Comparative percussion. Comparative and topographic percussion of the lungs: technique, diagnostic value Comparative percussion in pneumonia

For the study of the lungs, depending on the goal, all methods and methods of percussion are used. Examination of the lungs usually begins with comparative percussion.

Comparative percussion. Comparative percussion is always carried out in a certain sequence. First, the percussion sound is compared above the tops of the lungs in front. In this case, the plessimeter finger is placed parallel to the collarbone. Then, with a finger-hammer, uniform blows are applied to the collarbone, which replaces the plessimeter. When percussion of the lungs below the clavicles, the finger-plessimeter is placed in the intercostal spaces parallel to the ribs and strictly in symmetrical sections of the right and left halves of the chest. According to the midclavicular lines and medially, their percussion sound is compared only to the level of the IV rib, below which the left ventricle of the heart is located on the left, changing the percussion sound. To conduct comparative percussion in the axillary regions, the patient should raise his hands up and lay his palms behind his head. Comparative percussion of the lungs from behind begins with the suprascapular regions. The finger-plesimeter is installed horizontally. When percussion of the interscapular areas, the finger-plessimeter is placed vertically. The patient at this moment crosses his arms over his chest and thereby takes the shoulder blades outwards from the spine. Below the angle of the scapula, the finger-plessimeter is again applied horizontally to the body, in the intercostal space, parallel to the ribs.

With comparative percussion of the lungs of a healthy person, the percussion sound at symmetrical points may not be of the same strength, duration and height, which depends both on the mass or thickness of the lung layer, and on the influence of neighboring organs on the percussion sound. The percussion sound is somewhat quieter and shorter: 1) above the right apex, since it is located slightly below the left apex due to the shorter right upper bronchus, on the one hand, and as a result of the large development of the muscles of the right shoulder girdle, on the other; 2) in the second and third intercostal spaces on the left due to the closer location of the heart; 3) above the upper lobes of the lungs compared with the lower lobes as a result of different thicknesses of the air-containing lung tissue; 4) in the right axillary region compared with the left due to the proximity of the liver. The difference in percussion sound here is also due to the fact that the stomach adjoins the diaphragm and the lung on the left, the bottom of which is filled with air and gives a loud tympanic sound during percussion (the so-called Traube's semilunar space). Therefore, the percussion sound in the left axillary region, due to resonance with the "air bubble" of the stomach, becomes louder and higher, with a tympanic tinge.

In pathological processes, a change in percussion sound may be due to: a decrease in the content or complete absence of air in a part of the lung, filling the pleural cavity with fluid (transudate, exudate, blood), an increase in the airiness of the lung tissue, the presence of air in the pleural cavity (pneumothorax).

A decrease in the amount of air in the lungs is observed with: a) pneumosclerosis, fibrofocal pulmonary tuberculosis; b) the presence of pleural adhesions or obliteration of the pleural cavity, which impedes the complete expansion of the lung during inspiration; at the same time, the difference in percussion sound will be more clearly expressed at the height of inhalation and weaker - on exhalation; c) focal, especially confluent pneumonia, when areas of lung air tissue will alternate with areas of compaction; d) significant pulmonary edema, especially in the lower lateral sections, which occurs due to weakening of the contractile function of the left ventricle of the heart; e) compression of lung tissue by pleural fluid (compression atelectasis) above the fluid level; f) complete blockage of a large bronchus by a tumor and gradual resorption of air from the lungs below the closure of the lumen (obstructive atelectasis). In the above pathological conditions, the percussion sound instead of a clear lung sound becomes shorter, quieter and higher, i.e., dull. If at the same time there is also a decrease in the tension of the elastic elements of the lung tissue, as, for example, with compression or obturation atelectasis, then percussion over the atelectasis zone produces a dull sound with a tympanic tinge (dull tympanic sound). It can also be obtained by percussion of a patient with croupous inflammation of the lungs in the first stage of its course, when the alveoli of the inflamed lobe contain a small amount of liquid along with air.

The complete absence of air in the whole lobe of the lung or part of it (segment) is observed with:

a) croupous pneumonia in the stage of compaction, when the alveoli are filled with inflammatory exudate containing fibrin;

b) the formation in the lung of a large cavity filled with inflammatory fluid (sputum, pus, echinococcal cyst, etc.), or foreign airless tissue (tumor); c) accumulation of fluid in the pleural cavity (transudate, exudate, blood). Percussion over the airless areas of the lung or over the fluid accumulated in the pleural cavity will give a quiet, short and high sound, which is called dull or, by its similarity with the sound during percussion of airless organs and tissues (liver, muscles), liver, or muscle sound. However, absolute dullness, completely identical to the liver sound, can only be observed if there is a large amount of fluid in the pleural cavity.

An increase in the air content in the lungs is observed with their emphysema. With emphysema of the lungs, the percussion sound due to increased airiness and a decrease in the elastic tension of the lung tissue, in contrast to the blunt-tympanic one, will be loud, but also with a tympanic tint. It resembles the sound that occurs when a box or pillow is struck, which is why it is called box sound.

An increase in the airiness of the lung over a large area occurs when a smooth-walled cavity is formed in it, filled with air and communicating with the bronchus (abscess, tuberculous cavity). Percussion sound over such a cavity will be tympanic. If the cavity in the lung is small and located deep from the surface of the chest, fluctuations in the lung tissue during percussion may not reach the cavity and tympanitis in such cases will be absent. Such a cavity in the lung will be detected only with fluoroscopy.

Above a very large (diameter 6-8 cm) smooth-walled cavity - the percussion sound will be tympanic, resembling the sound when hitting metal. Such a sound is called a metallic percussion sound. If such a large cavity is located superficially, and communicates with the bronchus through a narrow slit-like opening, the percussion sound above it acquires a peculiar quiet rattling sound - “the sound of a cracked pot”.

Topographic percussion. Topographic percussion is used to determine 1) the upper boundaries of the lungs or the height of the tops, 2) the lower boundaries; 3) mobility of the lower edge of the lungs.

The upper border of the lungs from behind is always determined by the relation of their position to the spinous process of the VII cervical vertebra. to a point located 3-4 cm lateral to the spinous process of the VII cervical vertebra, at its level, and percuss until dullness appears. Normally, the height of the position of the tops behind is approximately at the level of the spinous process of the VII cervical vertebra.

To determine the lower boundaries of the lungs, percussion is performed from top to bottom along conventionally drawn vertical topographic lines. First, the lower border of the right lung is determined in front along the parasternal and midclavicular lines, laterally (on the side) along the anterior, middle and posterior axillary lines, behind - along the scapular and paravertebral lines. The lower border of the left lung is determined only from the lateral side along three axillary lines and from the back along the scapular and paravertebral lines (in front, due to the location of the heart, the lower border of the left lung is not determined). The finger-plessimeter during percussion is placed on the intercostal space parallel to the ribs and weak and uniform blows are applied to it. Percussion of the chest, as a rule, begins to be performed along the anterior surface from the second and third intercostal spaces (with a horizontal or vertical position of the subject); on the lateral surface - from the axillary fossa (in the position of the patient sitting or standing with hands raised up on his head) and along the back surface - from the seventh intercostal space, or from the angle of the scapula, which ends at the VII rib.

The lower border of the right lung, as a rule, is located at the point of transition of a clear pulmonary sound to a dull one (lung-hepatic border). As an exception, in the presence of air in the abdominal cavity, for example, when a gastric or duodenal ulcer is perforated, hepatic dullness may disappear. Then, at the location of the lower border, a clear pulmonary sound will turn into a tympanic one. The lower border of the left lung along the anterior and middle axillary lines is determined by the transition of a clear pulmonary sound to a blunt-tympanic one. This is due to the fact that the lower surface of the left lung comes into contact through the diaphragm with a small airless organ - the spleen and the fundus of the stomach, which gives a tympanic percussion sound (Traube's space).

In persons of normosthenic physique, the lower limit has the following location (Table 1).

The position of the lower border of the lungs may vary depending on the constitutional features of the organism. In persons of asthenic physique, it is somewhat lower than in normosthenics, and is located not on the rib, but in the intercostal space corresponding to this rib, in hypersthenics it is somewhat higher. The lower border of the lungs temporarily shifts upward in women in the last months of pregnancy.

Table 1

Place of percussion	Right lung	Left lung
peristernal line	Fifth intercostal space
midclavicular line
anterior axillary line
Middle axillary line
Posterior axillary line
scapular line
Paravertebral line		Spinous process of XI thoracic vertebra

The position of the lower border of the lungs can also change in various pathological conditions that develop both in the lungs and in the pleura; diaphragm and abdominal organs. This change can occur both due to the displacement or lowering of the boundary, and due to its rise: It can be either one-sided or two-sided.

Bilateral descent of the lower border of the lungs is observed with acute (an attack of bronchial asthma) or chronic (emphysema of the lungs) expansion of the lungs, as well as with a sharp weakening of the tone of the abdominal muscles and prolapse of the abdominal organs (splanchnoptosis). One-sided descent of the lower border of the lung can be caused by vicarious emphysema of one lung when the other lung is turned off from the act of breathing (exudative pleurisy, hydrothorax, pneumothorax), with unilateral paralysis of the diaphragm.

The displacement of the lower border of the lungs upward is more often unilateral and depends on Firstly, from wrinkling of the lung as a result of the growth of connective tissue in it (pneumosclerosis, pulmonary fibrosis) or with complete blockage of the lower lobe bronchus by a tumor, which leads to a gradual collapse of the lung - atelectasis; Secondly, with the accumulation of fluid or air in the pleural cavity, which gradually push the lung up and medially to its root; third, with a sharp increase in the liver (cancer, sarcoma, echinococcus) or an increase in the spleen, for example, with chronic myeloid leukemia. A bilateral rise in the lower border of the lungs can be with a large accumulation of fluid in the abdominal cavity (ascites), or air due to an acute perforation of a stomach or duodenal ulcer, as well as with a sharp flatulence.

After examining the position of the lower border of the lungs during quiet breathing, the mobility of the lung edges is determined during maximum inspiration and expiration. This mobility of the lungs is called active. Usually, the mobility of only the lower edge of the lungs is determined, moreover, on the right along three lines - linea medioclavicularis, axyllaris media et linea scapularis, on the left - along two lines - linea axyllaris media et linea scapularis.

The mobility of the lower edge of the left lung along the midclavicular line is not determined due to the location of the heart in this area.

The mobility of the lower edge of the lungs is determined as follows: first, the lower border of the lungs is established during normal physiological breathing and marked with a dermograph. Then they ask the patient to take a maximum breath and hold his breath at his height. The finger-plesimeter before inhalation should be on the discovered line of the lower border of the lung. Following a deep breath, percussion is continued, gradually moving the finger down by 1-2 cm until absolute dullness appears, where a second mark is made with a dermograph along the upper edge of the finger. Then the patient makes a maximum exhalation and holds his breath at the height. Immediately after expiration, percussion is performed upward until a clear pulmonary sound appears, and on the border with relative dullness, a thermograph makes a third mark. Then measure the distance between the second and third marks with a centimeter tape, which corresponds to the maximum mobility of the lower edge of the lungs. Physiological fluctuations in the active mobility of the lower edge of the lungs average 6-8 cm (on inspiration and expiration).

In a serious condition of the patient, when he cannot hold his breath, another method is used to determine the mobility of the lower edge of the lungs. After the first mark, indicating the lower border of the lung during quiet breathing, the patient is asked to take a deep breath and exhale, during which continuous percussion is performed, gradually moving the finger down. At first, the percussion sound during inhalation is loud and low, and during exhalation it is quiet and higher. Finally, they reach a point above which the percussion sound becomes of the same strength and height both during inhalation and exhalation. This point is considered the lower limit at maximum inspiration. Then, in the same sequence, the lower border of the lung is determined at the maximum exhalation.

A decrease in the active mobility of the lower edge of the lungs is observed with inflammatory infiltration or congestive plethora of the lungs, a decrease in the elastic properties of the lung tissue (emphysema), a massive effusion of fluid into the pleural cavity, and with fusion or obliteration of the pleural sheets.

In some pathological conditions of the lungs, the so-called passive mobility of the lower edges of the lungs is also determined, that is, the mobility of the edges of the lungs when the patient's body changes position. When the body moves from a vertical to a horizontal position, the lower edge of the lungs drops down by about 2 cm, and when positioned on the left side, the lower edge of the right lung can move down by 3-4 cm. In pathological conditions, such as pleural adhesions, displacement the lower edge of the lungs can be sharply limited.

Introduction

Percussion, as a method of physical examination of the patient, has been known since the time of Hippocrates. However, for many years, until the middle of the 18th century, this research method was thoroughly forgotten and was not used in medical practice. In 1761, the percussion method was again developed by Auenbrugger, which was regarded by his contemporaries as a new discovery.

Auenbrugger developed a method of direct percussion, the essence of which is to tap the ends of folded fingers on the patient's chest. In the 20s of the 19th century, a professor at the University of Paris, Corvisart, began to teach this method to his students. In 1827, Piorri introduced the plessimeter and developed a method of mediocre percussion - tapping the plessimeter with a finger. In 1839, Skoda gave a theoretical justification for the method. In 1841, Wintrich, and somewhat earlier Barry, proposed special percussion hammers, after which the method of mediocre percussion with a plessimeter and hammer became very popular. Subsequently, the development and modification of methods of direct and mediocre percussion was carried out. In 1835, Sokolsky introduced the percussion method into domestic medicine, proposing to use the middle finger of the left hand instead of the plessimeter, and the tops of the 2nd and 3rd fingers of the right hand folded together (bimanual method) instead of the hammer (bimanual method), Gerhardt suggested using it as a plessimeter and malleus middle fingers, V.P. Obraztsov developed the method of one-finger percussion, Kotovshchikov developed the method of topographic percussion, Kurlov determined the percussion dimensions of the internal organs, Yanovsky developed the method of percussion of the tops of the lungs.

Physiological substantiation of the method

Tapping on the surface of the human body or on a metal plate tightly pressed to it causes local oscillation of organs and tissues in the percussion zone. The vibration wave propagates approximately 7-8 cm deep into the body, which causes a reflected vibration wave, which we perceive with the ear in the form of a percussion sound.

Percussion sound has its own physical characteristics, which are determined by the nature of the underlying tissues: their density, elasticity, the amount of air or gas in their composition, the size and tension of the cavities containing air. Depending on this, the main characteristics of percussion sound also change, such as:

- loudness (strength, intensity of sound), depending on the amplitude of sound vibrations,

- the duration of the percussion sound, depending on the duration of the sound wave,

- the pitch of the sound, depending on the frequency of vibrations,

- the timbre of sound, depending on the harmony of sound vibrations, the number and nature of overtones in their composition.

In terms of intensity, the percussion sound can be loud (or clear) and quiet (or dull), depending on the amount of air and the volume of dense tissues in the percussion zone.

A loud (clear) percussion sound occurs during percussion of the lungs, trachea, gas bladder area of ​​​​the stomach and intestinal loops containing air, dull (quiet) - during percussion of airless tissue - muscles, liver, spleen, heart.

In terms of duration, the percussion sound can be long and short, which depends on the mass of the sounding body (vibrations of small bodies decay faster) and the amount of air in its composition (vibrations of tissues that do not contain air also quickly decay). Long sound - full, for example, pulmonary, short - empty, for example, femoral.

In terms of height, the percussion sound can be high and low: the height of the sound is inversely proportional to its strength - a clear pulmonary sound is strong and low, a dull sound is quiet and high.

According to the timbre, the percussion sound can be tympanic (consonant) and non-tympanic (dissonant). Tympanic sound is detected above the cavities containing air, which creates conditions for cavity resonance and the appearance of harmonic oscillations, reminiscent of the sound of a drum (oral cavity, trachea, larynx, stomach, intestines). A non-tympanic sound occurs when percussion of the chest over the lung tissue and percussion of tissues that do not contain air.

Typical sounds produced by percussion of the human body:

- femoral, occurs during percussion of airless tissues (muscles, heart, liver, spleen), according to its characteristics, it is a quiet, short, high, non-tympanic sound,

- pulmonary, detected by percussion of the lungs - this is a loud, prolonged, low, non-tympanic sound

- tympanic, occurs during percussion of the trachea, gas bubble of the stomach, intestinal loops containing air - this is a loud, prolonged, harmonic (tympanic) sound.

In the study of the lungs, comparative and topographic percussion is used.

Comparative percussion of the lungs makes it possible to conduct a detailed assessment of the nature of changes in percussion sound in symmetrical areas of the chest, to get a clear idea of ​​the state of the lung tissue in a healthy person and with pathology of the respiratory system

At the same time, alternately strong and weak percussion are used, which allows you to determine the nature of the change in the lung tissue at different depths of the chest: superficial changes with strong percussion may not be detected, as well as deeper ones with weak percussion.

Comparative percussion is performed in the following sequence: apices, anterior surface of the chest along the midclavicular lines at the level of I, II and III intercostal spaces, axillary regions, posterior surface of the chest in the suprascapular region, in the interscapular space, below the angles of the shoulder blades along the scapular lines.

In a healthy person, in symmetrical parts of the chest, with the same strength of the percussion blow, a clear pulmonary sound of the same sonority is determined. However, due to some anatomical features of the compared percussion zones, percussion sound can have different intensity and timbre:

- over the right apex of the lungs, the percussion sound is shorter than over the left, since the muscle layer is better developed on the right,

- on the left in the II-III intercostal space, it is somewhat shorter than on the right (proximity of the heart),

- on the right in the armpit is shorter than on the left (next to the liver),

- in the left axillary region may have a tympanic shade (next to the gas bubble of the stomach).

Change in percussion sound in pathology

A decrease in the strength (clarity) and duration of a lung sound with an increase in its height can lead to a shortening and dulling of the percussion sound or the transformation of a clear lung sound into a dull one, which is observed when:

- compaction of the lung tissue,

- decreased airiness of the lungs

- accumulation of fluid in the pleural cavity.

The degree of the above changes in percussion sound depends on the degree of compaction of the lung tissue, the degree of decrease in its airiness, the volume of pathological changes in the lung, the depth of the pathological focus, and the volume of pleural effusion.

For example, in case of focal pneumonia over the area of ​​inflammatory infiltration of the lungs, an area of ​​shortening or dullness of the percussion sound is detected, while in case of lobar pneumonia, a dull percussion sound is determined over the airless and compacted lobe of the lung.

Changing the timbre of the lung sound

A tympanic sound over the lungs appears with abdominal syndrome and pneumothorax, provided that the diameter of the air cavity is at least 3-4 cm and the cavity is located close to the chest wall. Large tense cavities (more than 6 cm in diameter) and the accumulation of a large amount of air in the pleura with tension pneumothorax give a tympanic sound with a metallic tint (high tympanitis). The cavities communicating with the bronchus through a narrow opening make a sound reminiscent of the sound of a cracked pot.

Dull-tympanic sound occurs with a decrease in the elastic properties of the lung tissue, which occurs in the initial stage of croupous pneumonia, in the zone of incomplete compression and obstructive atelectasis of the lungs.

One variation of the tympanic sound is the box sound, which is similar to the sound produced by tapping on the surface of an empty box or table. It is detected in emphysema (obstructive bronchitis, bronchial asthma) and acute pulmonary distention (severe asthma attack) as a result of its hyperairiness and changes in the structure of the lung tissue.

Topographic percussion, in which silent percussion is used, is performed to determine the boundaries of the lungs.

The position of the borders of the lungs in a healthy person depends on the type of constitution and the height of the diaphragm, which is determined by the amount of fatty tissue in the abdominal cavity.

The upper border of the right lung is located approximately 2-3 cm, the left - 3-4 cm above the clavicle. In persons of asthenic constitution with low body weight and low standing of the diaphragm, the upper border of the lungs is lower, in hypersthenics with overweight and high standing of the diaphragm, it is higher than in normosthenics with normal body weight. During pregnancy, the upper border of the lungs shifts upward.

The displacement of the upper border is observed in extrapulmonary pathology and pathology of the bronchopulmonary apparatus.

The upward shift of the upper border is observed with the accumulation of free fluid in the abdominal cavity (ascites), in the pericardial cavity (hydropericardium, exudative pericarditis), with tumors of the mediastinum, a significant increase in the size of the liver and spleen, downward - with severe exhaustion of patients, which occurs with chronic debilitating diseases (eg, bacterial endocarditis, chronic enteritis, myeloproliferative diseases, etc.).

Depending on the purpose of the study, topographic and comparative percussion are distinguished.

Topographic percussion is used to determine the boundaries of the lungs, heart, liver, spleen and other organs (with subsequent assessment of their size), observing certain rules for the location of the pessimeter finger and the direction of percussion: they usually percuss in the direction from a clear sound to a dull one.

Comparative percussion is performed with strong or quiet, but equal in strength blows over symmetrical sections of the chest in order to identify pathological formations in the chest cavity.

The tissues of the human body are heterogeneous in density. Bones, muscles, fluids in the cavities, liver, spleen, heart have a high density. Percussion in the location of these organs gives a short, quiet, high or dull percussion sound.

Low-density tissues or organs are those that contain a lot of air (lungs). Percussion of the lungs with normal airiness gives a sufficiently long, loud, low sound, which is called a clear lung.

With percussion of the lungs, the following most important symptoms of the presence of fluid in the pleural cavity are revealed: a dull percussion sound over the effusion zone.

It is believed that with the help of percussion it is possible to determine the presence of fluid in the pleural cavity if its amount is at least 300-400 ml, and an increase in the level of dullness by one rib corresponds to an increase in the amount of fluid by 500 ml.

An extremely pronounced dullness of the percussion sound ("dull femoral sound"), growing downwards, is characteristic. The upper limit of dullness (the Sokolov-Ellis-Damuazo line) runs from the spine upward outward to the scapular or posterior axillary line and further anteriorly obliquely downward. With exudative pleurisy, due to the stickiness of the exudate, both pleural sheets stick together at the upper border of the fluid, so the configuration of dullness and the direction of the Sokolov-Ellis-Damuazo line almost does not change when the patient's position changes.

If there is tracedata in the pleural cavity, the direction of the line changes after 15-30 minutes. Anteriorly along the mid-clavicular line, dullness is determined only when the amount of fluid in the pleural cavity is about 2-3 liters, while behind the upper limit of dullness usually reaches the middle of the scapula; dullness of percussion sound on the healthy side in the form of a right-angled Raufus triangle.

The hypotenuse of this triangle is the continuation of the Sokolov-Ellis-Damoiseau line on the healthy half of the chest, one leg is the spine, the other is the lower edge of the healthy lung.

Dullness of percussion sound in the region of this triangle is due to a shift to the healthy side of the thoracic aorta, which gives a dull sound during percussion; clear pulmonary sound in the area of ​​Garland's right triangle on the affected side.

The hypotenuse of this triangle is the part of the Sokolov-Ellis-Damuazo line starting from the spine, one leg is the spine, and the other is a straight line connecting the top of the Sokolov Ellis-Damuazo line with the spine; the zone of tympanic sound (Skoda zone) is located above the upper border of the exudate, has a height of 4-5 cm.

In this zone, the lung is subjected to some compression, the walls of the alveoli collapse and relax, their elasticity, and the ability to fluctuate decreases, as a result of which, during percussion of the lungs in this zone, air vibrations in the alveoli begin to prevail over the vibrations of their walls and the percussion sound acquires a tympanic tone; with left-sided exudative pleurisy, the Traube space disappears (the zone of tympanitis in the lower parts of the left half of the chest, caused by the gas bubble of the stomach); the displacement of the heart to the healthy side is determined. With right-sided exudative pleurisy, the mediastinum shifts to the left, the left border of the relative dullness of the heart and the apex beat can shift to the axillary lines. With left-sided exudative pleurisy, the right border of relative dullness may shift beyond the midclavicular line. The displacement of the heart to the right is very dangerous due to the possible bending of the inferior vena cava and the violation of blood flow to the heart.

Comparative percussion is used to detect pathological changes in any part of the lung.

Comparative percussion should be carried out strictly on symmetrical areas of the chest. At the same time, the percussion sound obtained in this area is compared with that in the symmetrical area of ​​the other half of the chest (pathological changes are evidenced not so much by the nature of the percussion sound as by its difference in the symmetrical areas of the chest). The difference between percussion sounds is better captured if a normal sound is heard first, and then an altered sound. Therefore, first you need to percuss on the healthy, and then on the diseased side of the chest. The stronger the percussion blow, the greater the depth of its penetration. However, each time you start comparative percussion, you should assess the degree of thickness of the chest wall and apply percussion blows of appropriate strength. It must be remembered that even the strongest blow does not penetrate deeper than 6-7 cm. The concussions caused by the percussion blow spread both in depth and to the sides of the percussed area. Therefore, during percussion, the tissues vibrate not only under the plessimeter finger, but also located on the sides of it. This whole area is called the percussion sphere. Percussion should be carried out along the intercostal spaces, since the bone tissue is capable of significant fluctuations and therefore the percussion sphere expands during percussion along the rib.

Comparative percussion is always performed in a certain sequence.

Rice. 29. Comparative percussion of the lungs:
a - finger on finger;
b, c - by the methods of Yanovsky and Obraztsov, respectively;
d - the position of the finger-plessimeter during percussion of the tops of the lungs;
e - percussion on the collarbone;
e - the position of the fingers during percussion of the lungs in front;
g - percussion along the axillary lines;
h - the position of the fingers during percussion of the lungs from behind;
and, k, l - percussion, respectively, of the supra-, inter- and subscapular regions along the scapular lines.

Compare the percussion sound above the tops of the lungs in front (Fig. 29, d). In this case, the plessimeter finger is placed parallel to the collarbone.

With a hammer finger, uniform blows are applied to the collarbone (direct percussion according to Yanovsky or Obraztsov; Fig. 29, e).

When the lungs are percussed below the clavicle (Fig. 29, f), the pessimeter finger is placed in the intercostal spaces parallel to the ribs in strictly symmetrical sections of the right and left halves of the chest.

Percussion sound along the parasternal lines is compared on both sides to the level of the III rib. Then they percuss only along the right parasternal line (the heart is on the left), comparing the sounds obtained during percussion of the lower located areas, i.e., III, IV, V intercostal spaces.

If the left border of the heart is displaced outward, comparative percussion of the chest along the mid-clavicular line is carried out in the same way as along the peristernal line.

When conducting comparative percussion along the axillary lines (Fig. 29, g), the patient is offered to raise his hands up and lay his palms behind his head; on the scapular and paravertebral - cross your arms over your chest to take the shoulder blades away from the spine.

When percussion of the supra- and subscapular regions, the finger-plessimeter is placed parallel to the ribs, i.e. horizontally, interscapular - vertically (Fig. 29, h, i, k, l).

When conducting comparative percussion, it is advisable to apply blows of different strength to detect pathological areas at different depths: at first they percussion quietly to identify superficial foci, and then more loudly to identify deep-seated foci.

With comparative percussion of the lungs of a healthy person, the percussion sound in symmetrical areas may not be exactly the same, which depends on the mass or thickness of the lung layer, muscle development, and the effect on the percussion sound of neighboring organs. A quieter and shorter percussion sound is determined by:

1) above the right apex - due to the shorter right upper bronchus, which reduces its airiness, and greater development of the muscles of the right shoulder girdle;

2) above the upper lobes of the lungs due to the smaller thickness of its alveolar tissue compared to the lower ones;

3) in the right axillary region, since the liver is located nearby, reducing the volume and duration of the sound, and on the left, the stomach is adjacent to the diaphragm, the bottom of which is filled with air, which gives a loud tympanic sound during percussion. This so-called Traube space. It is limited to the right by the lower edge of the left lobe of the liver and partly by the lower edge of the dullness of the heart, from above by the lower edge of the left lung, to the left by the anterior edge of the spleen, and from below by the left costal arch. Traube's space is absent in left-sided exudative pleurisy, in which the pleural sinus is filled with exudate. Therefore, the percussion blow in this case does not reach the gas bubble of the stomach. Traube's space may decrease due to changes in the organs that form its boundaries.

In pathological conditions, the percussion pulmonary sound may become dull or blunted. This happens with a decrease in the airiness of the lung, the formation of an airless tissue in some part of it, when the pleural cavity is filled with a liquid or other dense medium.

A decrease in the airiness of the lung can be when the alveoli are filled with dense masses (exudate - with inflammation of the lung, transudate - with edema, blood - with lung infarction), with scarring of the lungs, their collapse - atelectasis (with blockage of the afferent bronchus, followed by resorption of air from the switched off part lung - obstructive atelectasis - or when the lung tissue is compressed by pleural fluid or an enlarged heart - compression atelectasis - at the stage when there is no air in the alveoli).

The formation in the lungs of some other airless tissue is observed with tumors that displace the lung tissue, with an abscess of the lung filled with fluid. The filling of the pleural cavity with a dense medium is observed with the accumulation of fluid in the pleural cavity, with inflammatory thickening of the pleura, with the development of a tumor in the pleura.

Dullness of percussion sound is also determined by inflammation or swelling of the tissues of the chest wall (subcutaneous tissue, muscles, etc.).

A tympanic sound or a tympanic shade of percussion sound over the lungs appears when cavities containing air are formed in the lung tissue, with large bronchiectasis (bronchial dilation), accumulation of air in the pleural cavity, a decrease in the tension of the elastic elements of the lung tissue, which occurs in the initial stage of compression or obstructive atelectasis , when the air has not yet been completely expelled from the alveoli, as well as in the first stage of pneumonia, when the tension of the alveoli and, consequently, their ability to fluctuate decreases due to the impregnation of their walls with exudate. In the next two cases, the tympanic tone of the percussion sound is mainly due to air fluctuations in the alveoli.

Depending on the change in the timbre of the pulmonary percussion sound, several of its varieties are distinguished: boxed, metallic, the noise of a cracked pot.

box sound loud, tympanic. The name was given because of the similarity with the sound that occurs when tapping on an empty box. It is observed with a sharp weakening of the elasticity of the lungs with simultaneous expansion and swelling of the alveoli, which is noted with emphysema.

metallic sound reminiscent of the sound when hitting a metal vessel. Occurs during percussion over a large superficially located smooth-walled cavity containing air (above the cavity).

The noise of a cracked pot intermittent rattling. Occurs when air is forced out of the cavity through a narrow slot-like opening. Auscultated over a large cavity communicating with the bronchus through a narrow opening.

Percussion of the lungs is most convenient to produce with a calm vertical (standing or sitting) position of the patient. His hands should be lowered or placed on his knees.

Identification lines of the chest:

anterior median line- a vertical line passing through the middle of the sternum;

right and left sternal lines- lines running along the edges of the sternum;

right and left mid-clavicular lines- vertical lines passing through the middle of both clavicles;

right and left parasternal lines- vertical lines passing in the middle between the sternal and mid-clavicular lines;

right and left anterior, middle and posterior axillary (axillary) lines- vertical lines running along the front edges, middle and rear edge of the armpit;

right and left scapular lines- vertical lines passing through the corners of the shoulder blades;

posterior midline- a vertical line passing through the spinous processes of the vertebrae;

paravertebral lines (right and left)- vertical lines passing in the middle of the distance between the posterior vertebral and scapular lines.

Percussion is divided into comparative and topographic. It is necessary to start the study with comparative percussion and conduct it in the following sequence: supraclavicular fossae; anterior surface in I and II intercostal spaces; lateral surfaces (the hands of the patient are placed on the head); back surface in the suprascapular regions, in the interscapular space and below the angles of the shoulder blades. The finger-plessimeter in the supraclavicular and subclavian areas is installed parallel to the clavicle, on the anterior and lateral surfaces - along the intercostal spaces, in the suprascapular areas - parallel to the spine of the scapula, in the interscapular space - parallel to the spine, and below the angle of the scapula - again horizontally, along the intercostal spaces. By applying percussion blows of the same strength sequentially to symmetrical sections of the chest above the projection of the lungs, the physical characteristics of the percussion sound (loudness, duration, height) above them are evaluated and compared. In cases where it is possible, according to complaints and examination data, to approximately localize the side of the lesion (right or left lung), comparative percussion should begin from the healthy side. Comparative percussion of each new symmetrical area should start from the same side. In this case, the patient should be sitting or standing, and the doctor - standing. Percussion of the chest over the lungs is carried out in a certain sequence: in front, in the lateral sections and behind. Front: the patient's hands should be lowered, the doctor stands in front and to the right of the patient. Begin percussion from the upper chest. The plessimeter finger is placed in the supraclavicular fossa parallel to the clavicle, the mid-clavicular line should cross the middle of the middle phalanx of the plessimeter finger. With a finger-hammer, medium-strength blows are applied to the finger-plessimeter. The finger-plessimeter is moved to a symmetrical supraclavicular fossa (in the same position) and strikes of the same force are applied. Percussion sound is evaluated at each point of percussion and sounds are compared at symmetrical points. Then, with a hammer finger, the same force is applied to the middle of the clavicles (in this case, the clavicles are natural plessimeters). Then the study is continued, percussing the chest at the level of the 1st intercostal space, the 2nd intercostal space and the 3rd intercostal space. In this case, the finger-plessimeter is placed on the intercostal space and directed parallel to the ribs. The middle of the middle phalanx is crossed by the mid-clavicular line, while the plessimeter finger is somewhat pressed into the intercostal space.

In the side sections: the patient's hands should be folded into the lock and raised to the head. The doctor stands in front of the patient to face him. The plesimeter finger is placed on the chest in the armpit. The finger is directed parallel to the ribs, the middle of the middle phalanx is crossed by the middle axillary line. Then, percussion of the symmetrical lateral parts of the chest is performed at the level of the intercostal spaces (up to and including the VII-VIII ribs).

Behind: the patient should cross his arms over his chest. At the same time, the shoulder blades diverge, expanding the interscapular space. Percussion begins in the suprascapular areas. The plesimeter finger is placed parallel to the spine of the scapula. Then percussion in the interscapular space. The plesimeter finger is placed on the chest parallel to the line of the spine at the edge of the shoulder blades. After percussion of the interscapular space, the chest is percussed under the shoulder blades at the level of the VII, VIII and IX intercostal spaces (the plessimeter finger is placed on the intercostal space parallel to the ribs). At the end of the comparative percussion, a conclusion is made about the homogeneity of the percussion sound over the symmetrical areas of the lungs and its physical characteristics (clear, pulmonary, dull, tympanic, dull-tympanic, dull, boxed). If a pathological focus is found in the lungs, by changing the strength of the percussion blow, it is possible to determine the depth of its location. Percussion with quiet percussion penetrates to a depth of 2-3 cm, with percussion of medium strength - up to 4-5 cm, and loud percussion - up to 6-7 cm. Chest percussion gives all 3 main types of percussion sound: clear pulmonary, dull and tympanic. A clear pulmonary sound occurs with percussion of those places where, directly behind the chest, there is an unchanged lung tissue. The strength and height of the pulmonary sound vary depending on age, shape of the chest, muscle development, and the size of the subcutaneous fat layer. A dull sound is obtained on the chest wherever dense parenchymal organs adjoin it - the heart, liver, spleen. In pathological conditions, it is determined in all cases of a decrease or disappearance of the airiness of the lung tissue, thickening of the pleura, filling the pleural cavity with fluid. Tympanic sound occurs where cavities containing air are adjacent to the chest wall. Under normal conditions, it is determined only in one area - at the bottom left and in front, in the so-called Traube semilunar space, where the stomach with an air bladder is adjacent to the chest wall. Under pathological conditions, tympanic sound is observed when air accumulates in the pleural cavity, in the presence of an air-filled cavity (abscess, cavity) in the lung, with emphysema of the lungs as a result of an increase in their airiness and a decrease in the elasticity of the lung tissue.

Table. Interpretation of the results of comparative percussion and the definition of voice trembling