Transcript 08 Auscultation of the lungs

Auscultation of the lungs.
Semiotics of the respiratory
system diseases. The
respiratory distress syndromes
of and respiratory failure,
general clinical symptoms
Respiratory System:
Primary function is to obtain
oxygen for use by body's cells
& eliminate carbon dioxide that
cells produce
Includes respiratory airways
leading into (& out of) lungs
plus the lungs themselves helpusobi 1
Pathway of air: nasal cavities (or
oral cavity) > pharynx >
trachea > primary bronchi
(right & left) > secondary
bronchi > tertiary bronchi >
bronchioles > alveoli (site of
gas exchange)
• The excha nge of gases (O2 & CO2) between the alveoli & the
blood occurs by simple diffusion: O2 diffusing from the alveoli into
the blood & CO2 from the blood into the alveoli. Diffusion requires a
concentration gradient. So, the concentration (or pressure) of O2 in
the alveoli must be kept at a higher level than in the blood & the
concentration (or pressure) of CO2 in the alveoli must be kept at a
lower lever than in the blood. We do this, of course, by breathing continuously bringing fresh air (with lots of O2 & little CO2) into the
lungs & the alveoli.
• Breathing is an active process - requiring the contraction of skeletal
muscles. The primary muscles of respiration include the external
intercostal muscles (located between the ribs) and the diaphragm (a
sheet of muscle located between the thoracic & abdominal cavities).
The external intercostals plus the diaphragm contract
to bring about inspiration:
• Contraction of
external intercostal
muscles > elevation
of ribs & sternum >
increased front- toback dimension of
thoracic cavity >
lowers air pressure in
lungs > air moves into
lungs
• Contrcnion of
diaphragm:
• diaphragm moves
downward >
increases vertical
dimension of thoracic
cavity > lowers air
pressure in lungs >
air moves into lungs:
The mecanizm of breathing
The mecanizm of breathing
The considerable differences in respiratory physiology between
infants and adults explain why infants and young children have a
higher susceptibility to more severe manifestations of respiratory
diseases, and why respiratory failure is common problem in
neonatal and pediatric intensive care units. The appreciation of the
peculiarities of pediatric respiratory physiology is not only essential
for correct assessment of any ill child, but also for correct
interpretation of any pulmonary function test performed in this
population.
Physiologicoanatomical
peculiarities of the respiratory
system
The peculiarities of the nose at the
neonate
a) The nose consists particular by of
cartilage,
b) The nasal meatuses are narrow,
c) There are not inferior nasal meatuses
(until 4 years),
d) Undeveloped submucosal membrane
(until 8-9 years).
The peculiarities of sinuses in
children
a) The maxillary sinus is
usually present at birth,
b) The frontal sinuses
begin to develop in early
infancy,
c) The ethmoid and
sphenoid sinuses develop
later in childhood.
The peculiarities of the pharynx at
the neonate
a) The
pharynx is relatively small and
narrow,
b) The auditory tubes are small, wide,
straight and horizontal
The peculiarities of the larynx at the
neonate
• a) The larynx is funnel-shaped (in the adult
it is relatively round),
• b) It is relatively long,
• c) The cricoid’s cartilage descendents
The peculiarities of the trachea at the
neonate
• a) The length of the trachea is relatively larger
(about 4 cm (in the adult -7)) and wide,
• b) It is composed of 15-17 cartilage rings (the
amount does not increase),
• c) The bifurcation of the trachea lies opposite the
third thoracic vertebra in infant and descends to
a position opposite the fourth vertebra in the
adult,
• d) Mucus membrane is soft, well-blood supplied,
but sometime dry,
• f) It can collapse easily.
The peculiarities of the bronchi at
the neonate
• a) In young children the bronchi are relatively
wide,
• b) The right bronchus is a straight continuation
of the trachea,
• c) The muscle and elastic fibers are
undeveloped,
• d) The bronchi are well blood supplied,
• e) The lobules and segmental bronchus are
narrow.
The functions of the bronchus
• a) The ciliated of mucus membrane
“sweeps” out dust particles,
• b) Transfer the gases into the lungs,
• c) Immunologic function
The functions of the lung are
• a) The main function of the lungs is the
exchange of oxygen and carbon dioxide,
• b) To produce surfactant
The peculiarities of the lungs at the
neonate
• a) Size of alveoli is smaller than in the
adult;
• b) Quantity of alveoli is relatively less than
in the adult.
Physiological reasons for the
increased susceptibility of infants for
respiratory compromise in comparison
to adults
Metabolism ^--------------------------------------Risk of apnoea ^---------------------------------Airway resistance ^
• Upper airway resistance ^-----------------
•
Lower airway resistance ^-----------------
Lung volume v------------------------------------Efficiency of respiratory muscles v-----------
Endurance of respiratory muscles v---------
O2 consumption ^
Immaturity of control of breathing
Nose breathing; Large tongue ;Airway size
v;Collapsibility ^;Pharyngeal muscle tone
v;
Compliance of upper airway structures ^
Airway size v; Collapsibility ^; Airway wall
compliance ^; Elastic recoil v
Numbers of alveoli v; Lack of collateral
ventilation
Efficiency of diaphragm v; Rib cage
compliance ^; Horizontal insertion at the
rib cage; Efficiency of intercostal muscles
v; Horizontal ribs
Respiratory rate ^; Fatigue-resistant type I
muscle fibres v
An average respiratory rate at rest of the
child of different age is:
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newborn
40-35 per minute,
•
infant at 6 months 35-30 per minute,
•
at 1 year
30 per minute,
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5 years
25 per minute,
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10 years
20 per minute,
• 12-18 years
16-20 per minute.
Disorders of the respiratory rate
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Tachypnea is the increase of the
respiratory rate.
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Bradypnea is the decrease of the
respiratory rate.
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Dyspnea is the distress during
breathing.
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Apnea is the cessation of breathing
Factors involved in increasing
respiratory rate
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Chemoreceptors - located in aorta & carotid
arteries (peripheral chemoreceptors) & in
the medulla (central chemoreceptors)
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Chemoreceptors (stimulated more by
increased CO2 levels than by decreased O2
levels) > stimulate Rhythmicity Area > Result
= increased rate of respiration
Heavy exercise ==> greatly increases
respiratory rate
Mechanism?
1.
NOT increased CO2
2.
Possible factors:
3.
–
reflexes originating from body
movements (proprioceptors)
–
increase in body temperature
–
epinephrine release (during exercise)
impulses from the cerebral cortex (may
simultaneously stimulate rhythmicity area &
motor neurons)
Form of thorax
Normostenic type
Disorders of the respiratory
depth
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Hyperpnea is an increased depth.
Hypoventilation is a decreased depth
and irregular rhythm.
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Hyperventilation is an increased rate
and depth.
Pathological respiration
• Seesaw (paradoxic) respirations: the
chest falls on inspiration and rises on
expiration. It is usually observed in
respiratory failure of third degree;
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Kussmau’sl breathing is
hyperventilation, gasping and labored
respiration, usually seen in diabetic coma
or other states of respiratory acidosis:
Decreased vocal fremitus in the upper
airway may indicate
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a) the obstruction of a major bronchus,
b) pneumo-, hydro-, haemothorax,
c) emphysema of lungs,
d) adiposity can also be the cause of
decreased vocal fremitus.
The voice of fremitus is
increased
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a) in pneumonia,
b) in abscess,
b) in atelectasis,
c) in cavern.
The pathological dullness is
heard in cause of
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pneumonia,
hydro-, haemothorax,
pulmonary edema,
lung or mediastinal tumor
The bandbox is heard in cause of
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emphysema of lungs,
cavern of lung,
abscess of lung,
pneumothorax,
bronchial asthma,
asthmatic bronchitis.
In topographic percussion the chest, the doctor
looks for the lungs’ borders.
Auscultation
Vesicular breath sounds are normally heard
over the entire surface of the lungs, with
the exception of the upper intrascapular
area and the area beneath the
manubrium. Inspiration is louder, longer,
and higher-pitched than expiration.
Sometimes the expiratory phase seems
nearly absent in comparison to the long
inspiratory phase. The sound is a soft,
swishing noise.
Bronchovesicular breath sounds
Bronchovesicular breath sounds are
normally heard over the manubrium and in
the upper intrascapular regions where
there are bifurcations of large airways,
such as the trachea and bronchi.
Inspiration is louder and higher in pitch
than that heard in vesicular breathing
Puerile breath sounds
Puerile breath sounds are one of normal
types of breathing in children by three
years old. Puerile breath sounds have shot
inspiration and louder, a hollow expiratory
phase, blowing character
Bronchial breath sounds
They are almost the reverse of vesicular
sounds; the inspiratory phase is short and
the expiratory phase is longer, louder, and
of higher pitch. They are usually louder
than any of the normal breath sounds and
have a hollow, blowing character.
Rough breath sounds
Have shot inspiration and louder
expiratory phase. Rough breath has
hollow and blowing character.
Absent or diminished breath
sounds
are always an abnormal finding
warranting investigation. Fluid, air, or solid
masses in the pleural space all interfere
with the conduction of breath sounds
(pneumonia, pneumo-, hydro-,
haemothorax, tumor of lung or
mediastinal, emphysema of lungs,
atelectasis, airways obstruction, a foreing
body in the bronchus).
Voice sounds
Voice sounds are also part of auscultation
of the lungs. Normally voice sounds or
vocal resonance is heard, but the syllables
are indistinct. They are elicited in the same
manner as vocal fremitus, except that the
doctor listens with the stethoscope
Whispered pectoriloquy,
• Whispered pectoriloquy, in which the child
whispers words and the nurse, hears the
syllables
Bronchophony,
Bronchophony, in which the child speaks
words that are not distinguishable but the
vocal resonance is increased in intensity
and clarity
Egophony
Egophony, in which the child says "ee,"
which is heard as the nasal sound "ay"
through the stethoscope
Method of percussion
Rales
Rales result from the passage of air through fluid
or moisture. They are more pronounced when
the child takes a deep breath. Even though the
sound may seem continuous, it is actually
composed of several discrete sounds, each
originating from the rupture of a small bubble.
The type of rales is determined by the size of the
passageway and the type of exudate the air
passes through. They are roughly divided into
three categories: fine, medium, and coarse
Fine rales
Fine rales (sometimes called crepitant rales) can
be simulated by rubbing a few strands of hair
between the thumb and index finger close to the
ear or by slowly separating the thumb and index
finger after they have been moistened with
saliva. The result is a series of fine crackling
sounds. Fine rales are most prominent at the
end of inspiration and are not cleared by
coughing. They occur in the smallest
passageways, the alveoli and bronchioles
Medium rales
Medium rales are not as delicate as fine
rales and can be simulated by listening to
the "fizz" from recently opened carbonated
drinks or by rolling a dry cigar between the
fingers. They are prominent earlier during
inspiration and occur in the larger
passages of the bronchioles and small
bronchi.
Coarse rales
Coarse rales are relatively loud, coarse,
bubbling, gurgling sounds that occur in the large
airways of the trachea, bronchi, and smaller
bronchi. Often they clear partially during
coughing. They are frequently heard in dying
patients because the cough reflex is depressed,
allowing thick secretions to accumulate in the
trachea and major bronchi. Because they are so
common when death is imminent, coarse rales
are often called "the death rattle."
Rhonchi
Rhonchi are sounds produced as air passes
through narrowed passageways, regardless of
the cause, such as exudate, inflammation,
spasm, or tumor. Rhonchi are continuous, since
sound is produced as long as air is being forced
past an obstruction. Although they are often
more prominent during expiration, they are
usually present during both phases of
respiration. Rhonchi are classified according to
pitch as sibilant or sonorous
Sibilant rhonchi
Sibilant rhonchi are high pitched, musical,
wheezing, or squeaking in character. The
wheezing quality is often more
pronounced on forced expiration. Sibilant
rhonchi are produced in the smaller
bronchi and bronchioles
Sonorous rhonchi
Sonorous rhonchi are low pitched and
often snoring or moaning in character.
They are produced in the large passages
of the trachea and bronchi. Like coarse
rales, they can be partly cleared by
coughing
Respiratory system disorder
syndromes
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Syndrome of consolidation or compression of the lung tissue.
Syndrome of bronhoobstruction.
Syndrome of respiratory failure.
Syndrome of respiratory distress.
Syndrome of atelectasis.
Syndrome of pneumothorax.
Syndrome of liquid in the plural cavity.
Syndrome of laryngotracheitis.
Syndrome of bronchitis.
Syndrome of congenital stridor.
Syndrome of cough.
Croup Syndromes
1 Acute laryngotracheitis.
Laryngotracheobronchitis.
2.Spasmodic croup (more abrupt onset, milder course).
Etiology. Viral coup syndrome is caused by a viral infection in the subglottic area of
the larynx transmitted. Most cases involve children age 3 months to 3 years. Peak
incidence of the disease is in late autumn, early winter.
Clinical Findings
Often occurring at nigh.
Croupy (barky) cough.
Inspiratory dyspnea.
Hoarseness
Coryza (catarrh).
Fever.
Intercostal, suprasternal, infrasternal retractions.
Respiratory rate slightly increased
Croup Syndromes
Croup Syndromes
Croup Syndromes
Croup Syndromes
Acute Epiglottitis
Epiglottitis is an
infection of the
epiglottis and
supraglottic
structures.The child
may also show
intercostal retractions
and perioral cyanosis
and sounds stridorous
Acute Epiglottitis
Do not attempt direct
visualization of the
epiglottis by
depressing the
tongue as this may
cause reflex
laryngospasm and
obstruction, which
may lead to
respiratory arrest
Foreign body aspiration
Foreign body aspiration is occurred of aspiration of small objects (seeds, nuts, toy
parts, buttons, pebbles) into laryngotracheal are or main stem bronchus. Aspiration
is frequent in children between 7 months and 4 years.
Clinical Findings
Signs and symptoms depend on degree of obstruction and nature of the foreign body.
The parents describe in history of disease that child was swallowing or playing with a
small object followed by sudden onset of cough, choking or gagging or wheezing.
There may be a period of no symptoms following initial episode.
Foreign body aspiration clinic depends on the level of obstruction. Laryngeal foreign
bodies may completely obstruct airways and may elicit stridor, high pitched
wheezing, cough or aphonia and cyanosis.
Tracheal foreign bodies usually elicit cough, some stridor or wheezing and may
produce "slap" sound
Bronchial foreign bodies usually cause wheezing or coughing and are frequently
misdiagnosed as asthma; may present with decreased vocal fremitis, impaired or
hyperresonant percussion note, and diminishes breath sounds distal to foreign body.
Diagnostic tests
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Upper airway foreign bodies may be visualized on
standard roentgenography.
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Bronchoscopy is usually required for definitive
diagnosis of foreign bodies in the larynx and trachea.
Treatment
1. Establish airway if child is in obvious distress.
2. Back blows, Heimlich maneuver.
3. Removed by means of direct laryngoscopy or
bronchoscopy.
4. Prevention is most important aspect; age appropriate
anticipatory guidance, including siblings.
Thank you for attention