Percussion of the lungs

Percussion - tapping on the areas of the body surface, revealing the physical characteristics of the organs, tissues, various formations: cavitary (air), liquid (condensed), combined. In connection with this, the thorax, where the organs are located, differing in physical properties, is an important object for research. As already noted, percussion was widely spread after the famous J. Corvizar translated into French the treatise of the Viennese doctor L. Auenbruger (1722-1809) in the beginning of the 19th century, in which the latter described a method similar to the tapping of wine barrels used by his father winemaker for determining the level of wine in them. In the examination of the respiratory organs percussion occupies a special place. 

The different density of air, low-air and airless tissue corresponds to different shades of percussion sound, which reflects the state of the respiratory organs adjacent to the chest wall. The volume, height and duration of the sound produced by percussion of the thorax depend ultimately on the density and elasticity of the percussion area. The greatest impact on sound quality is provided by air and dense elements (muscles, bones, parenchyma of internal organs, blood). The more differences in density and elasticity of the medium through which vibrations pass, the more heterogeneous the percussion sound will be, the more it will differ from the sonorous, so-called tympanic sound, resembling the sound produced when striking a drum (tympanum-drum), and the emerging with percussion of air containing hollow formations (percussion of the gut region). The lower the air content in the percussion zone and the more dense elements, the sound will be more quiet, short, blunt (dullness of the percussion sound, absolutely stupid - "hepatic", "femoral" sound).

Types and rules of percussion of the lungs

You can get different shades of percussion sound using various techniques: tapping with a special hammer (most doctors use this finger as a finger) directly on the body of the subject (direct percussion) and tapping the body of the subject through an additional conductor (plessimeter) plate or more often the finger of the other arm, tightly attached to the surface of the body (mediated percussion). The overwhelming majority of doctors use percussion mediated by a "finger on the finger".

When percussion, remember that the blow should be directed strictly perpendicular to the surface of the plessimetre, be light, short (fast), resembling the elastic impact of a tennis ball, which is achieved only by moving the hand in the wrist joint while the forearm is stationary.

Percussion is carried out in order to detect changes in physical properties (air to dense elements ratio) of an organ or its part (comparative percussion) or to determine the boundaries of an organ and a zone of altered physical properties (topographic percussion).

Comparative percussion

With comparative percussion of the chest, which is carried out across the intercostal spaces and is loud, the nature of the sound obtained over the symmetrical regions of the lungs is primarily determined, naturally, except in this comparison the antero-lower part of the left half of the thorax is the projection of the region of the heart deprived of air. Some asymmetry of sound data is detected by percussion of the region of both apices of the lungs (supra- and subclavian spaces): due to the more developed muscles of the right half of the thorax and the greater narrowness of the right upper lobe bronchus, the percussion sound above the right apex is usually more dulled. It should be noted that the tapping of the apex of the lungs was earlier given special significance due to the high prevalence of pulmonary tuberculosis (for the infiltrative form of tuberculosis, this localization is characteristic). Comparative percussion allows you to reveal above the lungs a special percussion sound - clear pulmonary. This is the result of the transformations to which the tympanic tone is exposed (due to air fluctuations within the elastic alveoli) when passing through the non-uniform interstitial lung tissue, the thoracic wall. But more important is the detection over the individual sections of the chest of changes in this sound: blunt (from blunting to absolute dullness) or tympanic.

Dullness (shortening) of percussion sound is more, the more dense elements, the more lost airiness (fluid, infiltration, tumor tissue) in the percussion zone, which can detect this area at different depths with the help of different impact strengths: the stronger the shock (loud deep percussion), the more deeply located the compaction site is detected. Dullness of sound indicates the presence in the pleural cavity of fluid, with a large number of which there is a dull percussion sound (exudate, pus, transudate, blood). At the same time, usually not less than 500 ml of liquid should be accumulated, but with fluid (weak) percussion it is possible to detect fluid in pleural sinuses. The features of the upper boundary of the blunting zone make it possible to distinguish the nature of the pleural fluid. In the presence of inflammation (exudate), the upper limit of dullness has the form of a curve of the line with a peak along the axillary lines, which is characteristic for an uneven rise in the level of the liquid (the Damoiso-Sokolov line) associated with the different compliance of the fluid that is subject to pulmonary tissue. For the transudate, the level of the blunting zone is closer to the horizontal.

Dullness pulmonary percussion sound characteristic of early stages of infiltrative process in the lungs ( pneumonia ) and other seals lung tissue (expressed atelectasis, especially obstructive, pulmonary infarction, lung tumor, pleural thickening sheets).

With decreasing or thinning of dense elements of pulmonary structures, the tympanic tone of percussion sound is amplified, which acquires the character of "boxed" or "cushion" in emphysema (loss of elasticity of the alveoli, but preservation of the integrity of most alveolar septa, which prevents the appearance of true tympanitis); the sound becomes pronounced tympanic over the lung cavity (cavity, emptying abscess, large bronchiectasis, pneumothorax, large emphysematous bullae).

[1], [2], [3], [4], [5]

Topographic percussion of the lungs

Topographic percussion of the lungs reveals the boundaries of an organ or a detected pathological formation, while a quiet percussion is used on the ribs and intercostals, and the finger-plessimeter is parallel to the percutaneous border (for example, horizontally when determining the lower border of the lung). The fixation of the position of the defined boundary is carried out by means of identification marks. For chest organs, clavicles, ribs, intercostal spaces, vertebrae and vertical lines (anterior middle, right and left sternal, parasternal, middling, anterior, middle, posterior axillary, scapula, posterior median line) serve for the organs of the thorax. The count of the ribs is made from the front, beginning with the second rib (the place of attachment to the sternum is between the sternum's handle and its body), the first rib corresponds to the collarbone. Behind the score, the ribs are guided by the spinous processes of the vertebrae (it is easy to define the spinous process of the VII cervical vertebra: it protrudes most when the head is tilted forward) and the lower angle of the scapula, which corresponds to the 7th rib.

The lower edge of the lung is located on the right and left at the same level (naturally, on the left it is determined starting from the anterior axillary line due to the presence of the cardiac notch and the spleen region), respectively on the right parasternal line - the upper edge of the VI rib, the right sredneklyuchichnoy - the sixth intercostal space, both anterior axillary - VII rib, middle axillary lines - VIII rib, posterior axillary - IX rib, scapular lines - X rib, posterior median line - XI thoracic vertebra.

The displacement of the lower border of the lungs is revealed primarily in emphysema, less often in the period of asthma attack. In the first case, this bias is permanent, tends to increase due to the progression of the hyperemotion of the lungs, in the second case it is observed without emphysema as a result of the acute onset of lung enlargement due to the difficulty of exhalation characteristic for bronchial asthma. The presence of fluid and gas in the pleural cavity leads to a shift of the lower edge of the lungs to the top, which is also observed when the diaphragm is high (pronounced obesity, pregnancy, large ascites, flatulence), which is usually accompanied by a decrease in the volume of the chest and filling the lungs with air (decrease in vital capacity of the lungs ), and this leads to respiratory failure and hemodynamic disorders in the small circulation.

The indicated displacements of the lower border of the lungs are usually accompanied by a decrease in the mobility (excursion) of the lower pulmonary margin, which is determined by the average axillary line: in normal with respect to the VIII rib, the pulmonary margin drops by 4 cm at a deep inspiration and also by 4 cm at maximum expiration, , thus, the respiratory excursion of the lower pulmonary margin along this line is 8 cm. If it is difficult to make and hold the breath, this indicator is determined by successively using several regular inhalations and noting each the first percussion position of the lower pulmonary margin.

The determination of the border of the pulmonary margin and the degree of its displacement during respiration is an important technique for early detection of pulmonary emphysema, which is of course particularly valuable in the dynamic observation of the patient.

To clarify these or other changes in the corresponding lobes, it is important to know their topography. On the right, the upper and middle lobes are projected to the front surface (the border between them begins at the level of attachment of the IV rib to the sternum, then it goes obliquely to the sixth rib along the mid-incision line, where it reaches the border of the lower lobe), on the right side - the middle and lower lobes, to the left the front surface occupies the upper lobe, the upper left and the lower side (the border between them, as on the right, starts from the VI rib on the midclavicular line, but then goes obliquely upward towards the scapula), a small portion of the upper lobes projecting from the rear, the main surface of both halves of the thorax are the lower lobes.

Height of standing of apexes

	On right	Left
Front	3 cm above the clavicle level	3.5 cm above the clavicle level
Behind	at the level of the spinous process of the VII cervical vertebra	0.5 cm above the level of the spinous process of the VII cervical vertebra

The width of the fields Kreniga: on the right - 5 cm, on the left - 5.5 cm

Lower border of the lungs

Typographic lines	On right	Left
The pericarp	Fifth intercostal space	-
Mid-succulent	VI Rib	-
Anterior axillary	VIIth rib	VIIth rib
Medium axillary	VIII rib	VIII rib
Rear axillary	IX Rib	IX Rib
Shoulder	X edge	X edge
Near-vertebral	Spines of the XI thoracic vertebra	Spines of the XI thoracic vertebra

Mobility of the lower edges of the lungs, cm

	On right			Left
Topographic line	On inspiration	On exhale	In total	On inspiration	On exhale	In total
Mid-succulent	2	2	4	-	-	-
Medium axillary	3	3	6th	3	3	B
Shoulder	2	2	4	2	2	4