Bronchophony, determination method, diagnostic value. Vi
Bronchophony, determination method, diagnostic value
. Bronchophony
Bronchophony - carrying the voice from the larynx along the air column of the bronchi to the surface chest. Assessed using auscultation. In contrast to the definition of vocal tremor, words containing the letter “p” or “ch” are pronounced in a whisper when studying bronchophony. Under physiological conditions, voice conducted to the surface of the skin of the chest is heard very weakly and equally on both sides. symmetrical points. Increased voice conduction - enhanced bronchophony, as well as enhanced voice tremors, appears in the presence of compaction of lung tissue, which better conducts sound waves, and cavities in the lung that resonate and amplify sounds. Bronchophony allows better than vocal trembling to identify foci of compaction in the lungs in weakened individuals with a quiet and high-pitched voice.
Collection of sputum. Macroscopic examination of sputum. Reasons for changes in its color, smell, appearance pathological elements. Dividing sputum into layers. Types of sputum. Analysis of sputum microscopy results.
Sputum examination. Sputum is a pathological secretion from the respiratory system, expelled when coughing. Sputum may contain mucus, serous fluid, blood and respiratory tract cells, protozoa, and rarely helminths and their eggs. Sputum examination helps establish the character pathological process in the respiratory organs, and in some cases determine its etiology.
Sputum for examination should be taken in the morning, fresh, if possible before meals and after rinsing the mouth. Only for the detection of Mycobacterium tuberculosis, sputum can be collected within 1-2 days (if the patient secretes little of it). In stale sputum, saprophytic microflora multiply and are destroyed shaped elements. To collect sputum, special jars (spittoons) with screw caps and measuring divisions are used.
The study of sputum begins with its examination, first in a transparent jar, and then in a Petri dish, which is placed alternately on black and white background. The following signs are noted.
Character, color and consistency of sputum. Mucous sputum is usually colorless, viscous, and occurs in acute bronchitis. Serous sputum is also colorless, liquid, foamy, and is observed with pulmonary edema. Muco- purulent sputum, yellow or greenish, viscous, occurs with chronic bronchitis, tuberculosis, etc. Pure purulent sputum is homogeneous, semi-liquid, greenish-yellow, characteristic of a lung abscess when it ruptures. Bloody sputum can be either purely bloody with pulmonary bleeding (tuberculosis, cancer, bronchiectasis), or mixed, for example, mucopurulent with streaks of blood (with bronchiectasis), serous-bloody foamy (with pulmonary edema), muco-bloody (with pulmonary infarction or stagnation in the pulmonary circulation system), purulent-bloody, semi-liquid, brownish-gray (with gangrene and lung abscess). If blood from the respiratory tract is not released immediately, but is retained in it for a long time, its hemoglobin turns into hemosiderin and gives the sputum a rusty color (typical of lobar pneumonia).
When standing, the sputum may separate. Chronic suppurative processes are characterized by three-layer sputum: top layer mucopurulent, middle-serous, lower-purulent. Sometimes purulent sputum is divided into two layers - serous and purulent.
Individual elements visible to the naked eye. Kurshman spirals can be found in sputum in the form of small dense, twisted whitish threads; fibrin clots - whitish and reddish tree-like branched elastic formations, found in fibrinous bronchitis, occasionally in pneumonia; “lentils” - small greenish-yellow dense lumps consisting of calcified elastic fibers, cholesterol crystals and soaps and containing mycobacterium tuberculosis; Dietrich's plugs, similar to “lentils” in appearance and composition, but not containing tuberculous mycobacteria and emitting a foul odor when crushed (occurs in gangrene, chronic abscess, putrefactive bronchitis); lime grains found during the disintegration of old tuberculosis lesions; drusen of actinomycetes in the form of small yellowish grains, reminiscent of semolina; necrotic pieces lung tissue and tumors; leftover food.
Environmental reaction. In sputum, the reaction of the environment is usually alkaline; it becomes acidic when sputum decomposes and from the admixture of gastric juice, which helps differentiate hemoptysis from hematemesis.
Microscopic examination of sputum. It is produced in both native and colored preparations. For the first, purulent, bloody, crumbly lumps and twisted white threads are selected from the material poured into a Petri dish and transferred to a glass slide in such an amount that when covered with a cover glass, a thin translucent preparation is formed. It is viewed first at low magnification for initial orientation and searches for Kurshman spirals, and then at high magnification to differentiate shaped elements. Kurshman's spirals are strands of mucus, consisting of a central dense axial thread and a spiral-shaped mantle enveloping it, in which leukocytes (often eosinophilic) and Charcot-Leyden crystals are interspersed (Fig. 27). Kurshman spirals appear in sputum during bronchospasm, most often with bronchial asthma, less often with pneumonia, lung cancer. With high magnification, leukocytes can be detected in the native preparation, a small number of which is present in any sputum, and a large number in inflammatory and especially suppurative processes; eosinophils (Fig. 28) can be distinguished in the native preparation by their uniform, large, shiny granularity, but they are easier to recognize when stained. Red blood cells appear during the destruction of lung tissue, pneumonia, stagnation in the small circle of blood circulation, pulmonary infarction, etc.
Flat epithelium enters the sputum mainly from the oral cavity and has no diagnostic value. Columnar ciliated epithelium is present in small quantities in any sputum, and in large quantities in lesions of the respiratory tract (bronchitis, bronchial asthma). Alveolar macrophages are large cells (2-3 times more leukocytes) of reticulohistiocytic origin. Their cytoplasm contains abundant inclusions. They can be colorless (myelin grains), black from coal particles (dust cells) (Fig. 29) or yellow-brown from hemosiderin (cells of heart defects, siderophages). Alveolar macrophages are present in small quantities in any sputum; their content increases in inflammatory diseases. Cells of cardiac defects (Fig. 30) are found when red blood cells enter the cavity of the alveoli (with stagnation in the pulmonary circulation, especially with mitral stenosis, pulmonary infarction, as well as with lobar pneumonia and hemosiderosis). For a more reliable determination, the so-called Prussian blue reaction is performed: a little sputum is placed on a glass slide, 1-2 drops of a 5% solution of yellow blood salt are poured, after 2-3 minutes - the same amount of 2% hydrochloric acid solution, mixed and covered with a coverslip glass. After a few minutes, hemosiderin grains turn blue.
Cells malignant tumors often end up in the sputum, especially if the tumor grows endobronchially or disintegrates. In the native preparation, these cells are distinguished by their atypia: they are mostly large, have an ugly shape, a large nucleus, and sometimes several nuclei. During chronic inflammatory processes in the bronchi, the epithelium lining them metaplasizes, acquires atypical features and may resemble tumor cells. Therefore, it is possible to identify cells as tumor cells only if complexes of atypical and, moreover, polymorphic cells are found, especially if they are located on a fibrous base or together with elastic fibers.
Elastic fibers (Fig. 31) appear in sputum during the breakdown of lung tissue: tuberculosis, cancer, abscess. Elastic fibers have the appearance of thin double-circuit fibers of equal thickness throughout, dichotomously branching. They are often found in ring-shaped bundles that maintain an alveolar arrangement. Since these fibers are not found in every drop of sputum, to facilitate the search they resort to their concentration. For this purpose, an equal or double amount of 10% caustic alkali solution is added to several milliliters of sputum and heated until the mucus dissolves. In this case, all formed elements of sputum dissolve, except for elastic fibers. After cooling, the liquid is centrifuged by adding 3-5 drops of a 1% alcohol solution of eosin, and the sediment is examined under a microscope. The elastic fibers retain the character described above and are clearly distinguished by their bright red color.
Actinomycetes are found by selecting small dense yellowish grains - drusen - from sputum. Druses crushed under a cover glass in a drop of glycerin or alkali are visible under a microscope. central part, consisting of a plexus of mycelium, and a surrounding zone of radiant flask-shaped formations. When crushed drusen is stained with a Gram stain, the mycelium becomes purple and the cones become pink. Of other fungi found in sputum, highest value has Candida albicans, which affects the lungs with long-term antibiotic treatment and in very weakened people. In the native preparation, budding yeast-like cells and branched mycelium are found, on which the spores are located in whorls.
Of the crystals in the sputum, Charcot-Leyden crystals are found: colorless octahedra of different sizes, reminiscent of a compass needle in shape. They consist of a protein released during the breakdown of eosinophils, and therefore are found in sputum containing many eosinophils, and more of them in stale sputum. After pulmonary bleeding, if blood is not immediately released with sputum, hematoidin crystals can be detected - rhombic or needle-shaped formations of yellow-brown color.
Microscopy of stained preparations. It is produced for the purpose of studying the microbial flora of sputum and some of its cells. Of these, the most important is the identification of malignant cells
Bacterioscopic examination: for searching for mycobacteria tuberculosis - according to Ziehl-Neelsen, in other cases - according to Gram.
Bacteriological research(sputum culture on nutrient media). Used when bacterioscopic examination does not detect the suspected pathogen.
Bronchophony is a method of listening to a person's voice using a phonendoscope on the surface of the chest. Sound vibrations that occur when pronouncing words are transmitted from the larynx through the air column and bronchial tree to the periphery up to outer surface chest wall. As with the study of vocal tremor (see section Palpation of the chest), these sounds can also be assessed by auscultation.
The lungs are auscultated in the same places as during comparative auscultation, strictly observing symmetry; only the apexes are not auscultated, where the auscultatory picture is difficult to differentiate. The patient is asked to pronounce words containing the letter “P” in a calm voice, as in the study of th
vocal tremors. Listening to the lungs is done with a phonendoscope, but direct listening with the ear is considered ideal.
In healthy people, it is difficult to make out the words auscultated by the patient; instead of words, only vague, quiet, inarticulate muttering is heard, sometimes only buzzing and buzzing sounds are heard. In men with low voices and in older people, the sounds are more distinct.
The weakening and strengthening of bronchophony is of diagnostic importance. This occurs for the same reasons as the weakening and strengthening of vocal tremors. A weakening of bronchophony is observed in conditions of deterioration in the conduction of sounds through the bronchial tree, with emphysema, and accumulation of fluid and air in the pleural cavity. Increased bronchophony occurs under conditions of better sound conduction - when the lung tissue is compacted with preserved bronchial patency and in the presence of a cavity drained by the bronchus. Enhanced bronchophony will be heard only above the affected area, where the sound of words will be louder, the words will be more distinguishable. Words can be heard especially clearly over large cavities in the lungs, and a metallic tint to speech is noted.
A type of bronchophony is listening to whispered speech. This method is used in doubtful cases when determining vocal tremor and bronchophony and is usually used in limited areas, comparing them with healthy symmetrical areas. The patient is asked to whisper words containing the sound “Ch” - “cup of tea”. In healthy people, spoken words are also heard unintelligibly. When the lung tissue thickens and there is a cavity in the lung, words become distinguishable. Many clinicians prefer whispered speech to bronchophony as the most informative.
Additional (side) breathing sounds
They form in the pleural cavity, respiratory tract and alveoli. With only a few exceptions (physiological crepitus), they indicate pathology.
Additional breathing noises include:
- wheezing;
- crepitus;
- pleural friction noise;
- pleuropericardial murmur.
The term “dry wheezing” is somewhat arbitrary; it indicates that there is a viscous secretion or local narrowing of the lumen in the bronchial lumen.
The term “moist rales” means that in the lumen of the bronchi there is a liquid secretion through which air passes during inhalation and exhalation, creating a thin layer of bellies. Therefore, such wheezing is also called wheezing or blistering.
Dry wheezing
They can be heard over the entire surface of the lungs or in a limited area of the chest. Widespread dry wheezing (usually whistling) indicates total involvement of the bronchi - bronchospasm in bronchial asthma, allergies, inhalation of organophosphorus substances. Local dry wheezing
CREPITATION FRICTION NOISE
PLEURA
Rice. 312. Graphic representation of the occurrence of adverse respiratory sounds depending on the phase of breathing.
they talk about limited bronchitis, which happens when ordinary bronchitis, pulmonary tuberculosis, tumors.
Dry wheezing is heard in one or both phases of breathing, but sometimes it is better during inspiration, during the period of highest air flow in the bronchi. Dry wheezing is often prolonged and can be heard throughout the entire breathing phase.
The volume, pitch, and timbre of dry wheezing depends on the caliber of the bronchus, the viscosity of the secretion and the speed of the air stream. Dry wheezing is usually divided into:
- high - treble, whistle;
- low - bass, buzzing, buzzing (Fig. 313-L).
Rice. 313. Places of occurrence of adverse respiratory sounds A. Dry wheezing:
1 - low (bass, walking, buzzing), occur in the trachea, in large and medium bronchi.
2~3 - high-pitched (treble) wheezing, occurring in small bronchi and bronchioles.
B. Moist rales, crepitus, pleural friction noise:
- - large-bubble, occur in the trachea and large bronchi.
- - medium vesicular, arise in the middle bronchi.
- - finely bubbly, occur in small bronchi.
- - crepitus, occurs in the alveoli
- - pleural friction noise, occurs in the pleural cavity due to inflammation of the preural layers and their roughness.
High-pitched (wheezing) wheezing is a high-pitched wheezing sound, their sound is similar to a whistle or squeak. They are formed in small bronchi and bronchioles and are distinguished by auscultatory stability. The main reason for their occurrence is the narrowing of the lumen of the bronchi, which is facilitated by:
- spasm of small bronchi and bronchioles;
- swelling of their mucous membranes;
- accumulation of viscous secretion in them.
If wheezing is heard in a limited area, then the cause of its occurrence is inflammation of the small bronchi, which happens with focal pneumonia and pulmonary tuberculosis. Wheezing, caused by the accumulation of secretions in the small bronchi, disappears after coughing or changes in tone due to the movement of secretions into larger bronchi.
Low dry rales are formed in the bronchi of medium, large caliber and even in the trachea as a result of the accumulation in their lumen of a sticky, viscous secretion in the form of wall plugs, narrowing the internal diameter of the tube. When a powerful air flow passes during breathing, especially during inhalation, the secretion forms vibrating “tongues”, threads, membranes, bridges in the form of a string, generating sounds of varying strength, height and timbre, which depends on the caliber of the bronchus, the viscosity of the secretion and the speed of the air flow .
Sometimes parietal mucus plugs create whistling conditions, but the resulting wheezing will have a lower pitch. This can happen with bronchitis deformans in places where the bronchial lumen is narrowed.
The amount of low, dry wheezing depends on the prevalence of bronchitis. More often they are absent-minded. Humming rales are lower, dull. Buzzing wheezes are the loudest, roughest, most prolonged. They are so strong that it is easy to determine
are heard with a palm placed on the place of their auscultation. Vortex flows give such wheezing a musical coloring. Buzzing wheezes are better heard during inspiration throughout the entire phase. By localization, they are most often heard in the interscapular space, as they are formed in the bronchi of the pre-root zones.
Diagnostic value low dry rales are large, they are heard in acute and chronic bronchitis with damage to the bronchi of medium and large caliber.
Moist rales (Fig. 313~B)
The place of their occurrence is the bronchi of any caliber, containing liquid secretion of the mucous membrane, edematous fluid, blood or liquid pus. Air bubbles passing through these media during breathing burst on the surface of the liquid and create a peculiar sound phenomenon called moist or bubbly rales. Moist rales are short, often multiple sounds of different calibers. Their size depends on the diameter of the bronchus, where they arose; small-bubble, medium-bubble, and large-bubble rales are distinguished. Moist rales can form in cavities with liquid contents (tuberculous cavity, abscess, gangrene of the lung). Above them, medium- and large-sized perforated rales are often heard.
Moist rales are usually heard in both phases of breathing, while during inhalation their number and sonority are greater than during exhalation, which is due to the speed of the air flow; during inhalation it is greater. Moist rales are characterized by significant inconsistency; after forced breathing, after several deep breaths, they can disappear and then appear again. After coughing, they may disappear, change in size, or appear in more, which is associated with the movement of secretions from small to larger bronchi. Gross rales produce longer, lower, and louder sounds.
Based on the nature of the sound of moist rales, one can assume the localization of the pathological process, the involvement of bronchi of a certain caliber, however, one must take into account the ability of liquid secretion to move from small bronchi to larger ones.
The number and location of moist rales heard depend on the nature of the pathological process. With limited pathology, their number will be small and they can be heard in a limited area (focal pneumonia, tuberculosis, abscess)
With a widespread pathological process, their number increases sharply, and the listening area becomes significant. This is observed with total pneumonia, pulmonary edema.
Wet rales are divided into:
- silent (quiet, non-consonant);
- sonorous (voiced, high, consonant).
Silent moist rales ranging from slight to huge amount occur with pulmonary edema of any origin. Pulmonary edema of venous origin (acute or chronic left ventricular, left atrial failure) in the initial phases is manifested by congestive, silent, moist fine bubbling rales in the posterior lower parts of the lungs, with increasing edema top level auscultation rises up to the tops, the number of wheezing also increases, they become of different sizes, bubbling breathing appears due to the accumulation of fluid in the large bronchi and trachea. Wheezing is always heard in symmetrical places, but slightly more on the right. Bubbling moist rales also occur with significant pulmonary hemorrhage.
Loud (high-pitched) moist rales are heard when there is airless, compacted lung tissue around the bronchus in which the moist rales arose (Fig. 314). That is, there is a combination of local bronchitis with inflammatory infiltration of the lung tissue (focal pneumonia, tuberculosis, allergic infiltrate). Under these conditions, sounds arising in the bronchi are well transmitted to the periphery and are heard more clearly, loudly, sharply and with some musicality. Sometimes they acquire a crackling character.
The presence of a smooth-walled cavity communicating with the bronchus and especially having a fluid level contributes to the resonance of moist rales, and the inflammatory ridge around the cavity improves their conduction to the periphery.
Thus, infiltration around the affected bronchus and the cavity drained by the bronchus give rise to sonorous moist rales. Their you-
Rice. 314. Conditions conducive to the occurrence of sonorous moist rales. 
A. Sounding moist fine-bubble rales occur in the presence of inflammatory infiltration around the bronchus (pneumonia, tuberculosis, allergic edema), infiltration improves the conduction of sound to the chest wall.
B. Sounding moist large bubble rales occur when there is a large cavity in the lungs (tuberculous cavity, abscess, large bronchiectasis, festering cyst) Moist rales formed in large draining bronchi, I resonate! in the cavity, and the inflammatory ridge facilitates their better conduction to the ore wall. Moist rales arising in the bronchi of the inflammatory ridge are well conducted to the [ore C1enka; the adjacent band enhances the sonority of the rales due to resonance.
Listening to the song has enormous diagnostic value and allows us to assume focal pneumonia, tuberculosis (infiltration), a cavity in the lung, gangrene of the lungs, staphylococcal pneumonia, disintegrating tumor. It should be taken into account that sonorous small-bubble rales are characteristic of pneumonia and tuberculosis without decay, and large-bubble rales in most cases occur in the presence of a cavity (tuberculosis cavity or abscess). Moist rales with a metallic tint may be heard over large smooth-walled cavities with amphoric breathing. In these cases, the metallic tint is associated with the pronounced resonance of the existing cavities.
Bronchophony is the conduction of the voice from the larynx along the air column of the bronchi to the surface of the chest. Assessed using auscultation. In contrast to the definition of vocal tremor, words containing the letter “p” or “ch” are pronounced in a whisper when studying bronchophony. Under physiological conditions, voice conducted to the surface of the skin of the chest is heard very weakly and equally on both sides at symmetrical points. Increased voice conduction - increased bronchophony, as well as increased vocal tremors, appears in the presence of compaction of the lung tissue, which better conducts sound waves, and cavities in the lung, resonating and amplifying sounds. Bronchophony allows better than vocal trembling to identify foci of compaction in the lungs in weakened individuals with a quiet and high-pitched voice.
The weakening and strengthening of bronchophony is of diagnostic importance. This occurs for the same reasons as the weakening and strengthening of vocal tremors. A weakening of bronchophony is observed in conditions of deterioration in the conduction of sounds through the bronchial tree, with emphysema, and accumulation of fluid and air in the pleural cavity. Increased bronchophony occurs under conditions of better sound conduction - when the lung tissue is compacted with preserved bronchial patency and in the presence of a cavity drained by the bronchus. Enhanced bronchophony will be heard only above the affected area, where the sound of words will be louder, the words will be more distinguishable. Words can be heard especially clearly over large cavities in the lungs, and a metallic tint to speech is noted.
Voice tremors (fremitus vocalis, s. pectoralis) - vibration of the chest wall during phonation, felt by the hand of the examiner. It is caused by vibrations of the vocal cords, which are transmitted to the air column of the trachea and bronchi, and depends on the ability of the lungs and chest to resonate and conduct sound. G.D. is examined by comparative palpation of symmetrical areas of the chest when the person being examined pronounces words containing vowels and voiced consonants (for example, artillery). IN normal conditions G.D. is well felt with a low voice in people with a thin chest wall, mainly in adult men; it is better expressed in the upper part of the chest (near large bronchi), and also on the right, because right main bronchus wider and shorter than the left one.
Local strengthening of blood pressure indicates compaction of the lung area with preserved patency of the afferent bronchus. Increased blood pressure is observed over the area of pneumonia, the focus of pneumosclerosis, over the area of the compressed lung along upper limit intrapleural effusion. G. d. is weakened or absent above the fluid in the pleural cavity (hydrothorax, pleurisy), with pneumothorax, with obstructive pulmonary atelectasis, as well as with significant development of fatty tissue on the chest wall.
Pleural friction rub see question 22
24. The concept of fluoroscopy, radiography and tomography of the lungs. Bronchoscopy, indications and contraindications for bronchoscopy. The concept of biopsy of the mucous membrane of the bronchi, lungs, pleura, enlarged tracheobronchial lymph nodes. Study of bronchoalveolar contents.
X-ray of the lungs is the most common research method that allows you to determine the transparency of the pulmonary fields, detect foci of compaction (infiltrates, pneumosclerosis, neoplasms) and cavities in the lung tissue, foreign bodies of the trachea and bronchi, detect the presence of fluid or air in the pleural cavity, as well as rough pleural adhesions and mooring.
Radiography is used for the purpose of diagnosing and recording on X-ray film pathological changes in the respiratory organs detected during fluoroscopy; some changes (unsharp focal consolidations, bronchovascular pattern, etc.) are determined better on an x-ray than with fluoroscopy.
Tomography allows for layer-by-layer X-ray examination lungs. It is used for more accurate diagnosis of tumors, as well as small infiltrates, cavities and cavities.
Bronchography is used to study the bronchi. After preliminary anesthesia of the respiratory tract, the patient is injected into the lumen of the bronchi contrast agent(iodolipol), delaying x-rays. X-rays of the lungs are then taken, which provide a clear image of the bronchial tree. This method makes it possible to detect bronchiectasis, abscesses and lung cavities, and narrowing of the bronchial lumen by a tumor.
Fluorography is a type of x-ray examination of the lungs, in which a photograph is taken on a small-format reel film. Applicable for mass preventive examination population.
Bronchoscopy (from ancient Greek βρόγχος - windpipe, trachea and σκοπέω - looking, examining, observing), also called tracheobronchoscopy, is a method of direct examination and assessment of the condition of the mucous membranes of the tracheobronchial tree: trachea and bronchi using a special device - a bronchofiberscope or a rigid respiratory bronchoscope, a type of endoscope. A modern bronchofiberscope is a complex device consisting of a flexible rod with a controlled bend of the far end, a control handle and a lighting cable connecting the endoscope to a light source, often equipped with a photo or video camera, as well as manipulators for performing a biopsy and removing foreign bodies.
Indications
It is advisable to perform diagnostic bronchoscopy in all patients with respiratory tuberculosis (both newly diagnosed and with chronic forms) to assess the condition of the bronchial tree and identify bronchial pathology concomitant or complicating the main process.
Mandatory indications:
Clinical symptoms of tuberculosis of the trachea and bronchi:
Clinical symptoms of nonspecific inflammation of the tracheobronchial tree;
Unclear source of bacterial excretion;
hemoptysis or bleeding;
The presence of “bloated” or “blocked” cavities, especially with fluid levels;
Upcoming surgery or creation of a therapeutic pneumothorax;
Audit of the bronchial stump after surgery;
Unclear diagnosis diseases;
Dynamic observation for previously diagnosed diseases (tuberculosis of the trachea or bronchus, nonspecific endobronchitis);
Postoperative atelectasis;
Foreign bodies in the trachea and bronchi.
Indications for therapeutic bronchoscopy in patients with respiratory tuberculosis:
Tuberculosis of the trachea or large bronchi, especially in the presence of lymphobronchial fistulas (to remove granulations and broncholiths);
Atelectasis or hypoventilation of the lung in the postoperative period;
Sanitation of the tracheobronchial tree after pulmonary hemorrhage;
Sanitation of the tracheobronchial tree for purulent nonspecific endobronchitis;
Introduction to bronchial tree anti-tuberculosis or other drugs;
Failure of the bronchial stump after surgery (for removal of ligatures or tantalum staples and administration of medications).
Contraindications
Absolute:
Diseases of the cardiovascular system: aortic aneurysm, heart disease in the stage of decompensation, acute heart attack myocardium;
Pulmonary failure III degree not caused by obstruction of the tracheobronchial tree;
Uremia, shock, cerebral or pulmonary thrombosis. Relative:
Active tuberculosis of the upper respiratory tract;
Intercurrent diseases:
Menstrual period;
Hypertension II- III stages;
General serious condition of the patient (fever, shortness of breath, pneumothorax, presence of edema, ascites, etc.).
25. Research methods functional state lungs. Spirography. Respiratory volumes and capacities, diagnostic significance of their changes. Tiffno sample. The concept of pneumotachometry and pneumotachography.
Methods functional diagnostics
Spirography. The most reliable data is obtained from spirography (Fig. 25). In addition to measuring lung volumes, using a spirograph you can determine a number of additional ventilation indicators: tidal and minute ventilation volumes, maximum ventilation of the lungs, forced expiratory volume. Using a spirograph, you can also determine all the indicators for each lung (using a bronchoscope, supplying air separately from the right and left main bronchi - “separate bronchospirography”). The presence of an absorber for carbon monoxide (IV) allows you to establish absorption oxygen to the lungs subject in a minute.
Spirography also determines OO. For this purpose, a spirograph with a closed system having a CO 2 absorber is used. It is filled pure oxygen; the subject breathes into it for 10 minutes, then the residual volume is determined by calculating the concentration and amount of nitrogen that entered the spirograph from the subject’s lungs.
HFMP is difficult to determine. Its quantity can be judged from calculations of the ratio of the partial pressure of CO 2 in exhaled air and arterial blood. It increases in the presence of large cavities and ventilated, but insufficiently supplied with blood, areas of the lungs.
Pulmonary ventilation intensity study
Minute respiration volume (MRV) determined by multiplying the tidal volume by the respiratory frequency; on average it is 5000 ml. It can be more accurately determined using a Douglas bag and spirograms.
Maximum ventilation of the lungs (MVL,"breathing limit") - the amount of air that can be ventilated by the lungs at maximum exertion respiratory system. Determined by spirometry at maximum deep breathing with a frequency of about 50 per minute, normally equal to 80-200 l/min. According to A.G. Dembo, the proper MVL = vital capacity 35.
Breathing reserve (RR) determined by the formula RD = MVL - MOD. Normally, the RD exceeds the MOD by at least 15-20 times. In healthy individuals, RD is equal to 85% of MVL; in case of respiratory failure, it decreases to 60-55% and lower. This value largely reflects the functionality of the respiratory system healthy person under significant stress or in a patient with pathology of the respiratory system to compensate for significant respiratory failure by increasing the minute volume of breathing.
All these tests make it possible to study the state of pulmonary ventilation and its reserves, the need for which may arise when performing heavy physical work or in case of respiratory disease.
Study of the mechanics of the respiratory act. Allows you to determine changes in the ratio of inhalation and exhalation, respiratory effort in different phases of breathing and other indicators.
Expiratory forced vital capacity (EFVC) researched according to Votchal-Tiffno. The measurement is carried out in the same way as when determining vital capacity, but with the most rapid, forced exhalation. EFVC in healthy individuals is 8-11% (100-300 ml) less than VC, mainly due to an increase in resistance to air flow in the small bronchi. If this resistance increases (with bronchitis, bronchospasm, emphysema, etc.), the difference between EFVC and VC increases to 1500 ml or more. The volume of forced expiration in 1 second (FVC), which in healthy individuals is equal to an average of 82.7% of VC, and the duration of forced expiration until it sharply slows down are also determined; This study is carried out only using spirography. The use of bronchodilators (for example, theophedrine) during the determination of EFVC and various variants of this test makes it possible to assess the significance of bronchospasm in the occurrence of respiratory failure and a decrease in these indicators: if after taking theophedrine, the obtained test data remain significantly lower than normal, then bronchospasm is not the reason for their decrease.
Inspiratory forced vital capacity (IFVC) determined with the fastest possible forced inspiration. IFVC does not change with emphysema not complicated by bronchitis, but decreases with obstruction of the airway.
Pneumotachometry- a method for measuring “peak” air flow velocities during forced inhalation and exhalation; allows you to assess the state of bronchial patency.
Pneumotachography- a method for measuring volumetric velocity and pressures occurring in different phases of breathing (quiet and forced). It is carried out using a universal pneumotachograph. The principle of the method is based on recording pressures at various points in the movement of the air stream that change in connection with the respiratory cycle. Pneumotachography allows you to determine the volumetric velocity of air flow during inhalation and exhalation (normally, during quiet breathing it is 300-500 ml/s, during forced breathing - 5000-8000 ml/s), the duration of the phases respiratory cycle, MOD, intra-alveolar pressure, resistance of the respiratory tract to the movement of a stream of air, compliance of the lungs and chest wall, work of breathing and some other indicators.
Tests to detect obvious or hidden respiratory failure.Determination of oxygen consumption and oxygen deficiency carried out by spirography with a closed system and CO2 absorption. When studying oxygen deficiency, the resulting spirogram is compared with a spirogram recorded under the same conditions, but when the spirometer is filled with oxygen; make the appropriate calculations.
Ergospirography- a method that allows you to determine the amount of work that a subject can do without the appearance of signs of respiratory failure, i.e., to study the reserves of the respiratory system. The spirography method is used to determine oxygen consumption and oxygen deficiency in a patient in calm state and when he performs a certain physical activity on an ergometer. Respiratory failure is judged by the presence of spirographic oxygen deficiency of more than 100 l/min or latent oxygen deficiency of more than 20% (breathing becomes calmer when switching from air breathing to oxygen breathing), as well as by changes in the partial pressure of oxygen and carbohydrate oxide (IV) blood.
Blood Gas Study carry out as follows. Blood is obtained from a wound from a prick of the skin of a heated finger (it has been proven that capillary blood obtained under such conditions is similar in gas composition to arterial blood), collecting it immediately into a beaker under a layer of heated petroleum jelly to avoid oxidation by air oxygen. Then the gas composition of the blood is examined using a Van Slyke apparatus, which uses the principle of displacing gases from connection with hemoglobin chemically into vacuum space. The following indicators are determined: a) oxygen content in volumetric units; b) oxygen capacity of blood (i.e., the amount of oxygen that a unit of a given blood can bind); c) percentage of blood oxygen saturation (normally 95); d) partial pressure of blood oxygen (normally 90-100 mm Hg); e) the content of carbon monoxide (IV) in volume percent in arterial blood (normally about 48); f) partial pressure of carbon monoxide (IV) (normally about 40 mm Hg).
Recently, the partial tension of gases in arterial blood (PaO2 and PaCO2) is determined using the micro-Astrup apparatus or other methods.
determine the readings of the instrument scale while breathing air and then pure oxygen; a significant increase in the difference in readings in the second case indicates an oxygen debt in the blood.
Determination of blood flow speed separately in small and big circle blood circulation U
Patients with dysfunction external respiration it also provides valuable data for diagnosis and prognosis
Spirography- a method of graphically recording changes in lung volumes when performing natural breathing movements and volitional forced respiratory maneuvers. Spirography allows you to obtain a number of indicators that describe lung ventilation. First of all, these are static volumes and capacities that characterize the elastic properties of the lungs and chest wall, as well as dynamic indicators, which determine the amount of air ventilated through respiratory tract during inhalation and exhalation per unit of time. Indicators are determined in the mode calm breathing, and some - during forced breathing maneuvers.
In terms of technical performance, all spirographs are divided into on open and closed type devices. In open type devices, the patient inhales through the valve box atmospheric air, and exhaled air enters into a Douglas bag or into a Tiso spirometer(with a capacity of 100-200 l), sometimes to a gas meter, which continuously determines its volume. The air collected in this way is analyzed: the values of oxygen absorption and carbon dioxide release per unit of time are determined. Closed-type devices use the air from the bell of the device, circulating in a closed circuit without communication with the atmosphere. Exhaled carbon dioxide is absorbed by a special absorber.
Indications for spirography the following:
1. Determination of the type and degree of pulmonary insufficiency.
2.Monitoring of pulmonary ventilation indicators in order to determine the degree and speed of progression of the disease.
3.Performance assessment course treatment diseases with bronchial obstruction with bronchodilators, short- and long-acting β2-agonists, anticholinergics), inhaled corticosteroids and membrane-stabilizing drugs.
4.Conduct differential diagnosis between pulmonary and heart failure in combination with other research methods.
5.Identification initial signs ventilation failure in persons at risk pulmonary diseases, or in persons working under the influence of harmful production factors.
6.Expertise of performance and military examination based on assessment of pulmonary ventilation function in combination with clinical indicators.
7. Conducting bronchodilation tests to determine reversibility bronchial obstruction, as well as provocative inhalation tests to detect bronchial hyperreactivity.
Rice. 1. Schematic representation of a spirograph
Despite its widespread clinical use, spirography is contraindicated in the following diseases and pathological conditions:
1. heavy general condition patient, which does not allow the study to be carried out;
2. progressive angina, myocardial infarction, acute disorder cerebral circulation;
3. malignant arterial hypertension, hypertensive crisis;
4. toxicosis of pregnancy, second half of pregnancy;
5. stage III circulatory failure;
6. heavy pulmonary failure, which does not allow breathing maneuvers.
Spirography technique. The study is carried out in the morning on an empty stomach. Before the study, the patient is recommended to remain calm for 30 minutes, and also stop taking bronchodilators no later than 12 hours before the start of the study. The spirographic curve and pulmonary ventilation indicators are shown in Fig. 2.
Static indicators are determined during quiet breathing. Measure tidal volume (TO) - the average volume of air that the patient inhales and exhales during normal breathing at rest. Normally it is 500-800 ml. The part of sediments that takes part in gas exchange is called alveolar volume (JSC) and on average equals 2/3 of the value of DO. The remainder (1/3 of the DO value) is the volume functional dead space
(FMP). After a calm exhalation, the patient exhales as deeply as possible - measured expiratory reserve volume (ROVyd), which normally amounts to IOOO-1500 ml. After a calm inhalation, the maximum deep breath- measured inspiratory reserve volume (District Department of Internal Affairs). When analyzing static indicators, the inspiratory capacity (Evd) is calculated - the sum of IR and IRvd, which characterizes the ability of lung tissue to stretch, as well as the vital capacity of the lungs ( vital capacity) - the maximum volume that can be inhaled after the deepest possible exhalation (the sum of DO, ROVD and ROVd normally ranges from 3000 to 5000 ml). After normal quiet breathing, a breathing maneuver is performed: the deepest possible breath is taken, and then the deepest, sharpest and longest (at least 6 s) exhalation is taken. This is how it is determined forced vital capacity (FVC) - the volume of air that can be exhaled during forced exhalation after maximum inspiration (normally 70-80% vital capacity). How final stage research is being recorded maximum ventilation (MVL) - the maximum volume of air that can be ventilated by the lungs in 1 min. MVL characterizes the functional capacity of the external respiration apparatus and is normally 50-180 liters. A decrease in MVL is observed with a decrease in pulmonary volumes due to restrictive (limiting) and obstructive disorders of pulmonary ventilation.
Rice. 2. Spirographic curve and pulmonary ventilation indicators
When analyzing the spirographic curve obtained in a maneuver with forced exhalation, certain speed indicators are measured (Fig. 3): 1) o forced expiratory volume in the first second (FEV1) - the volume of air that is exhaled in the first second during the fastest possible exhalation; it is measured in ml and calculated as a percentage of FVC; healthy people exhale at least 70% of FVC in the first second; 2) sample or Tiffno index - ratio FEV1 (ml)/VC (ml), multiplied by 100%; normally is at least 70-75%; 3) maximum volumetric air velocity at the expiratory level 75% FVC ( MOS75), remaining in the lungs; 4) maximum volumetric air velocity at the expiratory level of 50% FVC (MOC50) remaining in the lungs; 5) maximum volumetric air velocity at expiratory level 25% FVC ( MOS25), remaining in the lungs; 6) average forced expiratory volumetric flow rate, calculated in the measurement interval from 25 to 75% FVC ( SOS25-75).
Rice. 3. Spirographic curve obtained in the forced expiratory maneuver. Calculation of FEV1 and SOS25-75 indicators
Calculation of speed indicators is of great importance in identifying signs of bronchial obstruction. Decrease Tiffno index and FEV1 is characteristic feature diseases that are accompanied by a decrease in bronchial patency - bronchial asthma, chronic obstructive pulmonary disease, bronchiectasis, etc. MOS indicators are of the greatest value in diagnosis initial manifestations bronchial obstruction. SOS25-75 displays the state of patency of small bronchi and bronchioles. The latter indicator is more informative than FEV1 for identifying early obstructive disorders.
All indicators of pulmonary ventilation are variable. They depend on gender, age, weight, height, body position, condition nervous system patient and other factors. Therefore, to correctly assess the functional state of pulmonary ventilation absolute value one or another indicator is insufficient. It is necessary to compare the obtained absolute indicators with the corresponding values in a healthy person of the same age, height, weight and gender - the so-called proper indicators. This comparison is expressed as a percentage relative to the proper indicator. Deviations exceeding 15-20% of the expected value are considered pathological.
1. Tympanic sound (loud, prolonged, low, tympanic) observed:
1. If there is an air cavity in the lung:
a) stage II lung abscess, when the liquid contents are separated through the bronchus communicating with the abscess and an air cavity is formed;
b) tuberculous cavity.
2. When air accumulates in the pleural cavity (pneumothorax). Types of tympanic sound:
Metal - resembles the sound of a blow on metal, is detected over a large, smooth-walled cavity with a diameter of at least 6-8 cm, located superficially, at a depth of no more than 1-2 cm. This sound is characteristic of pneumothorax, especially open one. Less commonly, it is observed with a large abscess or cavity.
The sound of a cracked pot - resembles the sound that is produced by beating a closed and empty pot with a crack in the wall. Such a percussion sound is determined over a large, smooth-walled, superficially located cavity, communicating with the bronchus through a narrow slit-like opening (abscess, cavern).
Dull tympanic sound
With the simultaneous accumulation of air and fluid in the alveoli, which is typical for lobar pneumonia of stages I and III. The appearance of inflammatory exudate in the cavity of the alveoli leads to compaction of the lung tissue and the appearance of a dull sound. The simultaneous presence of air in the cavity of the alveoli with reduced elasticity of the alveolar wall contributes to the appearance of a tympanic shade of percussion sound.
When the airiness of the lung tissue decreases and its elasticity decreases (compression atelectasis). Compression atelectasis occurs above the area of fluid accumulation in the pleural cavity. In this case, compression of the lung tissue occurs, reducing its airiness and the appearance of a compaction, which explains the presence of a dull sound. In addition, in the area of compression atelectasis, a decrease in the elasticity of the lung tissue occurs, which gives the sound a tympanic hue. It is known that the tympanicity of sound is inversely proportional to the elasticity of the tissue.
Boxed sound(loud, continuous, very low, tympanic) resembles the sound that appears when you tap on a pillow or box. It appears when the airiness of the lung tissue increases and its elasticity decreases (emphysema, bronchial asthma attack).
2. Dull tympanic sound (quiet, short, high, tympanic) is determined by:
1. With the simultaneous accumulation of air and fluid in the alveoli, which is typical for lobar pneumonia of stages I and III. The appearance of inflammatory exudate in the cavity of the alveoli leads to compaction of the lung tissue and the appearance of a dull sound. The simultaneous presence of air in the cavity of the alveoli with reduced elasticity of the alveolar wall contributes to the appearance of a tympanic shade of percussion sound.
2. When the airiness of the lung tissue decreases and its elasticity decreases (compression atelectasis). Compression atelectasis occurs above the area of fluid accumulation in the pleural cavity. In this case, compression of the lung tissue occurs, a decrease in its airiness and the appearance of compaction, which explains the presence of a dull sound. In addition, in the area of compression atelectasis, a decrease in the elasticity of the lung tissue occurs, which gives the sound a tympanic hue. It is known that the tympanicity of sound is inversely proportional to the elasticity of tissue
3.Bronchophony.
Stand in front to the right of the patient. Place the phonendoscope in the supraclavicular fossa on the right. Ask the patient to whisper words containing hissing sounds (“cup of tea”), move the stethoscope to a symmetrical area and ask the patient to repeat similar words. Evaluate the results of the study. In a similar way, perform bronchophony at all points of auscultation.
Increased bronchophony:
Compaction of lung tissue (pneumonia, fibrosis, pulmonary infarction, infiltrative tuberculosis).
An air cavity communicating with the bronchus (open pneumothorax, abscess, cavity, bronchiectasis).
Collapse of lung tissue due to external compression ( compression atelectasis).
Weakening of bronchophony:
Bronchial obstruction (obstructive atelectasis).
Liquid, air, connective tissue, in the pleural cavity (exudative pleurisy, hemothorax, closed pneumothorax, hydropneumothorax, fibrothorax).
4. Wet wheezing
Wet wheezing manifest themselves with short, abrupt sounds, reminiscent of bursting bubbles, and are heard in both phases of breathing, but better in the inhalation phase. Moist rales occur when there is liquid secretion (sputum, transudate, blood) in the trachea, bronchi, cavities communicating with the bronchus, and the passage of air through this secretion with the formation of air bubbles of different diameters, which burst and make peculiar sounds.
Depending on the caliber of the bronchi in which moist rales occur, large-, medium- and fine-bubble rales are distinguished:
1. Large bubble moist rales are formed when liquid secretions accumulate in the trachea, large bronchi, large cavities communicating with the bronchus ( pulmonary edema, pulmonary hemorrhage, stage II lung abscess, tuberculous cavity).
Medium-bubbly moist rales are observed when liquid secretions accumulate in the bronchi of medium caliber, in bronchiectasis (bronchitis, pulmonary edema, bronchiectasis, pulmonary hemorrhage).
Fine bubble moist rales occur when liquid secretions accumulate in the lumen of small bronchi, bronchioles (focal pneumonia, bronchitis, congestion in the pulmonary circulation, bronchiolitis). Fine bubbling rales sometimes sound like crepitus.
Based on volume (sonority), moist rales are divided into sonorous (voiced, consonant) and silent (non-voiced, non-consonant), which depends on the nature of the pathological process in the lungs:
1. Sounding moist rales occur in small bronchi, bronchioles, air cavities communicating with the bronchus, in the presence of changes in the surrounding lung tissue, which contribute to better conduction of sounds:
a) compaction of lung tissue (focal pneumonia, chronic bronchitis with symptoms of pneumosclerosis).
b) an air cavity communicating with the bronchus due to resonance and compaction of the lung tissue around the cavity due to perifocal inflammation (stage II lung abscess, tuberculous cavity).
Silent moist rales occur in the bronchi of all sizes, the trachea in the absence of changes in the lung tissue that contribute to better conduction of sounds. In this case, the sound of bursting bubbles arising in the bronchi is muffled by the lung tissue surrounding the bronchi (bronchitis, congestion in the pulmonary circulation, pulmonary edema).
Vocal tremor is a vibration of the chest during phonation, felt by the hand of the doctor who is examining the patient. Pulmonologists at the Yusupov Hospital determine vocal tremor during a physical examination of the patient. The therapy clinic has all the conditions for treating patients with respiratory diseases. Comfortable rooms are equipped with forced-air ventilation and air conditioning, which allows you to create a comfortable temperature regime. Patients are provided for by individual means personal hygiene and dietary nutrition. Pulmonologists use modern diagnostic devices leading companies in the world.
Doctors use individual schemes therapy, patients are prescribed effective medicines, registered in the Russian Federation, which have a minimum spectrum side effects. All complex cases are discussed at a meeting of the Expert Council with the participation of professors and doctors highest category. Pulmonologists make a collegial decision regarding the further management of patients with diseases of the respiratory system.
How to detect vocal tremors
To determine vocal tremors, 2 conditions are necessary: the bronchi must be patent, and the lung tissue must be adjacent to the chest. Pulmonologists at the Yusupov Hospital check vocal tremors simultaneously with both hands over symmetrical areas of the chest, sequentially in front and behind. To detect vocal tremors from the front, the patient must be in a sitting or standing position.
The doctor stands in front of the patient and faces him, places both hands with fingers closed and straightened with the palmar surface on symmetrical sections of the anterior chest wall longitudinally. The fingertips should be located in the supraclavicular fossa. They are lightly pressed against the chest. The patient is asked to say “thirty-three” loudly. In this case, the doctor focuses on the sensations in the fingers and the trembling under them. It determines whether the vibration under both hands is the same.
Then the pulmonologist changes the position of his hands and asks the patient to loudly say “thirty-three” again. He evaluates his sensations and compares the nature of the vibration under both hands. This is how the doctor finally determines whether the vocal tremor is the same over both apexes or whether it predominates over one of them.
A similar method is used to check vocal tremors in the front subclavian areas, lateral and posterior, in the suprascapular, interscapular and subscapular areas. This method of examining patients allows doctors at the Yusupov Hospital to determine the conduction of sound vibrations to the surface of the chest using palpation. If the patient does not have a pathology of the respiratory system, vocal tremor in symmetrical areas of the chest will be the same. In the presence of a pathological process, it becomes asymmetrical (weakened or strengthened).
Changing voice tremors
- thin chest;
- syndrome of compaction of lung tissue (with pneumonia, pulmonary tuberculosis, pneumosclerosis);
- compression atelectasis;
- the presence of abscesses and cavities surrounded by compacted lung tissue.
A weakening of vocal tremors is noted in the presence of fluid or gas in the pleural cavity (hydrothorax, exudative pleurisy, pneumothorax, hemothorax), syndrome of increased airiness of the lung tissue (pulmonary emphysema), massive adhesions.
Voice tremors due to pneumonia
Pneumonia is an inflammation of the lungs caused by bacteria, viruses, fungi or protozoa. After the penetration of infectious agents into the alveoli, inflammatory process. Patients' body temperature rises, they are bothered by a cough, a feeling of lack of air, general malaise and weakness, and shortness of breath develops. Over time, more join late signs pneumonia:
- chest pain;
- rapid breathing;
- cough with sputum production;
- increased vocal tremors.
With focal pneumonia, asymmetric vocal tremors are observed in the same places of the chest. Using auscultation, doctors determine bronchophony - a specific sound reminiscent of the buzzing of a bee. Bronchial breathing is expressed in the form of a characteristic dry sound, which is formed when air passes through the inflamed bronchi.
With lobar pneumonia, the change in vocal tremors depends on the stage of inflammation. At the beginning of the disease, vocal tremors are somewhat increased, because lung tissue compacted, but still contains a small amount of air. At the height of the disease, dense lung tissue better conducts vocal tremors to the surface of the chest, so vocal tremors intensify significantly. During the resolution stage of pneumonia, the lung tissue is still compacted, but already contains a small amount of air. On palpation, a slightly increased vocal tremor is detected.
If you have the first signs of respiratory disease, call the Yusupov Hospital. You will be scheduled for an appointment with a pulmonologist. The doctor will conduct an examination and prescribe individual treatment.
References
- ICD-10 ( International classification diseases)
- Yusupov Hospital
- "Diseases of the respiratory system." Guide ed. acad. RAMS, prof. N.R. Paleeva. M., Medicine, 2000.
- Respiratory failure and chronic obstructive pulmonary disease. Ed. V.A. Ignatieva and A.N. Kokosova, 2006, 248 p.
- Ilkovich M.M. and others. Diagnosis of diseases and conditions complicated by the development of spontaneous pneumothorax, 2004.
Prices for diagnosing voice tremors
*The information on the site is for informational purposes only. All materials and prices posted on the site are not a public offer, defined by the provisions of Art. 437 Civil Code of the Russian Federation. To receive accurate information contact the clinic staff or visit our clinic. List of services provided paid services indicated in the price list of the Yusupov Hospital.
*The information on the site is for informational purposes only. All materials and prices posted on the site are not a public offer, defined by the provisions of Art. 437 Civil Code of the Russian Federation. For accurate information, please contact the clinic staff or visit our clinic.
