《肺部听诊医学》PPT课件.ppt

肺部听诊Auscultation of lungs,黑龙江中医药大学诊断教研室王艳芬,肺部听诊 auscultation of lungs,概述：（一）听诊方法：Methods of auscultation 1.Stethoscope should be placed firmly against the chest wall.2.The examination is usually conducted symmetrically from top to bottom,and anterior to posterior of the thorax.顺序：肺尖上肺下肺，前胸侧胸背部强调两侧对比听诊（二）听诊内容：正常呼吸音 normal breath sounds 病理性呼吸音 abnormal breath sound 附加音 adventitious sounds 语音共振 vocal resonance 胸膜摩擦音 pleural friction rub,肺部听诊方法,返回,一.正常呼吸音：,（一）正常四种呼吸音：气管呼吸音 tracheal breath sound 支气管呼吸音 bronchial breath sound 支气管肺泡呼吸音 bronchovesicular sound 肺泡呼吸音 vesicular breath sound 鉴别要领：产生机制、分布、听诊特点。,1 肺泡呼吸音（vesicular breath sound),产生机制：空气在细支气管和肺泡内进出移动的结果。吸气时气流进入肺泡，冲击肺泡壁，使肺泡由松弛变为紧张；呼气时肺泡由紧张变为松弛，这种肺泡弹性的变化和气流的振动是肺泡呼吸音形成的主要因素特点：*声音似上齿咬下唇吸气时发出的“fu”声*吸气相较长，呼气相较短*吸气音响比呼气强，音调高 分布：肺组织相应的体表部位,2 支气管呼吸音（bronchial breath sound),特点似抬舌后经口腔呼气时发出“ha”的音响吸气相较呼气相短呼气音响强，音调高产生机制：吸入的空气在声门、气管或主支气管形成喘流所产生的声音分布喉部、胸骨上窝、背部第6、7颈椎及第1、2胸椎附近（越靠近气管区，其音响越强，音调越低）,3 支气管肺泡呼吸音（bronchovesicular breath sound),产生机制：兼有支气管呼吸音和肺泡呼吸音特点的混合性呼吸音特点*吸气音的性质与肺泡呼吸音相似，但音响较强，音调略高*呼气音的性质与支气管呼吸音相似，音响较弱，音调稍低*吸气相与呼气相相同分布：胸骨角附近1、2肋间及背部肩胛间区的3、4胸椎水平及肺尖前后部,3种正常呼吸音特征的比较,一.正常呼吸音：,（二）影响肺泡呼吸音强弱的因素：1.呼吸的深浅 the depth of respiration 2.肺组织弹性 the elasticity of the lung tissue 3.胸壁厚度 the thickness of the chest wall 4.年龄:儿童老年人 readily audible in children,and heard lightly in the aged 5.性别:男女 It is louder in male than in female 6.部位：乳房下部及肩胛下部最强，其次为腋窝，肺尖 及肺下缘区域较弱,二.异常呼吸音,1.异常肺泡呼吸音：（1）肺泡呼吸音减弱或消失：decrease or absence 1)decreased of motion of chest wall 2)disorder of respiratory muscles 3)bronchial obstruction,4)compression the lung,by pleural effusion 5)emphysema(2)肺泡呼吸音增强 increase 1）bilateral increase 2）unilateral increase:compensatory mechanism of the healthy lung.,二.异常呼吸音,1.异常肺泡呼吸音（3）呼气音延长 prolongation of expiration Narrowing of the lower respiratory tract,seen in asthma,or by loss of elasticity of the lung as in emphysema.（4）断续性呼吸音Cogwheel breathing sound（5）粗糙性呼吸音,二.异常呼吸音：,2.异常支气管呼吸音：tubular breath sound the sounds are heard over the normal lung area（1）肺组织实变 consolidation of lung:(2）肺内大空洞 large cavity of the lung（3）压迫性肺不张 Compressed atelectassis,二.异常呼吸音：,3.异常支气管肺泡呼吸音 when broncho-vesicular breath sound is heard over the lung field,it is abnormal,seen in;bronchopneumonia,tuberculosis of lung partial atelectasis of lung,三.啰音（rale）adventitious sound,(一)湿啰音（moist rale）1.产生机理：吸气时气体通过呼吸道内的稀薄分泌物形成水泡破裂所产生的声音，或由于小支气管因分泌物粘着而闭陷，当吸气时突然张开重新充气所产生的爆裂音。They are produced by air-flow passing through secreation exudated in the bronchial tract,or by re-inflation of alveoli and bronchioles,the wall of which have be come adherent as the result of moisture.,(一)湿啰音（moist rale）,2.特点：*断续而短暂，一次常连续多个出现，*于吸气时或吸气终末较明显，*部位恒定，性质不易变，咳嗽后可减轻或消失,(一)湿啰音（moist rale）,3.分类：管腔径大小，渗出物多寡,时期：粗湿啰音 coarse rales:trachea,bronchi 中湿啰音 medium rales:small and medium bronchus 细湿啰音 fine rales:alveoli,bronchioles Velcro;crepitus捻发音；4.意义：见于支气管炎、支气管肺炎、肺泡炎、肺淤血肺水肿、支气管扩张、肺梗塞等。,罗音的产生机制,(二)干啰音：dry rales（rhonchi）,1.产生机理：由于气管、支气管或细支气管狭窄或部分阻塞，空气吸入或呼出时发生湍流所产生的声音.They are produced by narrowing or partial obstruction of trachea or major bronchus by various causes such as inflammation,congestion,spasm of the bronchial tree,tumor and foreign body.,(二)干啰音：dry rales（rhonchi）,2.特点：音调较高，持续时间长，呼气时明显，部位不恒定，性质易变。They are rather high pitched,musical and continuous sound heard in both inspiratory and expiratory phases.,(二)干啰音：dry rales（rhonchi）,3.分类：高调干啰音(哨笛音)sibilant rhonchi、起源于支气管、细支气管低调干啰音（鼾音）sonorous rhonchi多发生在气管，主支气管。4.意义：双侧支气管哮喘，慢支炎，心源性哮喘 单侧支气管结核或肿瘤,四.语音共振（vocal resonance,1.原理：同语颤vocal resonance is produced in the same fashion as vocal fremitus.2.检查方法：嘱被检查者用一般的声音强度重复发“yi”长音，喉部发音产生的振动经气管、支气管、肺泡传至胸壁，由听诊器听及。,四.语音共振（vocal resonance),3.语音共振增强及分类：*支气管语音 bronchophony：*胸语音 pectoriloquy：*羊鸣音 egophony:*耳语音 whispered:四种语音均可见于肺实变，羊语音多见于胸腔积液上方受压 肺区：耳语音对诊断肺实变及其范围价值更具重要意义。,四.语音共振（vocal resonance),4.singnificance：increased:1 consolidation of lung 2 large cavity formation 3 Compressed atelectassis decreasd:bronchial obstruction pleural effusion pleural thickening pulmonary emphsema,五.胸膜摩擦音pleural friction rub,1.发生原理：胸膜炎症纤维蛋白渗出沉积于胸膜胸膜变粗糙深呼吸，出现胸膜摩擦音。It is present whenever there is acute fibrinous pleurisy of any cause.2.检查方法：深呼吸动作，在前下侧胸壁和腋窝下部听诊。,五.胸膜摩擦音pleural friction rub,3 听诊特点：*听诊部位以前下侧胸壁最清楚*听诊器加压，深呼吸听诊更清楚*可变性大，时消时现，屏住呼吸可消失.意义：Its clinical significance are the same as friction rub by palpation.胸膜炎，肺梗塞，胸膜肿瘤，尿毒症等,思考题：,1.肺泡呼吸音听诊时其呼气时相短，是因为呼气期短于吸气期，对吗？为什么？2.何谓Tubular breath sound？其临床意义如何?3.影响肺泡呼吸音的因素有哪些？4.湿罗音的形成机制及特点？5.如何在听诊上鉴别干，湿罗音？,Thank you,