Topic of the lecture:

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• Topic of the lecture
• Symptoms of diseases of respiratory organs based
  o data of auscultaion of lungs

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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 other4. 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.
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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.
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1. Apices of lungs extend above clavicles.2.
Horizontal fissure follows right 4th rib3.
Oblique fissures on both sides extend to 6th rib
anteriorly4. Left lung has large deficit
anteriorly extending from 4th to 6th rib and from
sternum to costochondral joint cardiac
notch5. Both lungs extend to 8th rib
laterally6. Parietal pleura extends down to 9th
rib laterally
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Posterior Aspect7. 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 laterally10. Parietal pleura extend to T12
medially and 10th rib laterally
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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.

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Expiration
Inspiration
heard only during the first third of the
expiration phase
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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.
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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.
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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.
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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.
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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)
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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
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Respiratory sounds known as bronchial or tubular
breathing arise in the larynx and the trachea as
air passes through the vocal slit.

?xpiration
Inspiration
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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.
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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.
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Adventitious sounds are rales, crepitation, and
pleural friction.
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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.
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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.
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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).
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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.
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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.
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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.
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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.
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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.
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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.
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Common errors of auscultation __Auscultating
one entire lung, and then moving to the other
lung __Auscultating over a patients gown or
article of clothing __Beginning auscultation
inferiorly at the lower lung fields __Moving
your stethoscope before each exhalation is
complete __Examiner does not make the room quiet
enough to hear breath sounds.
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Listen to the respiratory rate, including rhythm
and depth of respirations. Compare rate with
normal respiratory rates for the age of the
client.
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Auscultate the lungs, listening to inspiration
and expiration at each site.
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?Vesicular breathing sounds
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Normal and abnormal respiratory patterns
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