胸部检查专业知识培训专家讲座.pptx

physical examination肺部检验肺部检验(2)Pulmonary Examination pulmonary auscultation pulmonary auscultation 肺部听诊肺部听诊肺部听诊肺部听诊 signs in pulmonary disease signs in pulmonary disease 肺部常见疾病体征肺部常见疾病体征肺部常见疾病体征肺部常见疾病体征胸部检查专业知识培训第1页Auscultation of the Lung肺部听诊肺部听诊 breath soundbreath sound 呼吸音呼吸音呼吸音呼吸音 ralesrales 啰啰啰啰音音音音 vocal resonancevocal resonance 语音共振语音共振语音共振语音共振 pleural friction pleural friction rubrub 胸膜摩擦音胸膜摩擦音胸膜摩擦音胸膜摩擦音胸部检查专业知识培训第2页Principles of Sound Transmission声音传导声音传导n nDistanceDistance 传导距离传导距离传导距离传导距离n nNumber of interfacesNumber of interfaces 界面数量界面数量界面数量界面数量n nThe nature of the transmitting mediumThe nature of the transmitting medium 传导介质性质传导介质性质传导介质性质传导介质性质n nThe more dense the medium,the The more dense the medium,the better the transmissionbetter the transmission 传导介质密度越高传导介质密度越高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传导性能越好传导性能越好胸部检查专业知识培训第3页Breath Sounds呼吸音呼吸音n nAirflow tremorAirflow tremorn nInspiratory phase:Inspiratory phase:Ascending branchAscending branchn nExpiratory phase:Expiratory phase:Descending branchDescending branchn nHearing duration:Length Hearing duration:Length of the line of the line n nLoudness:Thickness of Loudness:Thickness of the line the line n nPitch:AnglePitch:Anglen n气流产生震动气流产生震动气流产生震动气流产生震动n n吸气相吸气相吸气相吸气相:升支升支升支升支n n呼气相呼气相呼气相呼气相:降支降支降支降支n n声音时间声音时间声音时间声音时间:线条长短线条长短线条长短线条长短n n音响强弱音响强弱音响强弱音响强弱:线条粗细线条粗细线条粗细线条粗细n n音调高低音调高低音调高低音调高低:夹角大小夹角大小夹角大小夹角大小胸部检查专业知识培训第4页Classify of Breath Sound呼吸音分类呼吸音分类n nNormal and abnormalNormal and abnormal 正常和异常呼吸音正常和异常呼吸音正常和异常呼吸音正常和异常呼吸音n nBronchial breath soundsBronchial breath sounds 支气管呼吸音支气管呼吸音支气管呼吸音支气管呼吸音n nVesicular breath soundsVesicular breath sounds 肺泡呼吸音肺泡呼吸音肺泡呼吸音肺泡呼吸音n nBronchovesicular breath soundsBronchovesicular breath sounds 支气管肺泡呼吸音支气管肺泡呼吸音支气管肺泡呼吸音支气管肺泡呼吸音胸部检查专业知识培训第5页Normal Bronchial Breath SoundsNormal Bronchial Breath Sounds正常支气管呼吸音正常支气管呼吸音n nThey are harsher and of They are harsher and of higher pitch than higher pitch than vesicular sounds.vesicular sounds.n nIt is an expiratory sound.It is an expiratory sound.n nIn expiration phase,its In expiration phase,its relatively louder,higher relatively louder,higher pitched and lasts longer.pitched and lasts longer.n nBest heard at laryngeal,Best heard at laryngeal,suprasternal fossa,C 6-7,suprasternal fossa,C 6-7,and T 1-2.and T 1-2.n n气流经声门气道气流经声门气道气流经声门气道气流经声门气道 产生震动产生震动产生震动产生震动 n n“哈哈哈哈”声音声音声音声音 n n呼气时声门窄呼气时声门窄呼气时声门窄呼气时声门窄 声音响声音响声音响声音响 吸气相长强高吸气相长强高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呼气相更长更强更高呼气相更长更强更高n n听诊部位听诊部位听诊部位听诊部位 喉部喉部喉部喉部 胸骨上窝胸骨上窝胸骨上窝胸骨上窝 颈椎颈椎颈椎颈椎6,76,76,76,7和胸椎和胸椎和胸椎和胸椎1,21,21,21,2胸部检查专业知识培训第6页NormalNormal Vesicular Breath SoundsVesicular Breath Sounds正常肺泡呼吸音正常肺泡呼吸音n nLow pitched,fine,and Low pitched,fine,and heard well at the heard well at the periphery of the lung.periphery of the lung.n nIt is an inspiratory It is an inspiratory sound.sound.n nIn inspiration phase,its In inspiration phase,its relatively louder,higher relatively louder,higher pitched and lasts longerpitched and lasts longern n气流进出肺泡气流进出肺泡气流进出肺泡气流进出肺泡 产生振动产生振动产生振动产生振动n n“夫夫夫夫”声音声音声音声音 n n吸气时肺担心吸气时肺担心吸气时肺担心吸气时肺担心 声音响声音响声音响声音响 吸气相长吸气相长吸气相长吸气相长 强强强强 高高高高 呼气相短呼气相短呼气相短呼气相短 弱弱弱弱 低低低低n n听诊部位听诊部位听诊部位听诊部位:肺部区域肺部区域肺部区域肺部区域 乳房乳房乳房乳房 肩胛肩胛肩胛肩胛 腋窝下部腋窝下部腋窝下部腋窝下部 最清楚最清楚最清楚最清楚胸部检查专业知识培训第7页Normal Bronchovesicular Breath Sounds Normal Bronchovesicular Breath Sounds 正常支气管肺泡呼吸音正常支气管肺泡呼吸音n nA mixture of the two elementsA mixture of the two elementsn nThe two phases are quite similar The two phases are quite similar in intensity,duration,and pitch.in intensity,duration,and pitch.n nBest heard anteriorly over the Best heard anteriorly over the upper end of the sternum and upper end of the sternum and just beside it at the level of just beside it at the level of Louiss angle,and posteriorly Louiss angle,and posteriorly over the interscapular spaces at over the interscapular spaces at the level of the third and fourth the level of the third and fourth thoracic vertebrae,either or both thoracic vertebrae,either or both apices.apices.n n支气管和肺泡支气管和肺泡支气管和肺泡支气管和肺泡 呼吸音重合呼吸音重合呼吸音重合呼吸音重合n n吸气似肺泡呼吸音吸气似肺泡呼吸音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但稍弱稍低但稍弱稍低n n听诊部位听诊部位听诊部位听诊部位 胸骨角两侧胸骨角两侧胸骨角两侧胸骨角两侧 肺尖前后肺尖前后肺尖前后肺尖前后 肩胛间区肩胛间区肩胛间区肩胛间区胸部检查专业知识培训第8页Abnormal Breath Sounds异常呼吸音异常呼吸音Abnormalities in vesicular breath sound area,Abnormalities in vesicular breath sound area,including:including:在肺组织区域出现异常呼吸音在肺组织区域出现异常呼吸音在肺组织区域出现异常呼吸音在肺组织区域出现异常呼吸音n nExaggerated vesicular breathing and Exaggerated vesicular breathing and diminished vesicular breathingdiminished vesicular breathing 异常肺泡呼吸音异常肺泡呼吸音异常肺泡呼吸音异常肺泡呼吸音n nAbnormal bronchial breath soundsAbnormal bronchial breath sounds 异常支气管呼吸音异常支气管呼吸音异常支气管呼吸音异常支气管呼吸音n nAbnormal bronchovesicular breath soundsAbnormal bronchovesicular breath sounds 异常支气管肺泡呼吸音异常支气管肺泡呼吸音异常支气管肺泡呼吸音异常支气管肺泡呼吸音胸部检查专业知识培训第9页Abnormal Vesicular Breath Sounds异常肺泡呼吸音异常肺泡呼吸音(1)n nDiminished vesicular breath sounds:reduced Diminished vesicular breath sounds:reduced air inflow into the alveoli;decreased velocity of air inflow into the alveoli;decreased velocity of air flow into the lung;obstruction of breath air flow into the lung;obstruction of breath sound conduction.sound conduction.肺泡呼吸音减弱肺泡呼吸音减弱肺泡呼吸音减弱肺泡呼吸音减弱:气流量降低气流量降低气流量降低气流量降低 流速减慢流速减慢流速减慢流速减慢 传导障碍传导障碍传导障碍传导障碍n nExaggerated vesicular breath sounds,Exaggerated vesicular breath sounds,unilateral:compensatory breath sounds;unilateral:compensatory breath sounds;bilateral:enhanced respiratory movement and bilateral:enhanced respiratory movement and ventilatory function.ventilatory function.肺泡呼吸音增强肺泡呼吸音增强肺泡呼吸音增强肺泡呼吸音增强 单侧单侧单侧单侧:代偿原因代偿原因代偿原因代偿原因 双侧双侧双侧双侧:全身原因全身原因全身原因全身原因胸部检查专业知识培训第10页Abnormal Vesicular Breath Sounds异常肺泡呼吸音异常肺泡呼吸音(2)n nProlonged breath sounds:the lower Prolonged breath sounds:the lower respiratory tract spasm,or narrowing;respiratory tract spasm,or narrowing;diminished elasticity of the lung tissue.diminished elasticity of the lung tissue.呼吸音延长呼吸音延长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肺组织弹性减退肺组织弹性减退n nIntermittent and roughness:airflow Intermittent and roughness:airflow asymmetry and not smooth.asymmetry and not smooth.断续和粗糙断续和粗糙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气流不均匀或不畅气流不均匀或不畅胸部检查专业知识培训第11页Abnormal Bronchial Breath Sounds 异常支气管呼吸音异常支气管呼吸音n nBronchial breath sounds appears in the area Bronchial breath sounds appears in the area where the vesicular breath sounds dominate.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n nNamed“Named“tubular breath sound”tubular breath sound”又称管状呼吸音又称管状呼吸音又称管状呼吸音又称管状呼吸音n nMechanism:airway open but lung tissue with Mechanism:airway open but lung tissue with infiltration or large cavity.infiltration or large cavity.机制机制机制机制:气道通畅气道通畅气道通畅气道通畅 肺组织密度增加肺组织密度增加肺组织密度增加肺组织密度增加 肺内有空腔肺内有空腔肺内有空腔肺内有空腔n nCauses:consolidation of the lung,large cavity Causes:consolidation of the lung,large cavity inside the lung,compressive atelectasis.inside the lung,compressive atelectasis.原因原因原因原因:肺内炎症实变肺内炎症实变肺内炎症实变肺内炎症实变 压迫性肺不张压迫性肺不张压迫性肺不张压迫性肺不张 肺内大空洞肺内大空洞肺内大空洞肺内大空洞胸部检查专业知识培训第12页Abnormal Bronchovesicular Breath SoundsAbnormal Bronchovesicular Breath Sounds异常支气管肺泡呼吸音异常支气管肺泡呼吸音n nBronchovesicular breath sounds appears in the area Bronchovesicular breath sounds appears in the area where the vesicular breath sounds dominate.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n nMechanism:airway open with both normal lung tissue Mechanism:airway open with both normal lung tissue and consolidation.and consolidation.机制机制机制机制: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n nSeen in bronchial pneumonia,tuberculosis of the lung,Seen in bronchial pneumonia,tuberculosis of the lung,initial stages of lobar pneumonia,compressed area initial stages of lobar pneumonia,compressed area upper in pleural effusion.upper in pleural effusion.原因原因原因原因:支气管肺炎支气管肺炎支气管肺炎支气管肺炎 肺结核肺结核肺结核肺结核 大叶肺炎早期大叶肺炎早期大叶肺炎早期大叶肺炎早期 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胸部检查专业知识培训第13页Rales 啰音啰音n nrhonchirhonchi wheeze wheeze s stridortridorn nc cracklesrackles or moist rale or moist rale sonority and nonsonority sonority and nonsonority coarse,middle and fine coarse,middle and fine crepitus crepitusn n干干干干啰啰啰啰音音音音 哮鸣音哮鸣音哮鸣音哮鸣音 喘鸣喘鸣喘鸣喘鸣音音音音n n湿湿湿湿啰啰啰啰音音音音 响亮性响亮性响亮性响亮性 非响亮非响亮非响亮非响亮 粗粗粗粗 中中中中 细细细细 捻发音捻发音捻发音捻发音胸部检查专业知识培训第14页Rhonchi干啰音干啰音n nRhonchi are long continuous adventitious sounds,Rhonchi are long continuous adventitious sounds,generated by airway narrowing.generated by airway narrowing.由气道狭窄产生连续时间较长附加音由气道狭窄产生连续时间较长附加音由气道狭窄产生连续时间较长附加音由气道狭窄产生连续时间较长附加音n nInflammation-induced mucosal congestion and Inflammation-induced mucosal congestion and edema together with exudateedema together with exudate 炎症引发黏膜充血水肿伴分泌物增多炎症引发黏膜充血水肿伴分泌物增多炎症引发黏膜充血水肿伴分泌物增多炎症引发黏膜充血水肿伴分泌物增多 n nSpasmodic contraction of bronchial smooth muscleSpasmodic 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支气管平滑肌痉挛性收缩支气管平滑肌痉挛性收缩 n nIntralumenal tumor or foreign body obstructionIntralumenal 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管腔内肿瘤或异物堵塞管腔内肿瘤或异物堵塞n nNarrowing of lumen caused by compressionNarrowing of lumen caused by compression 管壁受压管腔狭窄管壁受压管腔狭窄管壁受压管腔狭窄管壁受压管腔狭窄胸部检查专业知识培训第15页Notice of Rhonchi听诊注意事项听诊注意事项n nDistributingDistributing:generalized or localized:generalized or localized 分布分布分布分布:弥漫弥漫弥漫弥漫 散在或局限散在或局限散在或局限散在或局限n nPhase:during inspiration or expirationPhase:during inspiration or expiration 时相时相时相时相:吸气相或呼气相吸气相或呼气相吸气相或呼气相吸气相或呼气相n nPitch:Pitch:high-pitched or high-pitched or deep-toneddeep-toned 音调音调音调音调:高调和低调高调和低调高调和低调高调和低调 pitch related to diameter of airwaypitch related to diameter of airway 音调高低与气道管径相关音调高低与气道管径相关音调高低与气道管径相关音调高低与气道管径相关胸部检查专业知识培训第16页Classify of Rhonchi干啰音分类干啰音分类n nGeneral rhonchi General rhonchi 普通干普通干普通干普通干啰啰啰啰音音音音 produced by produced by thick secretion in bronchusthick 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由支气管粘稠分泌物所致由支气管粘稠分泌物所致n nWheezes Wheezes 哮鸣音哮鸣音哮鸣音哮鸣音 produced by bronchial smooth muscle spasm 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由支气管平滑肌痉挛所致由支气管平滑肌痉挛所致n nStridor Stridor 喘鸣音喘鸣音喘鸣音喘鸣音 produced by produced by large airway narrowinglarge airway narrowing 由大气道阻塞所致由大气道阻塞所致由大气道阻塞所致由大气道阻塞所致胸部检查专业知识培训第17页Compares with General Rhonchi and WheezeCompares with General Rhonchi and Wheeze普通干啰音和哮鸣音比较普通干啰音和哮鸣音比较n nHeard Heard bothboth two two phasesphases 吸气呼气均可听到吸气呼气均可听到吸气呼气均可听到吸气呼气均可听到n nHigh-pitched or High-pitched or deep-toneddeep-toned 音调可高可低音调可高可低音调可高可低音调可高可低n nDistributing odds and dispelDistributing odds and dispel 散在分布不均散在分布不均散在分布不均散在分布不均n nAfter coughing:After coughing:number and part volatility number and part volatility 咳嗽后数量和部位易变咳嗽后数量和部位易变咳嗽后数量和部位易变咳嗽后数量和部位易变n nOnly in expirationOnly in expiration 在呼气相在呼气相在呼气相在呼气相n nHigh-pitchedHigh-pitched 音调高音调高音调高音调高n nPermeate or localizationPermeate or localization 弥漫或局限固定弥漫或局限固定弥漫或局限固定弥漫或局限固定n nAfter coughingAfter coughing invariability invariability 咳嗽后不变咳嗽后不变咳嗽后不变咳嗽后不变thick secretionthick secretionmuscle spasmmuscle spasm胸部检查专业知识培训第18页Specialty of Stridor喘鸣音特点喘鸣音特点n nLoud audible in throat and tracheaLoud audible in throat and trachea 在喉和气管附近听到在喉和气管附近听到在喉和气管附近听到在喉和气管附近听到n nHearing in inspiratory phaseHearing in inspiratory phase 吸气相显著吸气相显著吸气相显著吸气相显著n nUsually accompany inspiratory dyspneaUsually accompany inspiratory dyspnea 常伴有吸气费劲常伴有吸气费劲常伴有吸气费劲常伴有吸气费劲n nUsually accompany sign of Usually accompany sign of“three“three depressions sign”depressions sign”常伴有常伴有常伴有常伴有“三凹三凹三凹三凹”征征征征胸部检查专业知识培训第19页Clinical Significance临床意义临床意义n nChangeable and fugitive,Changeable and fugitive,varying tones:exudate in varying tones:exudate in respiratory tract:bronchitisrespiratory tract:bronchitisn nDiffuse wheeze:narrowing of Diffuse wheeze:narrowing of small airways:asthmasmall airways:asthman nLocalized fixed wheezes:Localized fixed wheezes:airway narrowing:tumor or airway narrowing:tumor or endobronchial tuberculosisendobronchial tuberculosisn nStridor:large airway Stridor:large airway obstruction:laryngeal spasm,obstruction:laryngeal spasm,foreign body,tumorforeign body,tumorn n易变多音调干易变多音调干易变多音调干易变多音调干啰啰啰啰音音音音 粘稠分泌物粘稠分泌物粘稠分泌物粘稠分泌物:支气管炎症支气管炎症支气管炎症支气管炎症n n弥漫哮鸣音弥漫哮鸣音弥漫哮鸣音弥漫哮鸣音 细支气管缩窄细支气管缩窄细支气管缩窄细支气管缩窄:哮喘哮喘哮喘哮喘n n局限固定哮鸣音局限固定哮鸣音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细支气管狭窄细支气管狭窄:肿瘤肿瘤肿瘤肿瘤 结核结核结核结核n n喘鸣音喘鸣音喘鸣音喘鸣音 大气道阻塞大气道阻塞大气道阻塞大气道阻塞:喉痉挛喉痉挛喉痉挛喉痉挛 异物异物异物异物 肿瘤肿瘤肿瘤肿瘤胸部检查专业知识培训第20页Clinical Significance临床意义临床意义n nLocalized rhonchi suggests obstruction of any Localized rhonchi suggests obstruction of any etiology e.g.,tumor,foreign body or mucous.etiology e.g.,tumor,foreign body or mucous.n nMucous secretions will disappear with Mucous secretions will disappear with coughing,so would the rhonchus.coughing,so would the rhonchus.n nExpiratory rhonchi implies obstruction to Expiratory rhonchi implies obstruction to intrathoracic airways.intrathoracic airways.n nDiffused rhonchi would suggest a disease with Diffused rhonchi would suggest a disease with generalized airway obstruction like asthma or generalized airway obstruction like asthma or COPD.COPD.n nAsthmatics can also have inspiratory rhonchi Asthmatics can also have inspiratory rhonchi while it is uncommon in COPD.while it is uncommon in COPD.胸部检查专业知识培训第21页Crackles湿湿啰啰音音n nInterrupted adventitious soundsInterrupted adventitious sounds 断续附加音断续附加音断续附加音断续附加音n nMake a notation about timing,intensity,effect with Make a notation about timing,intensity,effect with respiration,position,coughing and character.respiration,position,coughing and character.注意出现部位注意出现部位注意出现部位注意出现部位 时间时间时间时间 强度强度强度强度 呼吸和咳嗽影响呼吸和咳嗽影响呼吸和咳嗽影响呼吸和咳嗽影响n nMost Crackles induced by airflow through the fluid at the Most Crackles induced by airflow through the fluid at the airway and alveolus.airway and alveolus.多数多数多数多数由气流经过气道和肺泡内液体引发由气流经过气道和肺泡内液体引发由气流经过气道和肺泡内液体引发由气流经过气道和肺泡内液体引发n nthe pop open of the collapsed fine bronchiole and alveoli the pop open of the collapsed fine bronchiole and alveoli formed formed crepituscrepitus.陷闭细支气管和肺泡突然张开形成陷闭细支气管和肺泡突然张开形成陷闭细支气管和肺泡突然张开形成陷闭细支气管和肺泡突然张开形成捻发音捻发音捻发音捻发音胸部检查专业知识培训第22页Classification of Crackles湿啰音分类湿啰音分类n nCoarse crackles:exudate in trachea,bronchiole Coarse crackles:exudate in trachea,bronchiole or cavity.or cavity.粗湿粗湿粗湿粗湿啰啰啰啰音音音音:气管气管气管气管 主支气管或空洞内液体主支气管或空洞内液体主支气管或空洞内液体主支气管或空洞内液体n nMedium crackles:exudate in bronchiole.Medium crackles:exudate in bronchiole.中湿中湿中湿中湿啰啰啰啰音音音音:支气管内液体支气管内液体支气管内液体支气管内液体n nFine crackles:exudate in bronchiole or alveolus.Fine crackles:exudate in bronchiole or alveolus.细湿细湿细湿细湿啰啰啰啰音音音音:细支气管肺泡内液体细支气管肺泡内液体细支气管肺泡内液体细支气管肺泡内液体n nCrepitus:collapsed bronchiole or alveoli open.Crepitus:collapsed bronchiole or alveoli open.捻发音捻发音捻发音捻发音:陷闭细支气管肺泡开放陷闭细支气管肺泡开放陷闭细支气管肺泡开放陷闭细支气管肺泡开放胸部检查专业知识培训第23页Characters of the Crackles听诊特点听诊特点n nDominate during Dominate during inspiration phase or at inspiration phase or at the end of inspirationthe end of inspirationn nFixed site of auscultationFixed site of auscultationn nTransientTransientn nStable qualityStable qualityn nMedium and fine crackles Medium and fine crackles may coexistmay coexistn ncoarse crackl