Microsoft PowerPoint 張竣期- 胸腔理學檢查.ppt

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1 胸腔理學檢查胸腔內科張竣期醫師 98 年 9 月 7 日大綱 (A) 視診 (Inspection) (B) 觸診 (Palpation) (C) 叩診 (Percussion) (D) 聽診 (Auscultation) 1

2 (A) 視診 (1) 呼吸窘迫 (2) 呼吸次數 (3) 呼吸型態 (4) 胸廓外型 (5) 杵狀指 (1) 呼吸窘迫 (respiratory distress) 黑青 (cyanosis)? 端坐呼吸 (orthopnea)? 使用呼吸輔助肌? Paradoxical breathing? 蹶嘴吐氣 (pursed lip breathing)? 2

3 (2) 呼吸次數不要讓病人知道你正在量呼吸次數 ( 可以手假把脈搏分散病人注意力, 同時以眼睛注視胸部起伏, 在心中默數次數 ) 至少要數半分鐘正常人次數在 12-16/min 3

4 (3) 呼吸型態 Apnea( 停止呼吸 ):Cardiac arrest Biot s( 不規則呼吸間隔著一長段停止呼吸 ):IICP 呼吸抑制藥物腦受傷 ( 通常是延腦 ) Cheyne-Stokes( 漸強漸弱停止漸強漸弱停止. ): 呼吸抑制藥物腦受傷 ( 通常是大腦 ) CHF Kussmaul( 深而快 ): 代謝性酸中毒 4

5 (4) 胸廓外型 5

6 (5) 杵狀指 (Clubbing fingers) 通常代表長期缺氧的結果可見於各種胸腔疾病 ( 肺癌支氣管擴張肺纖維化等等 ), 也可見於心臟病 (CHF 亞急性心內膜炎 ) 或肝病 ( 肝癌肝硬化 ) 6

7 (B) 觸診 (1) 胸腔擴張度 (2) 觸覺震顫 (3) 氣管位置 (4) 頭頸部淋巴結 7

8 (1) 胸腔擴張度正常人可擴張 4-6cm 注意對稱性擴張不足 : 阻塞性肺病肺纖維化肌肉無力僵直性脊髓炎 (2) 觸覺震顫觸覺震顫 (tactile fremitus): 經由呼吸在胸腔表面所產生的震動語聲震顫 (vocal fremitus): 經由說話在胸腔表面所產生的震動震顫 : 肺炎肺塌陷震顫 : 肋膜積水氣胸單側氣管阻塞 COPD 胸壁太厚 ( 肌肉或脂肪 ) 8

9 (3) 氣管位置 A: 用食指估計氣管與兩側胸鎖乳突肌間的距離, 有否對稱 B: 當右肺塌陷時, 氣管被拉向右側 C: 當右肺有壓力性氣胸或大量肋膜積水時, 氣管被推向左側 (4) 頭頸部淋巴結 1. Pre-auricular 2. Post-auricular 3. Occipital 4. Tonsillar 5. Submaxillary 6. Submental 7. Superficial cervical 8. Posterior cervical 9. Deep cervical 10. Supraclavicular 9

Pre-auricular 2. Post-auricular 3. Occipital 4. Tonsillar 5. Submaxillary 6.

10 (C) 扣診 Dullness: low amplitude, short duration, without resonance 實心臟器 : 如肝 Resonance: higher amplitude, lower pitch 混合了氣體與組織的臟器 : 如肺 Tympany: high pitch, hollow quality 內含空氣的空心器官 : 如胃 Hyper-resonance: low pitch, hollow quality 較 resonance 有更多的空氣 : 如氣胸 COPD 評估橫膈移動正常女人 :3 cm; 男人 :5~6 cm 移動減少 : 兩側 -COPD 肌無力 ; 單側 - 膈神經麻痺 10

內含空氣的空心器官 : 如胃 Hyper-resonance: low pitch, hollow quality 較 resonance 有更多的空氣 :

11 叩診順序 (D) 聽診 Bell:low-pitched sounds; 輕置於皮膚上 Diaphragm:high-pitched sounds; 緊壓在皮膚上呼吸音多屬 high-pitch, 皆以 diaphragm 聽安靜的環境請病人張口以較深且快的方式呼吸不可隔著衣服聽 11

12 Lung Sounds Classification of Common Lung Sounds Acoustic Characteristics ATS Nomenclature Common Synonyms Normal Hz Decreasing power with increasing Hz Hz Flat until sharp decrease in power (900 Hz) Normal Bronchial Vesicular Bronchial Tracheal Discontinuous, interrupted explosive sounds (loud, low in pitch), early inspiratory or expiratory Coarse crackle Coarse rale Adventitious Discontinuous, interrupted explosive sounds (less loud than above and of shorter duration; higher in pitch than coarse crackles or rales), mid- to late inspiratory Continuous sounds (longer than 250 msec, high-pitched; dominant frequency of 400 Hz or more, a hissing sound) Fine crackle Wheeze Fine rale, crepitation Sibilant rhonchus Continuous sounds (longer than 250 msec, low-pitched; dominant frequency about 200 Hz or less, a snoring sound) Rhonchus Sonorous rhonchus 12

Adventitious Discontinuous, interrupted explosive sounds (less loud than above and of shorter duration; higher in pitch than coarse crackles or rales), mid- to late inspiratory Continuous sounds

13 Lung Sounds Normal Breath Sounds Adventitious ( 外來的 ) Lung Sounds Normal Breath Sounds Tracheobronchial sound Bronchovesicular sound Vesicular breath sound 13

14 正常呼吸音正常呼吸音 Tracheal Bronchia l Bronchovesicular vesicular 聲音強度非常大聲大聲中等小聲 Pitch Very high High Moderate Low I:E Ratio 1:1 1:3 1:1 3:1 特性描述 Harsh Tubular Rustling, but tubular Gentle rustling 正常位置胸腔外氣管胸骨柄大支氣管肺周邊 14

Moderate Low I:E Ratio 1:1 1:3 1:1 3:1 特性描述 Harsh Tubular

15 Tracheobronchial Sounds Loud and harsh High-pitched A pause between inspiratory and expiratory components Expiratory component is slightly longer than inspiratory component Heard over a major bronchus during normal breathing Bronchovesicular Sounds Softer in intensity than tracheobronchial sounds Lower pitched than tracheobronchial sounds An equal inspiratoey and expiratory component Heard distal to central airways 正常情況下只出現在胸骨柄位置當它在肺部較週邊的地方被聽到, 可能表示肺部有實質化 ( 例如肺炎 ) 15

Softer in intensity than tracheobronchial sounds Lower pitched than tracheobronchial sounds An equal inspiratoey and expiratory

16 Vesicular Breath Sounds Softer in intensity than bronchiovesicular sounds Inspiratory component is longer than expiratory component Heard over all areas of the chest distal to central airways during normal breathing Coarse breath sound with prominent expiratory component = Tracheobronchial breath sound 正常情況下只出現在大支氣管第一二肋間 ) 或背後兩肩胛骨間當它在肺部較週邊的地方被聽到, 可能表示肺部有實質化 ( 例如肺炎 ) 呼吸音變小聲肺氣腫 ( 肺泡數目減少 ) 橫膈麻痺 ( 呼吸肌無力 ) 支氣管完全阻塞 ( 沒有氣進出 ) 氣胸肋膜積水肋膜增厚 ( 傳導受阻 ) 呼吸音變大聲肺實質化 (Consolidation): 如肺炎肺塌陷肺癌等, 因為實質化以後的肺較先前充滿空氣的肺更利於聲音傳導, 所以更大聲 16

支氣管第一二肋間 ) 或背後兩肩胛骨間當它在肺部較週邊的地方被聽到, 可能表示肺部有實質化 ( 例如肺炎 ) 呼吸音變小聲肺氣腫 ( 肺泡數目減少 ) 橫膈麻痺 ( 呼吸肌無力 ) 支氣管完全阻

17 Adventitious Lung Sounds Continuous * Constant pitch * Duration from 200 msec to seconds * Often heard during expiration * Associated with airways obstruction Discontinuous * Intermittent pitch * Duration shorter than 20 msec * Often heard during inspiration Adventitious Lung Sounds Recommended Crackles Wheezes Rhonchi Classification Discontinuous High-pitched Continuous Low-pitched Continuous Terms used in other publications Rales Crepitations Sibilant rales Musical rales Sibilant rhonchus Low-pitched wheeze Sonorous rales Recommendations from ATS-ACCP Pulmonary Nomenclature Committee (Am Thor Soc News,1977, vol. 3, p.51.) 17

Rhonchi Classification Discontinuous High-pitched Continuous Low-pitched Continuous Terms used in other publications Rales Crepitations Sibilant rales Musical

18 Synonymous Nomenclature of Adventitious Lung Sounds Crackles (ATS-ACCP) = Rales Low-pitched wheezes (ATS-ACCP) = Rhonchi Coarse Crackles or Rales (others)= Rhonchi Delete the term rhonchi from clinical practice Stridor: high-pitched, continuous, heard over upper airway Qualifying Adjectives of Adventitious Lung Sounds Discontinuous * High-pitched or Low-pitched * Fine; Medium; Coarse Continuous * Mild; Moderate; Severe Terms such as wet, dry, sonorous, and sibilant which have no acoustical basis. 18

heard over upper airway Qualifying Adjectives of Adventitious Lung Sounds Discontinuous * High-pitched or Low-pitched * Fine;

19 Mechanisms of Adventitious Lung Sounds Crackles Mechanism: 1. Bubbling of air through airway secretion 2. Sudden opening of small airways Often heard during inspiration Crackles associated with the movement of airway secretions: coarse, occur during both inspiration and expiration Crackles Mechanisms of Adventitious Lung Sounds Crackles disappear after a few deep breath or after changes in position: transient airway atelectasis (secretion) Persistent crackles (Velcro rales): pulmonary fibrosis Early-inspiratory crackles: chronic obstructive airway disease Late-inspiratory crackles: restrictive lung disease 19

inspiration and expiration Crackles Mechanisms of Adventitious Lung Sounds Crackles disappear after a few deep breath or after changes in position:

20 Crackle 不連續音, 常出現在吸氣期, 類似在耳鬢搓揉頭髮的嗶嗶啵啵聲 ( 捻髮音 ) 聽見 crackle 時, 令病人咳嗽將痰清出後, 再聽有時 crackle 就會自然不見了成因 : 由於氣道內異常積水, 吐氣時肺泡會塌陷, 但吸氣時又會再被撐開當許多肺泡不同時被撐開, 就會發出 crackle 聲可見於心衰竭肺積水肺炎肺纖維化 Rhonchus 連續低音, 音頻 <200Hz, 近似打鼾或呻吟聲, 常出現在吐氣時由於氣流通過變窄後的較大支氣管所形成可見於氣喘病支氣管炎等病 20

開當許多肺泡不同時被撐開, 就會發出 crackle 聲可見於心衰竭肺積水肺炎肺纖維化 Rhonchus 連續低音, 音頻

21 Wheezes Mechanisms of Adventitious Lung Sounds Rapid flow past the site of intrathoracic airway obstruction Heard during expiration Higher-pitched wheeze: more rapid flow or tighter airway obstruction Lower-pitched wheeze: lower flow or less airway obstruction 連續高音, 音頻 >400Hz, 近似吹口哨音, 常出現在吐氣時 ( 但也可能跑到吸氣時 ) 由於氣流快速通過變狹窄的極小支氣管所發出的可見於 : 氣喘肺水腫心衰竭支氣管炎等疾病 Stridor Mechanisms of Adventitious Lung Sounds Flow past the site of extrathoracic airway obstruction Often heard during inspiration Fixed airway obstruction: stridor heard during both inspiration and expiration 是一種特別大聲的 wheeze, 可以在離病人稍遠的地方不用聽診器就聽到通常是因為上呼吸道狹窄造成的 21

22 Voice Sounds A normal air-filled lung transmits low frequency of voice sounds (<200Hz). Higher frequency of voice sounds are selectively filtered and attenuated. Alteration in lung pathology will change the transmission of voice sound, resulting in either increased or decreased transmission of voice resonance. 聽診時, 病人正在說話所聽到的異常聲音有以下三種 : Egophony Bronchophony Whispered pectoriloquy Voice Sounds Bronchophony Louder and clearer voice sounds Occur over areas of lung consolidation 正常聽診時若病人說話, 從聽診器聽到的聲音較小聲, 也較不清晰但是若聽診的部位有實質化 ( 如肺炎肺塌陷肺癌等 ) 說話的聲音將反常地大聲且清晰, 此謂之 Bronchophony 22

23 Egophony Voice Sounds Voice sound increases in intensity and takes on a nasal quality e-e-e heard as a-a-a Often combines with bronchophony Occur over areas of lung consolidation 若聽診的部位有實質化 (consolidation)( 如肺炎肺塌陷肺癌等 ) 令病人發出伊的聲音, 從聽診器聽起來會變得像在唸 A 的聲音, 此謂之 egophony Voice Sounds Whispered Pectoriloquy Whispering is normally heard as muffled, lowpitched sounds over chest wall by stethoscope. Whispering is transmitted to the chest wall with more clarity Occur over areas of lung consolidation 聽診時若病人以近乎耳語的小聲說話, 正常時應當幾乎無法被聽診器聽見但是若聽診的部位有實質化 ( 如肺炎肺塌陷肺癌等 ) 小聲耳語的聲音將變得異常地大聲且清晰, 此謂 whispered pectoriloquy 23

24 Miscellaneous Sounds Pleural Friction Rub Alternation in the pleura (pleural effusion, thickening, fibrosis) can result in added friction between pleural layers. Lower-pitched Longer duration than pulmonary crackles Commonly present during both inspiration and expiration 成因 : 當肋膜表面因發炎物堆積或變厚或長癌時, 兩層肋膜間隨著呼吸而彼此滑動的動作就會出現阻力, 此謂之 Friction rub 通常在吸氣末和吐氣初聽到較常出現的位置是腋下或是後面的肺基底部 Miscellaneous Sounds Maybe confused with lung crackles Chest hair, subcutaneous emphysema: crackling noise Pneumomediastinum: systolic crunch = xiphisternal crunch = Hamman s crunch Ribs /sternum fracture: bone crepitus Water present in the tube of ventilator or endotracheal tube: gargling or bubbling 24

25 Classic Physical Findings Disorder Inspection Palpation Percussion Auscultation Bronchial asthma (acute attack) Hyperinflation; use of accessory muscles Impaired expansion; decreased fremitus Hyperresonance; low diaphragm Prolonged expiration: inspiratory and expiratory wheezes Pneumothorax (complete) Lag on affected side Absent fremitus Hyperresonant or tympanitic Absent breath sounds Pleural effusion (large) Lag on affected side Decreased fremitus; trachea and heart shifted away from affected side Dullness or flatness Absent breath sounds Atelectasis (lobar obstruction) Lag on affected side Decreased fremitus; trachea and heart shifted toward affected side Dullness or flatness Absent breath sounds Consolidation (pneumonia) Possible lag or splinting on affected side Increased fremitus Dullness Bronchial breath sounds; bronchophony; pectoriloquy; crackles 牛刀小試 25

26 Case 1:Both Lungs Characteristics: Breathing sounds are very quiet in all lung fields Diagnosis: Emphysema (stable stage) Asthma (severe) Cystic Fibrosis (stable stage) Case 2:Neck Characteristics: Stridor during inspiration and expiration Diagnosis: Upper airway obstruction ( epiglottitis, foreign body aspiration, tumor compression ) 26

27 Case 3:Right Lung Characteristics: Diminished breathing sounds Diagnosis: Right pneumothorax Right massive pleural effusion Collapsed lung, right Lobar pneumonia, right Pulmonary embolism, right Case 4:RLL Characteristics: Inspiratory and expiratory pleural friction rub Diagnosis: Pleuritis Pulmonary embolism Pneumonia 27

28 Case 5:Both Lungs Characteristics: Inspiratory crackles with severe expiratory wheezing Diagnosis: Pneumonia + Asthma COPD with secondary infection Acute pulmonary edema Case 6:RLL / Voice Sound Characteristics: Tracheobroncial sounds with egophony limited to right chest Diagnosis: Pneumonia Pulmonary infarction Bronchogenic carcinoma 28

29 Case 7:Both Lungs Characteristics: Medium inspiratory and expiratory crackles Diagnosis: Pneumonia Pulmonary edema ARDS 29

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