



Side breathing noises [ modify | edit source ]
They are formed during air flow in the presence of a viscous or aqueous sector in the bronchi, bronchioles or alveoli, or above the pleura under pathological circumstances, also during bronchial spasm.

Noise

 * Dry Noise

Content viscous, semi-liquid (adhering to walls). The vibration of the contents by the air current, thus creating a whistling or creaking sound. It can also be caused by bronchial spasm. It occurs in acute and chronic bronchitis, in bronchial asthma. Whistling and screaming can be heard in both breathing phases.


 * Wet Noise

Liquid to semi-liquid content. division into small (medium-sized), medium and large bubbles. The sound is created by the bursting of a bubble on the surface of the fluid. We can divide chrops:


 * accented - clear, coming up close; infiltrated, well-conducting tissue - eg pneumonia, bronchiectasis ,
 * and unaccented - dark, comes from afar; airy, poorly conductive tissue.

Třaskání
Cracking, or crepitus, is only audible in inspiration. Clear, sharp tufts of small bubbles creating a continuous noise, comparison - rubbing hair between fingers.

It arises:


 * physiologically - in people breathing shallowly (eg after surgery), it disappears after a few deep breaths.
 * pathologically - in pneumonia, in beginning and ending pneumonia. It can be associated with pulmonary infarction and infiltrative pulmonary tuberculosis, as well as with idiopathic pulmonary fibrosis (dry cracking).

Stridor
Stridor is a whistling to wheezing phenomenon, the cause is a narrowing of the large airways, there is an expiratory stridor or an inspiratio

Pleural frictional murmur
This sound phenomenon sounds like walking on frozen snow, it is best heard in the axillary area at the base of the lung and at the angle of the shoulder blade, it is characteristic of dry pleurisy, it disappears when exudation occurs.

Bronchophony
We examine bronchophony, or chest voice, by asking the patient to count (1, 2, 3), for example, or to repeat the expression "thirty-three." Above a healthy lung, we hear a chest voice very vaguely. The chest voice can be clearly heard over the areas of physiological tube breathing. Above other areas of the lung tissue only during its pathological thickening, when its conductivity increases.


 * Amplification - over condensed lung tissue; in pneumonia and pulmonary infarction,
 * attenuation - is audible during effusion, in pneumothorax, atelectasis and in thickening of the pleura.



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