When studying the respiratory organs, the task of topographic percussion is as follows:

• determine the lower boundaries of the lungs on the left and right;
• determine the upper borders of the lungs on the left and right, that is, the height of the tops;
• determine the mobility of the lower edges of the lungs.

1. Perkit should be moved from a clear pulmonary sound to stupid. Beginners should be perfect only in the intercostal, since percussion of ribs increases the percussion zone and makes it difficult to study. With the accumulation of experience, it is possible to chop in a row - both on the intercostals, and in the ribs, moving a finger-plastic meter by 1 - 1.5 cm or on the width of the finger down.
2. The finger-platmeter is always located in parallel to the explosion of the lung.
3. Given the surface location of the edge of the lung and a small thickness, a quiet percussion is used. The exception is the percussion of the tops of the lights behind and the definition of Shi
   rena of the crennics fields, where, due to the thick layer of the muscles, a loud percussion is applied.
4. It begins the definition of the lower boundaries of the lung from the installation of a palyde-plesymeter on 2-3 ribs above (to the width of the palm) of the intended position of the edge, given the data of the comparative percussion.
5. Moving a finger down ends at the level of absolutely stupid sound, and the light bound mark is made on the side of the finger from the side of the lung sound, that is, along the top edge of the plaster.
6. The patient's position at percussion should be standing or sitting if the study is carried out lying, then you must remember the passive displacement of the lower borders of the lungs.

Fig. 295. Determination of the lower boundaries of the lungs in front.
Percussion is carried out on vertical topographic lines, on the right starts from the III intercostal, on the left - from the II intercosta.

Fig. 296. Determination of the lower borders of the lights behind and definition of mobility The bottom edge of the lungs on the left and right
Percussion begins on the level of the middle or lower third of the blades The mobility of the lower edge is determined by the blade and rear axle lines

air and airless organs (lungs - liver), and this greatly facilitates the capture of the difference in the percussion sound on the border of the organs. Then percussion left-hand side. The borders of the lungs are determined by all topographic lines, the film-plane is installed so that the middle of the II phalanxies accounted for the line.
Determination of the lower borders of the left lung, especially on the mid-clavical and front axillary lines, is difficult because of the adjacent organs containing gas - the stomach, the intestines that are given a tympanic sound at percussion. The border between the pulmonary sound and tympanite is difficult to install, we need a thin rumor and a large skill. Determination of the lower boundary on the left usually start with an anterior axillary line, then go from the side surface to the back surface chest. However, it is necessary to learn to determine the edge of the lung and by the parastinal line, remembering that from behind the heart clipping, she lies on the IV rib, it is on the VI edge right.

Having finished percussion on a certain topographic line, the border found is noted by a point of iodine tampon, chalk or felt-tip pen. By connecting points over all lines, you can get a holistic idea of \u200b\u200bthe position of the lower borders of the lungs on both sides.
The position of the lower lung borders depends on the type of constitution. In tab. 9 Create data for normostic.
Table 9. The position of the lower lung pages in the normostic

In persons of the hyperstate constitution, the level of lung edges lies on one edge above, asthenics are one rib lower than that of normostic.
In obesity, pregnancy, abdominal bloating The lower boundaries of the lungs are shifted up. Have a lot of women who gave birth to the injured, as well as due to weakness abdominal wall, reduce intra-risk pressure and omit internal organs The lower boundaries of the lungs are lowered.
Pulmoncy and other diseases accompanied by a decrease in or increasing the volume of lungs lead to the displacement of their boundaries up or down. It is possible on both sides, or on the one hand, or in a limited area.
Bilateral omission of boundaries is observed when the lungs are sweeping - the attack bronchial asthma, chronic emphysema of the lungs, as well as during visceoptosis. The one-sided displacement of the pages down is observed in vicinal emphysema, that is, the bloating of a healthy lung after removing other or off its breath from the act of breathing in different reasons
we * inflammation, decay, sclerosis, wrinkling. The false displacement of the lower boundary of the lung on the side of the lesion is possible with pneumothorax.
To the displacement of the lower borders of the light upwards on one side, the lung wrinkle, the cluster of the fluid in the pleural cavity, the bruboral inflammation, the atelectasis, the curtain process in Plegre. Bilateral displacement of borders upside occurs during ascite, large tumor or abdominal cavity cyst, diaphragm paralysis, a sharp abdominal swolish.
In addition to changes in the standing of the lower edges of the lungs, it is possible to displace the edge of the lung in the heart clipping area. When the light edge is sweeping down, the heart cut area decreases. Lung wrinkling, increasing heart size, the accumulation of fluid in pericardia leads to displacement of the edge of the light up, the heart cut area increases.
Percussion of the tops of the lungs. It presents some technical difficulties due to the small magnitude and the thick layer of the muscles over them from behind. The height of the standing of the tops in front and rear and their width is determined. A quiet percussion is applied in front, behind a loud. Patient Xui! Or sits. When a study is performed, a finger-plaster can be installed in three options (Fig. 297).

Fig. 297. Determination of the standing height of the tops from the front, right - by the method of fan-shaped percussion, on the left - percussion on the mid-croilent line.

The first (left top) - the finger is stacked above the clavicle in parallel to its edge, the middle of the phalanx should be at the level of the middle of the clavicle. During the percussion, a finger-plaster game gradually (0.5-1 cm) shifts up to the shoulder slope, sticking to the mid-crooking line, until a stupid sound appears. The mark is made from a clear pulmonary sound.
The second option (right upper) - a finger-platsemeter is installed in the same position, but only the final phalanx should be directed outside as the left, gas and right. Next, at percussion, the finger gradually moves up towards the outer edge of the mouse muscle, that is, up and slightly inside from the mid-crooked line (like a veser). Here is a pole of the top. The measurement is made from the found pole to the clavicle. The top height of the right - 3-4 cm above the clavicle, on the left - 3-5 cm, Yu is, the right tip is normal located just below the left.
The third option for determining the standing height of the top is presented in fig. 298.
At the percussion of the tops from the back of the patient, it is better to plant. The loud percussion is used due to the large thickness of the muscles. Polesimetre is installed in the middle of a superval of the final phalanx outside (Fig. 298). The movement of 0.5-1 cm is moving towards the VII cervical vertebra, the location of which is easy to determine the patient's head slope. But it is better to mark an estimated point for 3-4 cm before percussion.


Fig. 298. Determination of the height of the tops of the lungs in front - percussion is similar to fan-shaped, but the end of the thumb is horizontal, parallel to the clavicle. Rear - installing a finger in a supervoloral fossa parallel to the area, then perpendicular to the shoulder slope

aside from the vertex of the VII cervical, the process and peak towards it before the appearance of blunt sound. Normally, the top of the top of the back is at the level of the VII cervical vertebra,
at the same time, the right tip, like in front, just below the left. The position of the tops, as well as the level of the lower edges of the lungs, depends on the type of constitution.
The shift of the tops of the lungs up is most often noted in the emphysema of the lungs and at bronchial asthma. The rise of the diaphragm (pregnancy, obesity, bloating, ascites) little affects the level of the tops.
The decrease in the height of the tops is more likely to be unilateral and it is connected with the wrinkling of light, inflammation, tumor, obtuctational atelectasis, operational intervention On lung - resection of the share, lung.
A more complete idea of \u200b\u200bthe state of the tops can be obtained, exploring the field of the clining (Fig. 299). The crennics field is the projection of the tops on the body surface. It is a strip of a pulmonary sound with a width of 3-8 cm, right already than the left of 1 - 1.5 cm. Usually limited by the determination of the width of the lane, exploring it along the top edge of the trapezoid muscle in the patient's position sitting. The doctor at percussion is behind. The finger-plaster is installed across the edge of the trapezoid muscle, on the middle of the top, is used by a loud percussion. Initially, the movement of the finger goes in the medial direction until a dull sound is obtained, then from the starting point towards the shoulder joint, also before the appearance of blunt sound.

Fig. 299. Determination of the width of the landscape field.

The level of standing tops and the width of the fields of the crench is interrelated, high standing tops leads to expansion of fields, low standing - to narrow fields.
Determination of the mobility of the lower edges of the lungs. Select active and passive mobility. Active mobility is the displacement of the edges of the lungs due to their elasticity with a deep breath and with full exhalation. Passive mobility is the displacement of the edge of light down in the horizontal position of the body due to the reduction of intra-abdominal pressure and the messenger of the abdominal organs.
During the study of active mobility, the patient and doctor are in the same position as when determining the lower edge of the lung. Applied quiet percussion. The definition of active mobility is carried out in all topographic lines, however, after working out the technique of research for practical purposes, it is enough to limit the three lines - the middle-clavinary, medium axillary and the bladler, and as an indicative study - in places of the greatest mobility of the edges, that is, on medium or rear axillary Lines where the limitation of mobility is most often noted due to the adhesive process in the pleural cavity
The finger-plaster is installed on the border of the lower edge of the lung found. The patient is asked to inspire as much as much as much as possible, lingering breathing and immediately pick up until a stupid sound appears, moving by 0.5-1 cm. Stopping at the level of blunt sound, make a note from the bottom of the pulmonary sound. If it eats a sufficient skill on percussion, then immediately after determining the border, the command is given to the patient as much as possible to breathe air, after which the doctor immediately continues to twist up to the appearance of a pulmonary sound. Having finished percussion, do not forget to say to the patient to breathe as usual. The described reception requires distillation, clear and rapid movements.
However, in the period of mastering the equipment it is better to use next reception. After determining the displaceability of the edge of light down and set the patient's mark, it is immediately allowed to breathe as usual. At this time, the polesimeter moves up above the previously found light borders on the width of the palm. Next, the patient is offered to make 2-3 moderately deep breaths, and then deep exhalation and how much breathing is possible to delay. Since the exhalation, the doctor picks down from a clear pulmonary sound until
stupid. The mark is done in the finger from a clear pulmonary sound, then the distance between the marks is measured. This technique is more convenient because you have to do with a clear pulmonary sound to a stupid, the border between which the ear perceives better than when moving from stupid to the pulmonary. We give the numbers of the total (in the breath + in exhalation) the mobility of the lower edges of the lungs by the main lines:
the median-crook - 5-6 cm, the average axillary - 6-8 cm, scapular - 4-6 cm.
Passive mobility The bottom edge of the lungs is investigated in 2 stages. First determines the position of the lower edge of the lung during calm breathing standing, the mark is made. The patient is then stacked on the couch and again from the initial level, the boundary of the lower edge of the lung is determined. In the patient's position on the back, the edge of the lung on the mid-crook the line is descended by about 2 cm, in the side of the side of percussion along the mid axillary line, the edge is lowered by 3-4 cm.
The high indicators of the mobility of the lower edges of the lungs testify to the good condition of the respiratory system, about the good elasticity of the lungs. Limiting the mobility of the lower edges of the lungs, and sometimes the complete absence indicate the dysfunction, due to either extrapulic, or pulmonary reasons. Poor mobility of the edge of the lung can be detected on both sides or on the one hand.
Extralegal reasons include the pathology of the chest wall, pleura, respiratory muscles and high intraperous pressure. The limitation of the mobility of the lower edge of the lungs is often associated with the impaired ventilation of the lungs due to pain during injury of the chest, the fracture of the ribs, mositis, intercostal neuralgia, as well as because of the inflammation of the pleura (dry pleurisy). Bad ventilation of the lungs occurs when the rib-vertebral joints is infrequent, with the weakness of respiratory muscles (miastic), diaphragmatite, diaphragm paralysis. The restriction of the mobility of the lower edges of the lungs occurs with a high standing of the diaphragm due to the high intra-penetration pressure (obesity, flatulence, ascites).
The mobility of the lower edges of the lungs becomes bounded as a result of pulmonary processes that are manifested:

• violation of alveoli elasticity (acute bloating alveol chronic emphysema);
• reduced lung tensions due to diffuse or local pneumophibrosis;
• a decrease in the respiratory surface of the lungs with truck pneumonia, tuberculosis, obtutation atelectase, tumors, cystic hypoplasia of the lungs, after lobectomy.

• about the presence of interface adhesions;
• about the accumulation of fluid in pleural sinus;
• pneumothorax;
• on the pathology of the diaphragm.

There are two types of lung percussion: topographic and comparative.

Topographic percussion of the lungs

The topographic percussion of the lungs includes the topography of the tops of the lungs, the topography of the lower edge of the lungs and the definition of the mobility of the lower moor edge, as well as the topography of the lung share.

In front of the percussion is carried out from the middle of the clavicle up and medially towards the presenter process. Normally, the tip of the lung is 3 - 5 cm above the clavicle. In the presence of well-pronounced percussion pits, percussion on the nail phalange. Rear The definition of the border is carried out from the middle of the hollow of the blades towards an accelerated process of the VII-th cervical vertebra, at the level of which it is normal.

The diagnostic value is also determined by the width of the tops of the lungs or fields of the crotch. They are determined from both sides, as it is important to estimate their symmetry. Percussion is carried out at the top edge of the trapezoid muscle from its middle - medial and laterally. Normally, their value is 4 - 8 cm. When lesion of the top of a light tuberculosis process with the development of fibrosis, the magnitude of the field of the crumb decreases on the side of the lesion, and in the emphysema of the lungs - increases from both sides. The standards of the lower boundary of the lungs are shown in Table 3.

Table 3.

Long border standards

In pronounced hyperstenists, the lower edge may be one edge above, and asthenics are on the edge below.

The mobility of the lower light edge is determined by the method of percussion for each topographic line, be sure to breathe in the breath and in exhalation. At the beginning, the lower boundary of the lung in calm, breathing is determined, then they ask for a patient to breathe deeply and the breath delay is perfectly performed before dulling the peculorore sound. Then they ask for a patient to make a complete exhalation and also pepper from top to bottom until the sound appears. The distance between the borders of the gumption on the breath and exhale corresponds to the mobility of the pulmonary edge. In the axillary lines, it is 6 - 8 cm. When assessing the mobility of the lower edges of the lungs, it is important to pay attention not only to their value, but also on symmetry. Asymmetry is observed with one-sided inflammatory processes (pneumonia, pleurisy, in the presence of adhesions), and the bilateral decrease is characteristic of emphysema lungs,

Comparative percussion lungs

Comparative percussion of the lungs are carried out sequentially on the front, side and rear surfaces of the lungs. When conducting a comparative percussion, the following conditions should be observed:

a) Percussion to carry out in strictly symmetric areas;

b) Comply with the identity of the conditions, mean the position of the finger-plaster, pressure on the chest wall and the strength of the percussion strikes. Usually the percussion of the average force is used, but when the hearth is detected in the depths of the lung, use strong performer blows.

Percussion starts in front with the screwdriver, while the finger-plaster is located in parallel to the clavicle. Then he pick up the globe itself and the area of \u200b\u200bthe 1st and 2nd intercostal in the middleless lines, while the finger-plaster is located in the course of the intercreation.

On the lateral surfaces, the comparative percussion is carried out on the front, middle and rear-dimensional lines, with the hands of the patient raised. With percussion of the back surface of the lungs, the patient is offered to cross hands on the chest, while the blades are diverged and interspervoral space increases. Initially, the appropriate space is perfectly (a finger-plastermeter is located parallel to the hollow of the blade). Then consistently peculiarize the inter-pumping space (the finger-plaster is placed parallel to the spine). In the subordinate region, the paravertebrally percussion is perfectly, and then on the scaling lines, with a finger-plastermeter parallel to the edges.

Normally, when comparative percussion is reproduced clear Light Sound Mostly the same on symmetric sections of the chest, although it should be remembered that on the right, the percussion sound is determined more muted than the left, since the top of the right light is located below the left and the muscles of the shoulder belt in most patients on the right are stronger than the left and partially quenching the sound.

Stupid or dull light sound is observed when lighting light reduce (infiltration light fabric), clustering fluid in the pleural cavity, during the slope of the lung (atelectasis), if there is an easy cavity filled with liquid content.

The tympanic percussion sound is determined by increasing airiness of light tissue (acute and chronic emphysema), which is observed in different extensive formations: cavity, abscess, as well as aircraft accumulation in the cavity of the pleura (pneumothorax).

The dull-tympanic sound occurs under the condition of lowering the elasticity of light tissue and increasing its airiness. Such conditions occur with pneumococcal (brunt) pneumonia (stage of the tide and the resolution stage), in the region of the Skoda strip with an exudative pleurisite, with obturantic atelectase.

With the help of topographic percussion of the lungs determine:

a) lower lung boundaries;
b) the upper boundaries of the lungs, or the height of the surfaces of the lungs, as well as their width (centers);
c) the mobility of the lower edge of the lungs.

The volume of one or both lungs various diseases may increase or decrease. This is detected by percussion to change the position of the pulmonary edges compared to normal. The position of the edges of the lungs is determined in conventional breathing.

Fig. 30. Definition of lung boundaries:
a, b, in - bottom front and behind and its scheme;
g, d, e is the top front, behind, and its dimension.

The lower borders of the lungs are set as follows. They smash, moving a finger-molemeter on the intercreets from top to bottom (start with the II intercostal) until the clear pulmonary sound is completely blunt. At the same time, as noted, a weak percussion is applied. It is produced in all identification vertical lines on both sides, ranging from okaludinating and ending with the ocolotopotes (Fig. 30, a, b). On the left middle-key, and sometimes on the front axillary lines, the lower edge of the lung is quite difficult to determine, since it is bordered by the air-containing stomach. Having determined the position of the lower edge of the lung on all lines and noting at the level of each of them this place points, the latter are connected by a solid line, which will be the projection of the lower edge of the lung on the chest (Fig. 30, B). The lower edge of the lung in a healthy person at percussion in vertical position It passes through the ocalized line on the right - along the upper edge of the VI edges, on the left - at the bottom edge of IV (there is the upper limit of the absolute dullness of the heart), as well as on the right and left median-to-luminous lines - along the lower edge of the VI ribs, on the front axillary - On the VII edge, the middle axillary - on VIII, the rear axillary - on the IX, the bladder - on the X rib and in the octopotic lines at the level of the oestuscular process of the XI of the chest vertebra.

It should be remembered as healthy people There are some fluctuations in the position of the lower edge of the lung. This to a certain extent depends on the standing height of the dome of the diaphragm. The level of the latter is determined by the constitution, gender and age of a person. Compared to normostas, hyperstores the diaphragm is located above, in asthenics below; in the elderly - lower than in middle-aged people; Men are somewhat higher than women.

The upper boundary of the lungs is determined in the height of the standing of their tops. It is found in front of it as follows (Fig. 30, d): a finger-plastermeter is installed in parallel with the clavicle in the on-the-screw hole and percussion from the middle of the clavicle up the staircase muscles before changing the clear pulmonary sound. The tops of the lungs are located 3-4 cm above the clavicle (Fig. 30, e). To determine the upper boundary of the lungs, the finger-plaster is placed in a supervatory hole parallel to the spanner's axis and percussion from its middle to the point, located on a 3-4 cm laterally of an oestic process of the VII vertebrae before the appearance of blunt sound. In healthy people, the standing height of the tops behind (Fig. 30, e) corresponds to the level of an accelerated process of the VII vertebra.

Fig. 31. Determination of the width of the lamps.
Fig. 32. The boundaries of the right (A) and left (b) lungs and their shares:
1 - top; 2 - bottom; 3 - medium (A - bone-diaphragmal sine).

Fields of Carniga They are zones above the tops of the lung, where a clear pulmonary sound is perfect. To determine the width of the crennics fields, the polesimeter is put on the middle of the trapezoidal muscle perpendicular to its front edge and percussion first medially to the neck, the location of the clear pulmonary sound in the stupid point is marked; Then - laterally to the shoulder and again the point of change of clear pulmonary sound stupid. The distance between these points and will be the width of the crennics fields (Fig. 31). It is measured in centimeters and normally ranges from 4 to 7 cm. On the left, this zone is 1-1.5 cm more than on the right.

The boundaries between the pulmonary lobes be beginning on both sides at the level of the vanes. On the left side, the border goes down and the duck to the middle axillary line at the level of the IV rib and ends on the left middle-clearable line on the VI edge. On the right, it takes place between the pulmonary lobes, first the same as the left, and on the border between the middle and lower thirds, the blades are divided into two branches: the upper (the boundary between the upper and middle shares), which goes to the place of attachment to the sternum IV ribs, and The bottom (the boundary between the middle and lower shares), heading forward and ending in the right mid-crooking line on the VI edge. Thus, the top and middle rollers are located on the right, on the side - the upper, middle and lower, on the side - the top, on the side - the upper and lower, from behind on both sides - mostly lower, from above - small areas of the upper fractions (Fig. 32) .

In a healthy lung with percussion, it is impossible to establish boundaries between shares. However, with inflammatory compaction, it is possible to determine if its boundaries correspond to the boundaries of a whole share or only part of it.

With pathological conditions, the boundaries of the lungs can shift the book or upstairs compared to normal. The displacement of the lower edges of the light book is observed, for example, in emphysema of the lungs, during the attack of bronchial asthma, when the abdominal cavity is omitted. The offset will upstairs may be when wrinkling the lungs due to the growth in them connective tissue (Pneumosclerosis) followed by its scarring (pneumophibrosis). This is observed after an abscess or wound injury, after transferred pleurite, especially purulent, as well as with the accumulation of fluid in the pleural cavity (the liquid penses the easiest to the top); under ascite, pregnancy, meteorism (gas accumulation in the intestine), when the lung is pushed up upward with a diaphragm (due to the increase in pressure in the abdominal cavity). It is possible to appreciate the offset of the lower edge of the light up with an inflammatory seal in the lower edge area.

The offset of the upper boundary of the lungs down and the reduction of the crennics fields is observed when the tops are wrinkled. Most often it happens with the tuberculosis of their defeat. The offset of the upper boundaries of the lungs up and the increase in the crench fields is noted in the emphysema of the lungs, the attack of bronchial asthma.