Main breath sounds. Vesicular (alveolar) respiration; bronchial (laryngotracheal) breathing; mixed breathing. Respiratory system: auscultation of the lungs and determination of bronchophony

It is used to determine the nature of respiratory sounds and study the phenomenon of bronchophony. It is advisable to conduct the study with the patient standing or sitting. The patient's breathing should be smooth and of medium depth. Listening is carried out in symmetrical areas chest. Auscultation sequence various departments lungs is the same as during comparative percussion. If there is pronounced hair, the chest is moistened or greased before auscultation.

The doctor stands in front of the patient and alternately listens on both sides, first in the supra- and subclavian fossae, and then in the underlying sections on the left - to the level of the third rib, corresponding upper limit heart, and on the right - to the border of hepatic dullness (the woman, if necessary, at the request of the doctor, takes the right mammary gland outward).

After this, he invites the patient to raise his hands behind his head and listens in symmetrical areas in the lateral sections of the chest along the anterior, middle and posterior axillary lines from the axillary fossae to the lower borders of the lungs. Next, the doctor stands behind the patient, asks him to lean forward slightly, lowering his head, and cross his arms over his chest, placing his palms on his shoulders. At the same time, the shoulder blades move apart and the listening field in the interscapular space expands. First, he performs auscultation alternately in both suprascapular areas, then in the upper, middle and lower parts of the interscapular space on both sides of the spine and then in the subscapular areas along the scapular and paravertebral lines to the lower borders of the lungs. IN lower parts Auscultation of the lungs should be carried out taking into account the displacement of the pulmonary edge during inspiration.

First, the lungs are listened to as the patient breathes through the nose. At each point, auscultation is carried out for at least 2-3 respiratory cycles. The nature of the sounds that arise in the lungs in both phases of breathing is determined, first of all, the characteristics of the so-called main respiratory noise (timbre, volume, duration of sound during inhalation and exhalation) and compare it with the main respiratory noise over a symmetrical area of ​​the other lung.

If additional auscultatory respiratory phenomena (adverse respiratory sounds) are detected, auscultation is repeated in the appropriate areas, asking the patient to breathe more deeply and through the mouth. At the same time, the nature of the noise, its timbre, homogeneity, sound volume, relation to the phases of breathing, prevalence, as well as the variability of the noise over time, after coughing, with the deepest possible breathing and using the “imaginary breathing” technique are determined.

If necessary, listening is carried out with the patient lying on his back or side. In particular, sound phenomena in the central parts of the lungs are better identified by auscultation in the axillary fossae in a side lying position with a hand raised behind the head. During auscultation, the doctor must ensure that the patient's breathing is not too rapid, since, otherwise, hyperventilation syncope is possible.

If pathological auscultatory phenomena are detected, it is necessary to indicate the coordinates of the area of ​​the chest where they are heard.

With absence pathological changes in the respiratory system above the lungs, the so-called normal basic breath sounds. In particular, over most of the lung surface is determined vesicular respiration. It is perceived as a continuous, uniform, soft, blowing, rustling noise, reminiscent of the sound “f”. Vesicular breathing is heard during the entire inhalation and in the initial third of exhalation, with the maximum noise sound occurring at the end of the inhalation phase. Vesicular breathing noise, heard during the inhalation phase, is formed in the peripheral parts of the lungs. It represents the sound of an expanding lung and is caused by vibrations of the walls of many alveoli due to their transition from a collapsed state to a tense state when filled with air. In addition, vibrations that occur during repeated dissection of the air stream in the labyrinths of branches (dichotomies) of the smallest bronchi are important in the formation of vesicular respiration. It is believed that the short and quiet noise heard during vesicular breathing at the beginning of the expiratory phase is the sound of the alveoli transitioning to a relaxed state and, in part, a conductive sound from the larynx and trachea.

In children and adolescents, due to age-related anatomical features structure of lung tissue and thin chest wall, vesicular breathing is sharper and louder than in adults, slightly resonating, with a clearly audible exhalation - puerile breathing(from lat. puer - child, child). Vesicular breathing of a similar nature occurs in febrile patients.

Another type of normal basic breath sound heard over the larynx and trachea is called laryngotracheal breathing. This breath sound occurs as a result of vibration of the vocal cords as air passes through the glottis. In addition, the friction of the air stream against the walls of the trachea and large bronchi and its vortex at the places of their bifurcations are important in the formation of laryngotracheal breathing.

Laryngotracheal breathing in its sound resembles the sound “x” and is heard both during inhalation and throughout exhalation, and the noise heard during exhalation is rougher, louder and longer lasting than the noise heard during inspiration. This is mainly due to the fact that the glottis is narrower during exhalation than during inhalation.

Normally, during auscultation over the chest, laryngotracheal breathing is detected only at the manubrium of the sternum and sometimes also in the upper part of the interscapular space to level IV thoracic vertebra, i.e. in the projection of the tracheal bifurcation. Over the rest of the lungs, laryngotracheal breathing is not normally heard, since the vibrations that cause it are attenuated at the level of small bronchi (less than 4 mm in diameter) and, in addition, are drowned out by the noise of vesicular breathing.

In case of diseases of the respiratory system over the entire surface of the lungs or over individual areas of the lung tissue, instead of vesicular breathing, pathological basic respiratory sounds are determined, in particular, weakened vesicular, hard or bronchial breathing.

Weakened vesicular respiration differs from normal in a shortened and less clearly audible inhalation and almost inaudible exhalation. Its appearance over the entire surface of the chest is characteristic of patients with pulmonary emphysema and is caused by a decrease in the elasticity of the lung tissue and a slight expansion of the lungs during inhalation. In addition, weakening of vesicular breathing can be observed when the patency of the upper respiratory tract is impaired, as well as when the depth of breathing excursions lungs, for example, due to a sharp weakening of patients, damage to the muscles or nerves involved in breathing, ossification of the costal cartilages, increased intra-abdominal pressure or pain in the difficult cell caused by dry pleurisy, rib fractures, etc.

A sharp weakening of vesicular breathing or even the complete disappearance of respiratory sounds is observed when the lung is pushed away from the chest wall by the accumulation of air or fluid in the pleural cavity. With pneumothorax, vesicular breathing weakens evenly over the entire surface of the corresponding half of the chest, and in the presence of pleural effusion - only over its lower parts in places of fluid accumulation.

Local disappearance of vesicular breathing over any part of the lung can be caused by complete closure of the lumen of the corresponding bronchus as a result of its obstruction by a tumor or external compression by enlarged lymph nodes. Thickening of the pleura or the presence of pleural adhesions, which limit respiratory excursions of the lungs, can also lead to a local weakening of vesicular respiration.

Sometimes a kind of intermittent vesicular breathing is heard over a limited area of ​​the lung, characterized in that the inhalation phase consists of 2-3 separate short intermittent breaths, quickly following one after the other. Exhalation remains unchanged. The occurrence of such intermittent breathing is explained by the presence in the corresponding area of ​​a slight obstruction to the passage of air from the small bronchi and bronchioles to the alveoli, which leads to their non-simultaneous straightening. The cause of local intermittent breathing is most often a tuberculous infiltrate. Hard breathing occurs with inflammatory damage to the bronchi (bronchitis) and focal pneumonia. In patients with bronchitis, the bronchial wall thickens, which creates conditions for the weakened noise of laryngotracheal breathing to be transmitted to the surface of the chest, which is layered on the preserved noise of vesicular breathing. In addition, in the formation of hard breathing in patients with bronchitis, the uneven narrowing of the lumen of the bronchi and the unevenness of their surface are important, due to swelling and infiltration of the mucous membrane and deposits of viscous secretions on it, which causes an increase in the speed of air flow and increased friction of air against the walls of the bronchi.

In patients with focal pneumonia, heterogeneous small-focal infiltration of the lung tissue occurs. In this case, in the lesion, areas of inflammatory compaction and areas of unchanged lung tissue alternate, i.e. there are conditions for both the formation of vesicular respiration and the conduction of components of laryngotracheal respiration. As a result, a hard breathing.

The sound of hard breathing in its acoustic properties seems to be transitional between vesicular and laryngotracheal: it is louder and rougher, as if rough, and is heard not only during inhalation, but also during the entire exhalation phase. In case of severe obstruction of the patency of the smallest bronchi (bronchial asthma, acute asthmatic bronchitis, chronic obstructive bronchitis) the sound of hard breathing heard during exhalation becomes louder and longer lasting compared to the sound heard during inspiration.

In some pathological processes, vesicular respiration does not form in the affected areas of the lung tissue or it sharply weakens, while at the same time conditions arise that facilitate laryngotracheal respiration in the peripheral parts of the lungs. Such pathological laryngotracheal breathing, determined in places unusual for it, is called bronchial breathing. In its sound, bronchial breathing, like laryngotracheal breathing, resembles the sound “x” and is heard both on inhalation and exhalation, and the noise heard on exhalation is louder, rougher and longer lasting than the noise heard on inspiration. To make sure that what is being heard over the area lung respiratory the noise really represents bronchial breathing; for comparison, auscultation should be performed over the larynx and trachea.

Bronchial breathing is typical for patients with lobar pneumonia in the stage of hepatization, because in this case, a large focus of homogeneous compaction appears in the lung tissue, located continuously from the lobar or segmental bronchus to the surface of the corresponding lobe or segment, the alveoli of which are filled with fibrinous exudate. Less loud (weakened) bronchial breathing can also be detected with pulmonary infarction and incomplete compression atelectasis, since significant areas of lung tissue are compacted while the lumen of the corresponding large bronchi is fully or partially preserved.

A special type of bronchial breathing is amphoric breathing, which, under certain conditions, is heard over cavity formations in the lungs and represents increased and modified laryngotracheal breathing. It is heard both during inhalation and throughout exhalation, reminiscent of a booming sound that occurs if you blow, directing a stream of air obliquely, over the neck of an empty vessel, for example, a bottle or decanter (amphora - a Greek thin-walled clay vessel with an elongated narrow neck). The formation of amphoric respiration is explained by the addition of additional high overtones to laryngotracheal respiration due to repeated reflection sound vibrations from the walls of the cavity. For it to appear, it is necessary that the cavity formation be located close to lung surface, had large dimensions (at least 5 cm in diameter), and elastic, smooth walls surrounded by compacted lung tissue. In addition, the cavity must be filled with air and communicate with a sufficiently large bronchus. Such cavity formations in the lungs are most often a tuberculous cavity or an emptied abscess.

During pathological processes in the respiratory system above the lungs, so-called secondary respiratory sounds can be heard, layered on one or another, usually pathological, main respiratory sound. Adverse respiratory sounds include dry and moist rales, crepitus and pleural friction noise.

Wheezing are the most common adverse respiratory sounds that occur in the bronchi or pathological cavities due to the movement or fluctuation of pathological secretions in their lumen: mucus, exudate, pus, transudate or blood. The nature of wheezing depends on a number of factors, in particular, on the viscosity of the secretion, its quantity, localization in the bronchial tree, smoothness of the surface of the bronchi, bronchial patency, conductive properties of the lung tissue, etc. Wheezing is divided into dry and wet.

Dry wheezing(ronchi sicci) arise from pathology of the bronchi and are prolonged sound phenomena, often of a musical nature. Based on the timbre and pitch of sound, there are two types of dry wheezing: whistling and buzzing. Whistling, or treble, wheezing (ronchi sibilantes) are high-pitched sounds, reminiscent of a whistle or squeak, and buzzing, or bass, wheezing (romchi sonori) are lower-pitched sounds, like buzzing or howling.

The occurrence of dry wheezing is caused by an uneven narrowing of the lumen of the bronchi due to the accumulation of dense, viscous mucus in them. It is believed that wheezing wheezes are formed mainly in the small bronchi and bronchioles, and buzzing wheezes are formed mainly in the medium and large bronchi. It is also believed that vibrations created by threads and bridges formed from a viscous, viscous secretion in the lumen of the bronchi and vibrating as air passes have a certain significance in the occurrence of buzzing wheezing. At the same time, there is currently reason to believe that the pitch of dry wheezing depends not so much on the caliber of the bronchi, but on the speed of the air stream passing through the unevenly narrowed lumen of the bronchus.

Dry wheezing is heard both during inhalation and exhalation, and is usually combined with harsh breathing. They can be single or multiple, heard over the entire surface of both lungs or locally, sometimes so loud that they drown out the main respiratory noise and can be heard even at a distance. The prevalence and loudness of dry rales depend on the depth and extent of bronchial damage. Usually dry wheezing is unstable: after repeated deep breaths or coughing, they can disappear for a while or, conversely, intensify and change their timbre. However, if there is a spasm of the smooth muscles of the small and minute bronchi or a violation of the elastic properties of the bronchial wall, then dry, mainly wheezing wheezes become more stable, do not change after coughing and are heard mainly on exhalation. Such wheezing is typical for patients with bronchial asthma, acute asthmatic bronchitis and chronic obstructive bronchitis.

Wet wheezing(ronchi humidi) are intermittent sound phenomena, consisting, as it were, of individual short sounds, reminiscent of the sounds that arise in a liquid when air is passed through it. The formation of moist rales is associated with the accumulation of liquid secretions in the lumen of the bronchi or cavity formations. It is believed that when breathing, a stream of air, passing through such a secretion, foams a low-viscosity liquid and forms instantly bursting air bubbles on its surface, which is why moist rales are sometimes called bubbly rales.

Moist rales, as a rule, are heterogeneous in sound and are heard in both respiratory phases, and during inspiration they are usually louder and more abundant. In addition, moist rales are not constant: after coughing, they may temporarily disappear and then reappear.

Depending on the caliber of the bronchi in which moist rales arose, they are divided into small-, medium- and large-bubble.

Fine bubbling moist rales are formed in small bronchi and bronchioles, they are usually multiple and are perceived as the sounds of bursting small and tiny bubbles.

Medium and large bubbling moist rales arise, respectively, in the bronchi of medium and large caliber, as well as in cavity formations communicating with the bronchus and partially filled with fluid (tuberculous cavity, abscess, bronchiectasis). These wheezes are less abundant and are perceived as the sounds of larger bubbles bursting.

Based on the volume of sound, sonorous and silent moist rales are distinguished.

Sonorous (consonant) moist rales are characterized by clarity, sharpness of sound and are perceived as loudly bursting bubbles. They arise in compacted pulmonary tissue or in cavities with dense walls, therefore, sonorous moist rales are usually detected against the background of hard or bronchial breathing and, as a rule, are heard locally: small and medium bubbling - above the area of ​​pneumonic infiltration, and large bubbling - above cavity formations.

Silent (non-consonant) moist rales are perceived as muffled sounds, as if emanating from the depths of the lungs. They arise in the bronchi, surrounded by unchanged lung tissue, and can be heard over a significant surface of the lungs. Scattered, silent, fine, moist rales are sometimes detected in patients with bronchitis, usually in combination with dry rales and harsh breathing. At venous stagnation in the pulmonary circulation, intermittent small-bubbly, silent moist rales are heard over the lower parts of the lungs. In patients with increasing edema of the pulmonary tissue, silent moist rales consistently appear above the lower, middle and upper sections both lungs, while the caliber of wheezing gradually increases from small bubbles to medium and large bubbles, and in terminal stage swelling appears, the so-called bubbling wheezes that form in the trachea.

Crepitus(crepitatio - crackling) is an collateral respiratory noise formed as a result of the simultaneous disintegration of a large number of alveoli. Crepitation is perceived in the form of a short-term volley of many short homogeneous sounds appearing at the height of inspiration. In its sound, crepitus resembles the crackling of cellophane or the rustling sound that occurs when rubbing a tuft of hair near the ear with your fingers.

Crepitation is better heard during deep breathing and, unlike moist rales, is a stable sound phenomenon, because does not change after coughing. In the formation of crepitus, the main significance is the disruption of the production of surfactant in the alveoli. In normal lung tissue it is superficial active substance covers the walls of the alveoli and prevents them from sticking together during exhalation. If the alveoli are deprived of surfactant and moistened with sticky exudate, then when exhaling they stick together, and when inhaling they soundly come apart.

Most often, crepitus is heard in patients with lobar pneumonia. In particular, in the early stage of the disease when it appears in the alveoli fibrinous exudate The surfactant layer is disrupted, resulting in crepitation (crepitatio indux) above the lesion. However, as the alveoli fill with exudate and the lung tissue thickens, the crepitus soon gives way to sonorous, fine-bubbly moist rales. In the stage of resolution of pneumonic infiltration with partial resorption of exudate from the alveoli, but still insufficient production of surfactant, crepitation appears again (crepitatio redux).

With lower lobe lobar pneumonia in the resolution stage, the mobility of the lower pulmonary edge is gradually restored, so the area for listening to crepitus, which occurs at the height of inspiration, shifts downward. This fact must be taken into account when performing auscultation. Widespread and persistent crepitus is often detected in patients with diffuse inflammatory and fibrosing processes in the connective tissue lungs, in particular, with allergic alveolitis, Hammen-Rich disease, systemic scleroderma etc. Transient crepitus can sometimes be heard in early stages development of edema, atelectasis and pulmonary infarction.

Pleural friction rub is the characteristic and only objective symptom of dry (fibrinous) pleurisy. In addition, it can occur when it is seeded with cancer metastases, renal failure(uremia) and severe dehydration.

Normally, the sliding of smooth and moistened layers of pleura during breathing occurs silently. Pleural friction noise appears when fibrin films are deposited on the surface of the pleural layers, their uneven thickening, roughness or severe dryness. It is an intermittent sound, developing as if in several stages, heard in both phases of breathing. This noise can be quiet, gentle, similar to the rustling of silk fabric, in other cases, on the contrary, it can be loud, rough, as if scratching or scraping, reminiscent of the creaking of new leather, the rustle of two sheets of paper folded together, or a crunch. snow crust under your feet. Sometimes it is so intense that it is even palpable. It can be reproduced by pressing your palm tightly to your ear and running the finger of your other hand along its back surface.

Pleural friction noise is usually heard in a limited area. Most often it can be detected in the inferolateral parts of the chest, i.e. in places of maximum respiratory excursions of the lungs, and least often - in the area of ​​the apexes due to their insignificant respiratory mobility. The pleural friction noise is perceived during auscultation as a sound that occurs at the very surface of the chest wall, intensifies when pressing on it with a stethoscope, does not change after coughing, but can spontaneously disappear and then reappear.

When a significant amount of exudate accumulates in the pleural cavity, it usually disappears, but after resorption of the effusion or its removal by pleural puncture, the noise reappears, and sometimes persistently persists for many years after recovery due to irreversible cicatricial changes in the pleural layers.

Unlike other adverse respiratory sounds, pleural friction noise is also heard during “imaginary breathing”. This technique consists in the fact that the patient, having exhaled completely, then closed his mouth and pinched his nose with his fingers, makes movements with the diaphragm (stomach) or ribs as if inhaling air. In this case, the visceral layers of the pleura slide over the parietal layers, but there is practically no movement of air through the bronchi. Therefore, wheezing and crepitus with such “imaginary breathing” disappear, and the pleural friction noise continues to be heard. However, it should be taken into account that for some pathological conditions it may be associated with other associated breath sounds, such as moist rales.

If local changes are detected in a patient during examination of the respiratory system voice tremors, pathological percussion or auscultatory symptoms, it is necessary to determine bronchophony over this area of ​​the lung and a symmetrical area of ​​the other lung. This phenomenon is the acoustic equivalent of a palpable vocal tremor and gives an idea of ​​the propagation of sound from the vocal cords of the larynx along the air column of the bronchi to the surface of the chest.

The patient is asked to repeat in a whisper (without voice) words containing hissing sounds, for example: “a cup of tea” or “sixty-six”. The doctor listens to the areas of the lungs selected for examination. The words spoken by the patient are normally indistinguishable, the sounds merge and are perceived as an unclear hum. In this case, they speak of negative bronchophony. If the doctor clearly hears words spoken in a whisper (positive bronchophony), this indicates the presence of compaction of lung tissue in the area being examined (lobar pneumonia, pulmonary infarction, incomplete compression atelectasis) or a large cavity communicating with the bronchus and having dense walls. At the same time, it must be borne in mind that with a small size and deep location of the focus of compaction or cavity formation, bronchophony can be negative.

Methodology for studying the objective status of the patient Methods for studying objective status General examination Local examination Cardiovascular system Respiratory system

Finally, the voice is heard. Listening is done directly with the ear or through a stethoscope, which should be applied firmly and with moderate pressure on symmetrical areas of the chest. Both loud speech (possibly lower tones are desirable) and stomp are heard. When listening to a voice (directly with the ear), the vocal tremor is also very well felt, and this circumstance should be used to determine the latter, especially since it is usually felt under these conditions more clearly than when feeling it with the hand.

The order of listening sites is generally the same as for percussion, i.e. apexes, anterior surface of the lungs (from top to bottom), lateral surfaces (from the axillary fossae downwards with the arms thrown over the head), back surface(under the shoulder blades, in the interscapular areas, above the shoulder blades). They listen in symmetrical places and alternately on one side or the other, comparing the auscultation data with each other, i.e., in other words, comparative auscultation is performed each time in the same way as comparative percussion.

Indicative auscultation, i.e., rapid auscultation mainly in certain places where pulmonary-pleural changes are most often detected (apexes, especially behind; interscapular, subclavian and axillary areas), best performed directly by the ear in order to simultaneously capture a larger space, is desirable in general and convenient as a preliminary stage of research before systematic detailed auscultation of the lungs. In addition, such accelerated auscultation is mandatory in all severely ill patients to avoid unnecessary fatigue.

Perceived by listening respiratory organs spontaneously occurring sounds or noises are divided into three main groups: 1) respiratory sounds, 2) side sounds or wheezing and 3) pleural friction noise.

Breath sounds
Breathing noises, by their nature, can in turn be divided into two main types - vesicular and bronchial breathing.

When auscultated over the larynx (lower neck), trachea, and major bronchi (upper chest), a breath sound resembling an "x" sound is heard, with the exhalation being louder, rougher, and longer than the inhalation. This noise is formed in the larynx when air passes through the glottis due to the air circulation when inhaling above vocal cords, and when exhaling - under them. Since during exhalation the glottis is more narrowed than during inhalation, the sound produced is stronger, rougher and longer. This is the so-called laryngeal, tracheal or bronchial respiratory noise. It is usually called bronchial breathing.

When listening on the rest of the chest, a noise of a completely different nature is heard. This is a soft, blowing, sucking sound, reminiscent of the sound “f”. This sound, in contrast to bronchial noise, is stronger and longer when inhaling, weaker and shorter when exhaling. At the beginning of inhalation, in the first third, it is weak and hard to hear, then quickly intensifies, and with the beginning of exhalation it weakens again and is heard only in the first third of exhalation. This breathing noise is called vesicular breathing.

There is still no complete consensus regarding the origin of vesicular respiration. Basically, two theories oppose each other. One believes that vesicular breathing is essentially the same laryngeal noise, but modified when it spreads along the bronchial tree and when heard through the lung tissue. According to another theory, currently generally accepted and based on experiment, vesicular respiratory noise is an independent noise formed in the pulmonary parenchyma due to the penetration of air into the pulmonary alveoli and the resulting tension in their walls.

Vesicular respiration. The strength of vesicular respiration depends on the strength of respiratory movements, the power of the underlying areas of the lung tissue, the thickness of the tissue layer of the chest wall, etc. In connection with these points, the strength of vesicular respiration varies significantly among different people depending on their constitution (in asthenics it is stronger, in hypersthenics it is weaker), on age, state of nutrition, etc.; it also varies in different places of the chest of the same person. Pronounced vesicular breathing with clearly audible exhalation in children is called “puerile breathing” (puer - boy). This “puerile” breathing pattern persists in them until the age of twelve to fourteen and is explained, in addition to the thinness and elasticity of the chest, also by the relative narrowness of the bronchi.

Vesicular breathing is most clearly expressed on the anterior surface of the chest, especially in the subclavian regions. The second place in intensity is occupied by the subscapular areas. Behind them come the inferolateral parts of the lungs ( bottom half axillary region); further - the lower edges of the lungs (due to thinning of the lung tissue). Weak vesicular breathing is heard at the tops of the lungs (insignificant volume, low respiratory mobility, thick muscle cover behind).

There is also some difference in the breathing of different halves of the chest, both in its strength - on the left, breathing is usually somewhat clearer (due to the proximity of the gastric air bladder), - and especially in the degree of severity of exhalation: on the right, the exhalation is more pronounced than on the left (due to a wider and shorter main bronchus and the associated improvement in the conduction of physiological bronchial respiration from the larynx). This difference in terms of the intensity of exhalation is especially noticeable at the apexes: at the right apex the exhalation is much more defined and longer than at the left (more horizontal position of the right apical bronchus and greater proximity to the trachea of ​​the right apex than the left). Sometimes breathing is heard above the right apex, which is something between vesicular and bronchial breathing, as if a mixture of them - “broncho-vesicular or mixed breathing.” In general, this difference in auscultation data (as well as percussion and determination of vocal tremor) when examining the pulmonary apices must be clearly imagined, since it has a large practical significance. For Cabot is absolutely right when he says: “Respiratory sounds, which are completely normal over the right apex, would mean serious illness, if they were heard over the same part of the left lung.”

Special forms of vesicular respiration. This may include puerile respiration, which has already been mentioned and which is a more or less sharply enhanced vesicular respiration.

Intermittent, or saccadic, breathing is vesicular breathing that does not occur continuously, as usual, but in the form of a series of separate short breaths, interrupted by the same short pauses; exhalation, as a rule, remains continuous. The reason for such breathing, if it extends to the entire space of the lungs, is uneven contraction of the respiratory muscles (fatigue, muscle tremors in the cold, muscle disease, etc.). If saccadic breathing is heard in a specific and strictly limited place, then it indicates a narrowing of the small bronchi in this area of ​​the lung, an inflammatory process in them, usually of tuberculosis origin. The change in the nature of breathing depends in both cases on the fact that air enters the alveoli not in one, but in several stages.

Vesicular breathing, synchronous with cardiac systole, is often heard close to the heart and to the left behind, at the base of the lung. It is explained by the fact that with each systole, due to a decrease in the volume of the heart, the adjacent areas of the lung are released from compression, which are immediately filled with air from the parts surrounding them, which gives the characteristic noise. This form of vesicular breath sound in itself is not particularly significant. It must be known in order not to be confused with saccadic breathing and intracardiac murmurs.

Changes in vesicular respiration under pathological conditions. Vesicular respiration may vary depending on pathological cases either in the direction of strengthening it, or in the direction of weakening it.

Increased vesicular respiration may be limited to only one phase or spread to both. In the first case, it is usually about increased exhalation, and since this increase is always accompanied by an increase in its duration, this phenomenon is called prolonged exhalation.

Lengthening of exhalation is based on its difficulty, which in turn may depend either on the weakening of the elastic properties of the lung tissue, or on the narrowing of the small and minute bronchi.

The first reason occurs with pulmonary emphysema, the second - with widespread inflammation of the bronchial mucosa (spread bronchitis) or widespread bronchospasm (bronchial asthma). In these cases, it is clear that an extended exhalation is heard throughout the entire length of the lungs. Its appearance in limited areas indicates local reasons, mainly inflammatory processes leading to local compaction of lung tissue. Often, prolongation of exhalation occurs at the apexes of the lungs, but its assessment here requires special caution in connection with the already indicated physiological characteristics breathing and its difference at the tops.

Hard breathing. Strengthening both phases of vesicular respiratory noise, inhalation and exhalation, gives breathing the same acoustic character as puerile breathing, but the mechanism of its development is different. Three points mainly play a role here: 1) an increase in respiratory movements and the ventilation function of the lungs - both, for example, with an increase in body temperature (febrile diseases), or one of them when the other is affected - the so-called compensatory increase in breathing; 2) narrowing of the lumen (small bronchi (bronchitis) - narrowing, more pronounced than in cases of only prolonged exhalation; 3) compaction lung tissue and the associated improvement in sound conduction, whatever it is caused by, if the foci of compaction are small and interspersed with normal lung tissue (for example, bronchopneumonia). This enhanced and coarser vesicular breathing is called hard breathing.
The weakening of vesicular breathing, in addition to the general muffling of sound, is also characterized by the fact that the inhalation becomes shorter, and the exhalation is often not heard at all. The main causes of weakened vesicular breathing are: 1) difficulties in the passage of air into the lungs, 2) insufficient expansion of the lungs during inspiration, and 3) obstacles in the conduction of breath sounds to the ear of the examiner.

Difficulties in the passage of air are observed when there is narrowing or blockage of the upper respiratory tract (stenosis, edema, spasm of the larynx) or large bronchi (blockage, tumor). Insufficient expansion of the lungs can occur when different conditions: pain in the chest, limitation of its mobility (ossification of the costal cartilages), very high standing of the diaphragm (ascites, flatulence, swelling in the abdominal cavity), pronounced general weakness, disease of the respiratory muscles (paralysis or spasms), weakening of the elasticity of the lungs (emphysema). Obstacles to the conduction of breath sounds to the listener's ear are the most common cause of weakened vesicular breathing; this includes: clusters in pleural cavities fluid or air, pushing the lung away from the chest wall by sharply thickened pleura or tumor; sharp thickening of the integument of the chest (obesity, edema), etc.

Saccadirated vesicular breathing can also be pathological, as mentioned above, in cases where it is heard in limited places. In order to avoid a possible error, you only need to make sure with repeated studies that this phenomenon is not random, but persistent.

Bronchial breathing. Bronchial breathing is physiologically heard, as mentioned above, above the larynx (laryngeal), trachea (tracheal) and above the area of ​​distribution of large bronchi (bronchial itself) - in front on the manubrium of the sternum and behind in the upper part of the interscapular space, especially at level III-IV thoracic vertebrae (corresponding to the tracheal bifurcation). The intensity of bronchial breathing in these places and the possibility of some spread beyond them depends on many conditions; these conditions are more favorable in asthenics than in hypersthenics, due to the shallower depth of the chest cavity and the smaller thickness of the chest wall in the former.

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The strength of vesicular respiration varies from person to person and depends on the strength of respiratory movements, the power of the underlying areas of the lung tissue, and the thickness of the layer of chest tissue. Consequently, in persons of different ages and different fatness, the strength of vesicular respiration will be different.

Vesicular breathing is most clearly expressed on the anterior surface of the chest, especially in the subclavian regions; the second most intense place is occupied by the subscapular regions, and then the lower-lateral sections of the lungs. At the tops of the lungs, due to their small volume and thick muscle cover, weakened vesicular breathing is heard. On the left, breathing is usually somewhat clearer (proximity of the gastric air bubble), and if we compare the degree of severity of exhalation, then, on the contrary, on the right, inhalation is more pronounced than on the left (due to the wider and shorter main bronchus). This difference in terms of the duration of exhalation is especially noticeable at the apex: at the right apex the exhalation is much longer than at the left. Sometimes, under the right apex, breathing is heard that is intermediate between bronchial and vesicular, as if a mixture of them is “broncho-vesicular” or mixed breathing.

Measurement

Weakening of vesicular breathing, when in addition to the general muffling of sound, inhalation also becomes shorter, and exhalation is often not heard at all. It can be physiological and pathological.

A physiological weakening of vesicular respiration is observed with a thick chest wall due to excessive fat deposition or strong muscle development. With superficial breathing, the weakening of vesicular breathing depends on the insufficient distribution of the alveoli and the weaker, as a result, tension of their walls. In both cases, the weakening of vesicular breathing will be uniform throughout the chest.

Pathological weakening of vesicular respiration occurs due to the following reasons:

1. Difficulty in the passage of air in the lungs.

2. Insufficient expansion of the lungs when inhaling.

3. Obstacle to the conduction of respiratory sounds to the researcher’s ear.

Difficulty in the passage of air into the lungs is observed when the airways are narrowed (stenosis of the larynx, trachea or large bronchi) due to blockage foreign body or a growing tumor, scar. In this case, the weakening of vesicular respiration is the result of less stretching and, therefore, less tension of the alveoli, the oscillations of which therefore occur with less amplitude.

When the larynx and trachea are narrowed, vesicular breathing will weaken evenly on both halves of the chest. When the bronchus is narrowed, a weakening of vesicular breathing will be detected only in that part of the chest under which there is a section of the lung supplied with air through the narrowed bronchus. If the bronchial tube is completely blocked by a foreign body or tumor, breathing cannot be heard at all.

Weakening of vesicular respiration due to insufficient expansion of the alveoli during inspiration is observed in a number of lung diseases. Thus, with pulmonary emphysema, the lung tissue loses its elasticity, and the chest is constantly in an inspiratory position and almost does not expand during breathing - the pressure in the lungs changes little, as a result of which the walls almost do not straighten, and therefore do not produce the sound characteristic of vesicular breathing. The strength of sound, as Martini says, depends not only on the instrument, but also on the musician. And since in this case the instrument is the lung, and the role of the musician is the chest with its ability to expand. As you can see, with emphysema, both the instrument and the musician are upset.

Weakening of vesicular respiration in a limited area can be detected in small focal pneumonia, when the alveoli are not yet filled with dense exudate, and the tension of their walls is reduced. The same is observed in the resolution stage, when the lumen of the alveoli is free of exudate, and the walls are still saturated with it, and, therefore, the tension of their walls is less than normal.

A common cause of weakened vesicular breathing is an obstacle to the conduction of breath sounds to the ear of the examiner: edema subcutaneous tissue chest, accumulation of fluid or air in the pleural cavities, pushing the lung away from the chest by sharply thickened pleura or tumor. Breathing sounds are not heard at all in the area of ​​large pleural effusion.

Increased vesicular breathing over both lungs is heard during physical activity, with an increase in body temperature, and increased vesicular breathing will be over one lung or under one part of the lung, if the other lung is not involved in breathing (for example, compressed by effusion) or if there is a pathological process that prevents the expansion of the alveoli (compensatory increased breathing).

Harsh breathing is rougher than normal vesicular breathing. Harsh vesicular breathing should not be confused with forced breathing. Hard breathing is a qualitative change in vesicular breathing, and increased breathing is a quantitative increase in it. Forced breathing is as soft and even as normal breathing, but only louder than the latter. on the other hand, hard breathing can be of normal volume, or weakened, and for the most part at the same time intensified.

It is observed in bronchitis, bronchopneumonia, when due to accumulation in the lumen of the bronchi inflammatory exudate their lumen narrows unevenly and, as a result, the sound of air passing through the narrowed bronchi with a modified wall is mixed with vesicular breathing.

Extended exhalation is said to occur if during vesicular breathing not only the inhalation and the initial part of the exhalation are heard, but also all or most of the exhalation phase.

Extension of exhalation is caused by the same changes in the bronchi as hard breathing, so hard breathing with prolonged exhalation is often heard (with bronchitis, bronchial asthma due to bronchospasm).

Saccaded or intermittent breathing is called vesicular breathing, which does not occur continuously, but in the form of separate breaths, interrupted by the same separate pauses. If it spreads throughout the entire lung space, then the reason for its appearance is uneven contraction of the respiratory muscles (fatigue, muscle tremors in the cold, in psychopaths). The appearance of saccadic breathing in a strictly limited area indicates a narrowing of the small bronchi in this area of ​​the lung as a result inflammatory process they are often of tuberculous etiology. Breathing is intermittent because air enters the alveoli in several stages.

Pathological bronchial breathing occurs in all cases where in the lungs there are sufficiently large areas of compaction or cavities containing air and communicating with the bronchial tubes. Thanks to the compaction of the lung parenchyma, conditions are created for better physiological bronchial respiration; in the presence of cavities in the lungs, due to their resonance, physiological bronchial respiration also increases.

The reasons for compaction of the lung tissue are either its infiltration due to inflammation, soaking in blood (infarction) or germination by a tumor, or compression of the lung (with pleurisy, pneumothorax).

The formation of cavities is observed during the breakdown of lung tissue (tuberculosis, abscess, gangrene or dilatation of the bronchi - bronchiectasis).

Bronchial breathing can be clearly heard under two conditions:

1. The known size of the infiltration or cavity - and the area of ​​compaction or cavity should be larger the deeper it is located, and if it is located superficially, it should be at least 2 cm in diameter.

2. Large afferent bronchi in the affected area must be passable, i.e., there is no compression or blockage.

The infiltrated lung does not expand during breathing, air does not penetrate the alveoli and does not stretch them, and therefore there are no intrinsic vibrations of the lung tissue that normally cause characteristic vesicular breathing. The lung is silent, and we hear pure brochial breathing, which is transmitted through the infiltrated lung tissue of the chest to our ear.

Bronchial breathing of various origins can be distinguished by the properties of sound. Bronchial breathing, formed as a result of compaction of the lung, is distinguished by its intensity (loud) and height. Very loud, high in tone, occurring in tone, appearing as if right under the ear, is observed with lobar pneumonia in the stage of hepatization. Bronchial breathing is heard when medium degree atelectasis, when the alveoli collapse completely, but the bronchi still retain their lumen, the conditions will be the same as with compaction of the lung tissue. (In the initial stage of atelectasis, as I remember, there is weakened vesicular breathing; with complete atelectasis, breathing is not carried out).

When the lung is compressed, bronchial compression breathing is characterized by low intensity (quiet) and is heard as if from a distance (for example, with exudative pleurisy).

Bronchial breathing, heard above the cavities, often acquires a special character or timbre (amphoric or metallic bronchial breathing).

Bronchial breathing acquires a similar shade under the condition of: 1. a significant cavity size (at least 5-6 cm in diameter - very large cavities, bronchiectasis, pneumothorax); 2. smooth inner surface of the cavity walls; 3. moderate degree filling the cavity.

Amphoric bronchial breathing is a quiet, low and empty sound that is produced by blowing strongly over the throat of an empty glass vessel.

Metallic bronchial breathing is distinguished by a loud and high-pitched broom-like tone. It is very typical for open pneumothorax.

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A completely different sound is heard over the peripheral parts of the lungs, which is called vesicular breathing. Characteristics of vesicular breathing: a) It is an order of magnitude weaker than laryngeal breathing. Listening to him requires intense attention and numerous exercises. auditory analyzer; b) It has a different timbre, reminiscent of the sound produced if, with lips folded to pronounce the sound “f”, you slowly inhale and exhale air; c) Inhalation is heard throughout, and exhalation is heard only in the initial stage of the phase. The duration of the noise during exhalation is no more than 1/3 of the duration of the expiratory phase. During the rest of the expiratory time, no sounds are heard; d) Exhalation is quieter than inhalation, which is expressed in a decrease in the amplitude of vibration; e) Exhalation is lower in tone than inhalation, which is due to a decrease in the frequency of vibrations and their rapid attenuation. The determining and practically the only source of sound energy is the vibrations of the elastic structure of the lungs, the tension of which increases with inhalation and weakens with exhalation. An increase in voltage leads to oscillations. A decrease in voltage also causes vibrations, but these vibrations have a smaller amplitude (this explains the decrease in sound intensity on exhalation) and a lower frequency (this explains the decrease in the pitch of sound on exhalation compared to that on inspiration). Physiological types of vesicular respiration: a) Puerile (from Lat. puer - boy) breathing. It's more loud noise compared to vesicular breathing, and exhalation is heard throughout. Its mechanism is explained by: 1) the small diameter of the bronchi; 2) a thin chest wall in a child; 3) higher elasticity of the lungs. B) Saccaded (intermittent) breathing. As a rule, intermittent inhalations with several pauses are heard. This happens with excitement, chills, fatigue and is associated with changes in the regulation of breathing. B) Systolic breathing. During systole and the ejection of blood into the aorta, the volume of the heart decreases, and the vacuum formed in this case is filled by the adjacent sections of the lungs, the expansion of which gives a peculiar sound, in properties close to vesicular noise during inspiration. This sound is often heard when breathing stops and may resemble a systolic heart murmur. Pathological types of vesicular respiration: Weakened vesicular respiration. The essence of this variant of pathological vesicular breathing is a significant weakening of the noise during inspiration, and exhalation is not heard at all. Reasons for weakening: 1) pulmonary emphysema; 2) limitation of respiratory movements (chest pain, swelling, ascites, etc.); 3) obstruction to the passage of air into a certain part of the lungs; 4) displacement of the lungs by gas, liquid, tumor; 5) severe obesity, swelling of the chest wall. Extended exhalation. In this case, the breathing noise usually becomes rougher, and exhalation is heard for more than 2/5, 1/3 of the exhalation phase. The cause of this pathological respiratory noise is a violation of bronchial obstruction. As you exhale, the lumen of the bronchi decreases. To this decrease in the diameter of the bronchi is added a narrowing caused by pathological process: active narrowing under the influence of increased tone of the smooth muscles of the bronchi, swelling of the mucous membrane of various nature, hypersecretion of mucus and an increase in its viscosity, cicatricial narrowing. Hard vesicular breathing has a rougher character, reminiscent of the sound when pronouncing a double “f”. Exhalation is quieter than inhalation, lower in pitch and is audible throughout the exhalation phase. In essence, this is adequate to puerile breathing. Pathological saccadic breathing. It is heard in a limited area of ​​the lungs and is due to the fact that during inflammatory changes, the lung tissue during inhalation expands non-simultaneously, in jerks, with a delay, or in several stages. Rough breath. This is a breathing noise when an uneven, scratching, rough noise is mixed with the normal sound. Uncertain breathing. The respiratory noise is very weak and it is very difficult to assess its basic properties. Mixed breathing. Part of the respiratory noise is bronchial, and the other part is vesicular in various combinations.

Vesicular breathing is a respiratory phenomenon that occurs over the entire chest during the expansion of the respiratory tissue during inhalation. Its frequency is in the range of 80-600 Hz.

In a healthy person, the lungs are constantly in a stretched state, because they are affected by Atmosphere pressure. Expansion of the chest during inhalation occurs due to the work of the inspiratory muscles and one-sided atmospheric air pressure. The lungs expand following the chest. The airways have a fairly large lumen and do not provide significant resistance when inhaling. The process of inhalation involves a large number of alveoli, which move from a relaxed state to a tense one. Their straightening occurs sequentially and is accompanied by a sucking sound, which resembles the sound “f”.

According to another theory, noise occurs when a stream of air rubs against the walls of the bronchioles, which consist almost entirely of smooth muscle. The terminal bronchioles, called respiratory bronchioles, consist of epithelium, connective tissue and a few muscle fibers. In diseases accompanied by obstructions, small bronchi and bronchioles close due to excessive contraction of smooth muscles.

Vesicular breathing takes up the entire inhalation phase and almost half of the exhalation phase. In some cases, exhalation may be silent.

Physiological changes in vesicular respiration

Changes in the strength of vesicular respiration can be both physiological and pathological in nature.

Weakened breathing in the lungs is normally observed:

• large thickness of muscle or fat layer in the chest area;
• with tachypnea;
• in areas with a thinner layer of lung tissue.

In turn, tachypnea is a consequence of many diseases of the respiratory system, heart, endocrine system and brain. Inspiratory dyspnea develops with injuries, poisoning, stress, overwork, and pregnancy. Impaired ventilation of the lungs leads to hypoxia, the symptoms of which are dizziness, cyanosis, and headaches. Therefore, if the depth and rhythm are disturbed, you should consult a doctor.

Normally, vesicular breathing becomes more intense after physical activity. Children aged 1 to 7 years have louder breathing sounds than adults. This is due to the following features pediatric respiratory system:

• small distance between the glottis and the chest wall,
• abundance of elastic elements in tissues,
• relatively narrow lumen of the bronchi.

In infants under one year of age, breathing is weakened due to age-related underdevelopment of the alveoli.

Vesicular respiration disorders

Weak vesicular respiration is observed with:

• obstruction of bronchial patency by neoplasm, sputum, inflamed lymph nodes;
• ossification of costal cartilages;
• exudative and adhesive pleurisy;
• rib fractures,
• injuries to the nerves and muscles of the chest;
• a decrease in the number of alveoli in the lung mass with the development of tumors or foci of tuberculosis;
• pneumothorax;
• hydrothorax.

The intensity of vesicular respiration increases in healthy areas of the lung that are adjacent to tissues affected by the disease. This type is called vicarious or substitute. For example, if pneumothorax occurs in one lung, the healthy lung carries out gas exchange more intensively. The production of respiratory sounds improves with inflammation or sclerosis of the bronchi.

For comatose states, associated with a shift in pH to the acidic side, Kussmaul breathing is characteristic - noisy, rare and deep. The cause of pulmonary hyperventilation is an increased concentration of ketone bodies in the blood. The level of ketone bodies increases with kidney and liver dysfunction, diabetes mellitus, endocrine disorders.

Qualitative changes in vesicular respiration

Many diseases affect the quality of breathing.

Breathing becomes harsh when an inflammatory process develops in the bronchi. Due to swelling and accumulation of mucus, the surface of the airways becomes uneven. Breath sounds become equally loud during inhalation and exhalation. Wheezing often occurs. Hard is typical for bronchitis of various etiologies, pneumosclerosis, adenoiditis, focal pneumonia. During the recovery period after an acute respiratory infection, cough and changes in breathing persist for some time as residual effects.

In order to facilitate the discharge of sputum, mucolytic agents are used. Patients are also advised to spend more time in the fresh air, drink more fluids and regularly ventilate their room.

Hard breathing with prolongation of exhalation is characteristic of diseases accompanied by obstruction. In bronchial asthma or allergic bronchitis, contact with an allergen leads to the development of local allergic reaction. Mast cells and basophils release inflammatory mediators into the tissue, causing bronchospasm. The patient has difficulty exhaling. Others typical symptoms asthma are shortness of breath, cough, sleep disturbances.

Rhythm and depth are disrupted due to chest injuries, tuberculosis, and dysfunction of the respiratory muscles. Intermittent may also be a consequence of carbon dioxide poisoning or damage to the respiratory center of the medulla oblongata. In healthy people, intermittent breathing appears after hypothermia.

The cyclic change of shallow breathing with deep and frequent breathing movements is called Cheyne-Stokes breathing. It occurs with lesions of the cerebral cortex or severe metabolic disorders.

Characteristics research

Auscultation is performed using a stethoscope. The patient must stand or sit and breathe evenly and deeply. Upper part bodies must be freed from clothing. Auscultation is carried out in a warm room in conditions of maximum silence.

• fluorography or x-ray of the lungs,
• CT or MRI,
• spirometry,
• determination of oxygen concentration and carbon dioxide in blood.

If necessary, culture of sputum and bronchial washings is carried out on nutrient media and invasive examination methods are used.

If you suspect bronchial asthma you should contact an allergist. To determine the allergen, skin tests or a blood test for specific immunoglobulin E are performed.