物理诊断学：胸部检查-1

1、Contents Contents 内容内容 胸膜肥厚、粘连胸膜肥厚、粘连 compressive atelectasis: Auscultation of the Lung 肺部听诊肺部听诊 n breath sound 呼吸音呼吸音 n rales 啰啰音音 n vocal resonance 语音共振语音共振 n pleural friction rub 胸膜摩擦音胸膜摩擦音 Principles of Sound Transmission 声音的传导声音的传导 nDistance 传导距离传导距离 nNumber of interfaces 界面的数量界面的数量 nThe nature

2、 of the transmitting medium 传导介质的性质传导介质的性质 The more dense the medium, the better the transmission 传导介质密度越高传导介质密度越高 传导性能越好传导性能越好 Breath Sounds 呼吸音呼吸音 nAirflow tremor nInspiratory phase: Ascending branch nExpiratory phase: Descending branch nHearing duration: Length of the line nLoudness: Thickness of

3、 the line nPitch: Angle n气流产生震动气流产生震动 n吸气相吸气相: :升支升支 n呼气相呼气相: :降支降支 n声音时间声音时间: : 线条长短线条长短 n音响强弱音响强弱: : 线条粗细线条粗细 n音调高低音调高低: : 夹角大小夹角大小 Classify of Breath Sound 呼吸音分类呼吸音分类 nBronchial breath sounds 支气管呼吸音支气管呼吸音 nVesicular breath sounds 肺泡呼吸音肺泡呼吸音 nBronchovesicular breath sounds 支气管肺泡呼吸音支气管肺泡呼吸音 Normal

4、Bronchial Breath Sounds 正常支气管呼吸音正常支气管呼吸音 nThey are harsher and of higher pitch than vesicular sounds. nIt is an expiratory sound. nIn expiration phase, its relatively louder, higher pitched and lasts longer. nBest heard at laryngeal, suprasternal fossa, C 6-7, and T 1-2. n气流经声门、气管、主支气管气流经声门、气管、主支气管

5、产生震动产生震动 n “哈哈”的声音的声音 n呼气时声门窄呼气时声门窄 声音响声音响 吸气相长强高吸气相长强高 呼气相更长更强更高呼气相更长更强更高 n听诊部位听诊部位 喉部喉部 胸骨上窝胸骨上窝 颈椎颈椎6, 76, 7和胸椎和胸椎1, 21, 2 Normal Vesicular Breath Sounds 正常肺泡呼吸音正常肺泡呼吸音 nLow pitched, fine, and heard well at the periphery of the lung. nIt is an inspiratory sound. nIn inspiration phase, its relativ

6、ely louder, higher pitched and lasts longer n气流进出细支气管、肺泡气流进出细支气管、肺泡 产生振动产生振动 n“夫夫”的声音的声音 n吸气时肺紧张吸气时肺紧张 声音响声音响 吸气相长吸气相长 强强 高高 呼气相短呼气相短 弱弱 低低 n听诊部位听诊部位: : 肺部区域肺部区域 乳房下部乳房下部 肩胛下部肩胛下部 腋窝下部腋窝下部 最清晰最清晰 Normal Bronchovesicular Breath Sounds 正常支气管肺泡呼吸音正常支气管肺泡呼吸音 nA mixture of the two elements nThe two phase

7、s are quite similar in intensity, duration, and pitch. nBest heard anteriorly over the upper end of the sternum and just beside it at the level of Louiss angle, and posteriorly over the interscapular spaces at the level of the third and fourth thoracic vertebrae, right apice. n支气管和肺泡支气管和肺泡 呼吸音重叠呼吸音重

8、叠 n吸气似肺泡呼吸音吸气似肺泡呼吸音 但较高较响亮但较高较响亮 呼气似支气管呼吸音呼气似支气管呼吸音 但稍弱稍低但稍弱稍低 n听诊部位听诊部位 胸骨角两侧胸骨角两侧 右肺尖右肺尖 肩胛间区胸椎肩胛间区胸椎3 3，4 4水平水平 Abnormal Breath Sounds 异常呼吸音异常呼吸音 nAbnormal vesicular breath sounds 异常肺泡呼吸音异常肺泡呼吸音 nAbnormal bronchial breath sounds 异常支气管呼吸音异常支气管呼吸音 nAbnormal bronchovesicular breath sounds 异常支气管肺泡呼吸音

9、异常支气管肺泡呼吸音 Abnormal Vesicular Breath Sounds 异常肺泡呼吸音异常肺泡呼吸音 (1) nDiminished Exaggerated unilateral: compensatory breath sounds; bilateral: enhanced respiratory movement and ventilatory function. 肺泡呼吸音增强肺泡呼吸音增强 单侧单侧:代偿因素代偿因素 双侧双侧:全身因素全身因素 Abnormal Vesicular Breath Sounds 异常肺泡呼吸音异常肺泡呼吸音 (2) nProlonged

10、: the lower respiratory tract spasm, or narrowing; diminished elasticity of the lung tissue. 呼吸音延长呼吸音延长: : 下呼吸道痉挛或狭窄下呼吸道痉挛或狭窄 肺组织弹性减退肺组织弹性减退 nIntermittent and roughness: airflow asymmetry and not smooth. 断续和粗糙断续和粗糙: : 气流不均匀或不畅气流不均匀或不畅 Abnormal Bronchial Breath Sounds 异常支气管呼吸音异常支气管呼吸音 nBronchial brea

11、th sounds appears in the area where the vesicular breath sounds dominate. 肺泡呼吸音区出现支气管呼吸音肺泡呼吸音区出现支气管呼吸音 “tubular breath sound” 又称管状呼吸音又称管状呼吸音 nMechanism: airway open but lung tissue with infiltration or large cavity. 机制机制: :气道通畅气道通畅 肺组织密度增加肺组织密度增加 肺内有空腔肺内有空腔 nCauses: consolidation of the lung, large

12、cavity inside the lung, compressive atelectasis. 原因原因: :肺内炎症实变肺内炎症实变 压迫性肺不张压迫性肺不张 肺内大空洞肺内大空洞 Abnormal Bronchovesicular Breath Sounds 异常支气管肺泡呼吸音异常支气管肺泡呼吸音 nBronchovesicular breath sounds appears in the area where the vesicular breath sounds dominate. 肺泡呼吸音区出现支气管肺泡呼吸音肺泡呼吸音区出现支气管肺泡呼吸音 nMechanism: airwa

13、y open with both normal lung tissue and consolidation. 机制机制: : 气道通畅肺实变与正常肺并存气道通畅肺实变与正常肺并存 nSeen in bronchial pneumonia, tuberculosis of the lung, initial stages of lobar pneumonia, compressed area upper in pleural effusion. 原因原因: : 支气管肺炎支气管肺炎 肺结核肺结核 大叶肺炎初期大叶肺炎初期 胸腔积液上方肺膨胀不全区域胸腔积液上方肺膨胀不全区域 Rales 啰音啰音

14、 nrhonchi wheeze stridor ncrackles or moist rale sonority and nonsonority coarse, middle and fine crepitus n干干啰啰音音 哮鸣音哮鸣音 喘鸣喘鸣音音 n湿湿啰啰音音 响亮性响亮性 非响亮非响亮 粗粗 中中 细细 捻发音捻发音 Rhonchi 干啰音干啰音 nRhonchi are long continuous adventitious sounds, generated by airway narrowing. 由气道狭窄产生持续时间较长的附加音由气道狭窄产生持续时间较长的附加音 In

15、flammation-induced mucosal congestion and edema together with exudate 炎症引起的黏膜充血水肿伴分泌物增多炎症引起的黏膜充血水肿伴分泌物增多 Spasmodic contraction of bronchial smooth muscle 支气管平滑肌痉挛性收缩支气管平滑肌痉挛性收缩 Intralumenal tumor or foreign body obstruction 管腔内肿瘤或异物堵塞管腔内肿瘤或异物堵塞 Narrowing of lumen caused by compression 管壁受压管腔狭窄管壁受压管腔

16、狭窄 Classify of Rhonchi 干啰音分类干啰音分类 nGeneral rhonchi 一般干一般干啰啰音音 produced by thick secretion in bronchus 由支气管粘稠分泌物所致由支气管粘稠分泌物所致 nWheezes 哮鸣音哮鸣音 produced by bronchial smooth muscle spasm 由支气管平滑肌痉挛所致由支气管平滑肌痉挛所致 nStridor 喘鸣音喘鸣音 produced by large airway narrowing 由大气道阻塞所致由大气道阻塞所致 Compares with General Rhon

17、chi and Wheeze 一般干啰音和哮鸣音的比较一般干啰音和哮鸣音的比较 nHeard both two phases 吸气呼气均可听到吸气呼气均可听到 nHigh-pitched or deep-toned 音调可高可低音调可高可低 nDistributing odds and dispel 散在分布不均散在分布不均 nAfter coughing: number and part volatility 咳嗽后数量和部位易变咳嗽后数量和部位易变 nOnly in expiration 在呼气相在呼气相 nHigh-pitched 音调高音调高 nPermeate or localiza

18、tion 弥漫或局限固定弥漫或局限固定 nAfter coughing invariability 咳嗽后不变咳嗽后不变 thick secretion muscle spasm Specialty of Stridor 喘鸣音的特点喘鸣音的特点 nLoud audible in throat and trachea 在喉和气管附近听到在喉和气管附近听到 nHearing in inspiratory phase 吸气相明显吸气相明显 nUsually accompany inspiratory dyspnea 常伴有吸气费力常伴有吸气费力 nUsually accompany sign of

19、 “three depressions sign” 常伴有常伴有“三凹三凹”征征 Clinical Significance 临床意义临床意义 nChangeable and fugitive, varying tones: exudate in respiratory tract: bronchitis nDiffuse wheeze: narrowing of small airways: asthma nLocalized fixed wheezes: airway narrowing: tumor or endobronchial tuberculosis nStridor: larg

20、e airway obstruction: laryngeal spasm, foreign body, tumor n易变多音调干易变多音调干啰啰音音 粘稠分泌物粘稠分泌物: : 支气管炎症支气管炎症 n弥漫哮鸣音弥漫哮鸣音 细支气管缩窄细支气管缩窄: : 哮喘哮喘 n局限固定哮鸣音局限固定哮鸣音 细支气管狭窄细支气管狭窄: : 肿瘤肿瘤 结核结核 n喘鸣音喘鸣音 大气道阻塞大气道阻塞: : 喉痉挛喉痉挛 异物异物 肿瘤肿瘤 Crackles 湿湿啰啰音音 nInterrupted adventitious sounds 断续的附加音断续的附加音 nMake a notation about

21、 timing, intensity, effect with respiration, position, coughing and character. 注意出现部位注意出现部位 时间时间 强度强度 呼吸和咳嗽的影响呼吸和咳嗽的影响 nMost Crackles induced by airflow through the fluid at the airway and alveolus. 多数多数由气流通过气道和肺泡内的液体引起由气流通过气道和肺泡内的液体引起 nthe pop open of the collapsed fine bronchiole and alveoli forme

22、d crepitus. 陷闭的细支气管和肺泡突然张开形成陷闭的细支气管和肺泡突然张开形成捻发音捻发音 Classification of Crackles 湿啰音分类湿啰音分类 nCoarse crackles: exudate in trachea, bronchiole or cavity. 粗湿粗湿啰啰音音: : 气管气管 主支气管或空洞内液体主支气管或空洞内液体 nMedium crackles: exudate in bronchiole. 中湿中湿啰啰音音: : 支气管内液体支气管内液体 nFine crackles: exudate in bronchiole or alveol

23、us. 细湿细湿啰啰音音: : 细支气管肺泡内液体细支气管肺泡内液体 nCrepitus: collapsed bronchiole or alveoli open. 捻发音捻发音: : 陷闭的细支气管肺泡开放陷闭的细支气管肺泡开放 Characters of the Crackles 听诊特点听诊特点 nDominate during inspiration phase or at the end of inspiration nFixed site of auscultation nTransient nStable quality nMedium and fine crackles ma

24、y coexist ncoarse crackles may diminish or disappear after cough. n吸气时或吸气时或 吸气终末明显吸气终末明显 n部位较恒定部位较恒定 n时间较短暂时间较短暂 n性质不易变性质不易变 n中小水泡音可并存中小水泡音可并存 n大水泡音咳嗽后大水泡音咳嗽后 可减轻或消失可减轻或消失 Clinical Significance 临床意义临床意义 nLocalized crackles: regional diseases nBilateral crackles in lower field of the lungs with rhonc

25、hi: bronchitis with lung infection nCrackles in bilateral bases of the lungs: pulmonary congestion caused by heart failure nGeneralized coarse crackles in bilateral lung fields: acute pulmonary edema n局部湿局部湿啰啰音音: : 肺局部炎症肺局部炎症 n两下肺散在干湿两下肺散在干湿啰啰音音: : 支气管炎并感染支气管炎并感染 n两肺底对称性湿两肺底对称性湿啰啰音音: : 左心功能不全左心功能不全

26、n两肺满布湿两肺满布湿啰啰音音: : 急性肺水肿急性肺水肿 Clinical Significance 临床意义临床意义 ncoarse crackles: exudate in trachea, bronchiole or cavity.may be seen in bronchiectasis, pulmonary edema, tuberculosis or lung abscess. nmedium crackles: exudate in bronchea (medium size). may be met in bronchitis,bronchopeumonia. nfine c

27、rackles: exudate in bronchiole.may be seen in: bronchiolitis, bronchopneumonia, pulmonary congestion or pulmonary infarction. ncrepitus: exudate in bronchiole or alveoli. They may be seen in pulmonary congestion or early pneumonia. Vocal Resonance 语音共振语音共振 Mechanism and significance: same as tactile

28、 fremitus 机制和临床意义机制和临床意义: : 同触觉语颤同触觉语颤 nDecreased: bronchial obstruction and conduct distance add. 减弱减弱: : 支气管阻塞或传导距离增加支气管阻塞或传导距离增加 nIncreased: consolidation,large cavity inside the lung, compressive atelectasis. 增强增强: : 肺实变，肺内大空洞，压迫性肺不张肺实变，肺内大空洞，压迫性肺不张 Pleural Friction Rub 胸膜摩擦音胸膜摩擦音 nMechanism and

29、 Clinical significance : same as pleural friction feelings nDifference to pericardial friction sound： Disappear when stop breathing. 闭气时消失闭气时消失: : 与心包摩擦音区分与心包摩擦音区分 视视触触叩叩听听 胸廓形态胸廓形态气管位置气管位置肺音肺音呼吸音呼吸音 ( (正常，异常 正常，异常) ) 呼吸运动呼吸运动胸廓扩张度胸廓扩张度肺界肺界 ( (上界，下界 上界，下界) ) 啰啰音 音 ( (干，湿 干，湿) ) 呼吸频率呼吸频率语音震颤语音震颤肺下界肺下

30、界 移动度移动度 语音共振语音共振 呼吸深度和呼吸深度和 节律节律 胸膜摩擦感胸膜摩擦感胸膜摩擦音胸膜摩擦音 Summary inspection palpationpercussionauscultation Chest shapeChest shapeTracheal positonTracheal positonPercussion notePercussion noteBreath soundBreath sound Respiratory movement Respiratory movement Chest expansion Chest expansion SuperiorSup

31、erior InferiorInferior ralesrales (rhonchi(rhonchi， ，crackles) crackles) Respiratory rate Respiratory rate Tactile fremitusTactile fremitus Diaphragmatic excursion Diaphragmatic excursion Vocal ResonanceVocal Resonance Respiratory Respiratory depth depth Pleural friction feelingPleural friction feelingPleural Friction RubPleural Friction Rub Summary Common Lung Disease Signs 肺部常见疾病体征肺