1. Topic of the lecture: Symptoms of diseases of respiratory organs based o data of auscultaion of lungs

2. 1.It is important that you try to create a quiet environment as much as possible. 2. Put on your stethoscope so that the ear pieces are directed away from you. Adjust the head of the scope so that the diaphragm is engaged. If you're not sure, scratch lightly on the diaphragm, which should produce a noise. If not, twist the head and try again. Gently rub the head of the stethoscope on your shirt so that it is not too cold prior to placing it on the patient's skin. 3. The upper aspect of the posterior fields (i.e. towards the top of the patient's back) are examined first. Listen over one spot and then move the stethoscope to the same position on the opposite side and repeat. This again makes use of one lung as a source of comparison for the other 4. Then, move around to the front and listen to the anterior fields in the same fashion. 5. Don't get in the habit of performing auscultation through clothing.

3. 5. Ask the patient to take slow, deep breaths through their mouths while you are performing your exam. This forces the patient to move greater volumes of air with each breath, increasing the duration, intensity, and thus detectability of any abnormal breath sounds that might be present. 6. Sometimes it's helpful to have the patient cough a few times prior to beginning auscultation. This clears airway secretions and opens small atelectatic (i.e. collapsed) areas at the lung bases. 7. If the patient cannot sit up (e.g. in cases of neurologic disease, post-operative states, etc.), auscultation can be performed while the patient is lying on their side. 8. Requesting that the patient exhale forcibly will occasionally help to accentuate abnormal breath sounds (in particular, wheezing) that might not be heard when they are breathing at normal flow rates.

7. 1. Apices of lungs extend above clavicles. 2. Horizontal fissure follows right 4th rib 3. Oblique fissures on both sides extend to 6th rib anteriorly 4. Left lung has large deficit anteriorly extending from 4th to 6th rib and from sternum to costochondral joint – cardiac notch 5. Both lungs extend to 8th rib laterally 6. Parietal pleura extends down to 9th rib laterally

8. Posterior Aspect 7. Much of left and right upper portions of lungs are covered by scapulae. 8. Oblique fissures extend from spinous processes of T2. 9. Lungs extend down to T11 medially and 9th rib laterally 10. Parietal pleura extend to T12 medially and 10th rib laterally

11. 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. Inspiration Expiration heard only during the first third of the expiration phase

12. The vesicular breath sound can be simulated by pronouncing the sound “f” during inspiration, or by drawing tea from saucer. Alveolar walls still vibrateat the initial expiration phase to give a shorter second phase of the vesicular breathing, which is heard only during the first third of the expiration phase because vibrations of elastic alveolar walls are quickly dampened by the decreasing tension of the alveolar walls.

13. 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.

14. 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.

15. 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.

16. 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). 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)

17. Bronchial breathing. 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

18. Respiratory sounds known as bronchial or tubular breathing arise in the larynx and the trachea as air passes through the vocal slit. Еxpiration Inspiration

19. Bronchial breathing can be heard instead of vesiculai ( or in addition to the vesicular breathing) over the chest in pulmonary pathology. This breathing is called pathological bronchial respiration.

20. 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.

21. Adventitious sounds are rales, crepitation, and pleural friction.

22. 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.

23. 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.

24. 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).

25. 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.

26. 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.

27. 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. 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.

28. 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.

30. 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.

31. 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.

32. Common errors of auscultation: __Auscultating one entire lung, and then moving to the other lung __Auscultating over a patient’s 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.