The definition of the boundaries of the lungs has great importance for the diagnosis of many pathological conditions. Ability to percussion detect displacement of organs chest in one direction or another allows already at the stage of examination of the patient without the use of additional methods studies (in particular, x-ray) to suspect the presence of a certain disease.
How to measure the borders of the lungs?
Of course, you can use instrumental methods diagnostics, make X-ray and use it to assess how the lungs are located relative to the bone frame. However, this is best done without exposing the patient to radiation.
The determination of the boundaries of the lungs at the stage of examination is carried out by the method topographic percussion. What it is? Percussion is a study based on the identification of sounds that occur when tapping on the surface of the human body. The sound changes depending on the area in which the study is taking place. Over parenchymal organs (liver) or muscles, it turns out to be deaf, over hollow organs (intestine) - tympanic, and over filled air lungs acquires a special sound (pulmonary percussion sound).
Performed this study in the following way. One hand is placed with a palm on the area of study, two or one finger of the second hand hits the middle finger of the first (plessimeter), like a hammer on an anvil. As a result, you can hear one of the options for percussion sound, which was already mentioned above.
Percussion is comparative (sound is evaluated in symmetrical areas of the chest) and topographic. The latter is just designed to determine the boundaries of the lungs.
How to conduct topographic percussion?
The finger-pessimeter is set to the point from which the study begins (for example, when determining the upper border of the lung along the anterior surface, it starts above middle part clavicle) and then shifts to the point where this measurement should approximately end. The border is defined in the area where the pulmonary percussion sound becomes dull.
The finger-plesimeter for the convenience of research should lie parallel to the desired border. The displacement step is approximately 1 cm. Topographic percussion, in contrast to comparative, is performed by gentle (quiet) tapping.
Upper bound
The position of the tops of the lungs is assessed both anteriorly and posteriorly. On the front surface of the chest, the clavicle serves as a guide, on the back - the seventh cervical vertebra (it has a long spinous process, by which it can be easily distinguished from other vertebrae).
The upper borders of the lungs are normally located as follows:
- Anteriorly above the level of the clavicle by 30-40 mm.
- Behind usually on the same level with the seventh cervical vertebra.
Research should be done like this:
- From the front, the plessimeter finger is placed above the clavicle (approximately in the projection of its middle), and then shifted up and to the inside until the percussion sound becomes dull.
- Behind, the study starts from the middle of the spine of the scapula, and then the finger-plessimeter moves up so as to be on the side of the seventh cervical vertebra. Percussion is performed until a dull sound appears.
Displacement of the upper borders of the lungs
The upward displacement of the boundaries occurs due to excess airiness lung tissue. This condition is typical for emphysema - a disease in which the walls of the alveoli are overstretched, and in some cases their destruction with the formation of cavities (bulls). Changes in the lungs with emphysema are irreversible, the alveoli swell, the ability to collapse is lost, elasticity is sharply reduced.
Borders of human lungs (in this case the borders of the apex) can also shift downward. This is due to a decrease in the airiness of the lung tissue, a condition that is a sign of inflammation or its consequences (proliferation connective tissue and shriveling of the lung). Borders of the lungs (upper) located below normal level, - diagnostic feature pathologies such as tuberculosis, pneumonia, pneumosclerosis.
Bottom line
To measure it, you need to know the main topographic lines of the chest. The method is based on moving the researcher's hands along the indicated lines from top to bottom until the pulmonary percussion sound changes to dull. You should also know that the border of the anterior left lung is not symmetrical to the right one due to the presence of a pocket for the heart.
From the front, the lower borders of the lungs are determined along the line passing along the lateral surface of the sternum, as well as along the line descending down from the middle of the clavicle.
On the side, three axillary lines are important landmarks - anterior, middle and posterior, which start from the anterior margin, center and posterior margin armpit respectively. Behind the edge of the lungs is determined relative to the line descending from the angle of the scapula, and the line located on the side of the spine.
Displacement of the lower borders of the lungs
It should be noted that in the process of breathing, the volume of this organ changes. Therefore, the lower borders of the lungs are normally displaced by 20-40 mm up and down. A persistent change in the position of the boundary testifies to pathological process in the chest or abdominal cavity.
The lungs are excessively enlarged with emphysema, which leads to a bilateral downward displacement of the borders. Other causes may be hypotension of the diaphragm and pronounced prolapse of the abdominal organs. The lower limit shifts downward on one side in the case of compensatory expansion healthy lung when the second is in a collapsed state as a result, for example, of a total pneumothorax, hydrothorax, etc.
The borders of the lungs usually move upward due to wrinkling of the latter (pneumosclerosis), a decrease in the lobe as a result of bronchial obstruction, accumulation in pleural cavity exudate (as a result of which the lung collapses and is pressed against the root). Pathological conditions in the abdominal cavity can also shift the pulmonary boundaries upward: for example, accumulation of fluid (ascites) or air (with perforation of a hollow organ).
The borders of the lungs are normal: table
Lower limits in an adult |
||
Field of study | Right lung | Left lung |
Line at the lateral surface of the sternum | 5 intercostal space | |
Line descending from the middle of the clavicle | ||
Line originating from the anterior margin of the armpit | ||
A line from the center of the armpit | ||
Line from the posterior edge of the armpit | ||
Line to the side of the spine | 11 thoracic vertebrae | 11 thoracic vertebrae |
The location of the upper pulmonary borders is described above.
The change in the indicator depending on the physique
In asthenics, the lungs are elongated in the longitudinal direction, so they often fall slightly below the generally accepted norm, ending not on the ribs, but in the intercostal spaces. For hypersthenics, on the contrary, a higher position of the lower border is characteristic. Their lungs are wide and flattened in shape.
How are the lung borders located in a child?
Strictly speaking, the borders of the lungs in children practically correspond to those in an adult. The tops of this organ in children who have not yet reached preschool age, are not defined. Later, they are detected in front 20-40 mm above the middle of the clavicle, behind - at the level of the seventh cervical vertebra.
Location lower bounds discussed in the table below.
Borders of the lungs (table) |
||
Field of study | Age up to 10 years | Age over 10 years old |
A line from the middle of the clavicle | Right: 6 rib | Right: 6 rib |
Line originating from the center of the armpit | Right: 7-8 rib Left: 9 rib | Right: 8 rib Left: 8 rib |
Line descending from the angle of the scapula | Right: 9-10 rib Left: 10 rib | Right: 10th rib Left: 10 rib |
Reasons for the displacement of the pulmonary borders in children up or down relative to normal values the same as in adults.
How to determine the mobility of the lower edge of the organ?
It has already been said above that during breathing, the lower boundaries shift relative to normal indicators due to expansion of the lungs on inspiration and decrease on expiration. Normally, such a shift is possible within 20-40 mm upward from the lower border and the same amount downward.
The determination of mobility is carried out along three main lines starting from the middle of the clavicle, the center of the armpit and the angle of the scapula. The study is carried out as follows. First, the position of the lower border is determined and a mark is made on the skin (you can use a pen). Then the patient is asked to take a deep breath and hold his breath, after which the lower limit is again found and a mark is made. And finally, the position of the lung during maximum expiration is determined. Now, focusing on the marks, one can judge how the lung is displaced relative to its lower border.
In some diseases, lung mobility is markedly reduced. For example, this occurs during spikes or in large numbers exudate in the pleural cavities, loss of light elasticity in emphysema, etc.
Difficulties in conducting topographic percussion
This research method is not easy and requires certain skills, and even better - experience. The difficulties that arise in its application are usually associated with improper execution technique. Concerning anatomical features that can create problems for the researcher, mainly severe obesity. In general, it is easiest to perform percussion on asthenics. The sound is clear and loud.
What needs to be done to easily determine the boundaries of the lung?
- Know exactly where, how and exactly what boundaries to look for. Good theoretical background is the key to success.
- Move from a clear sound to a dull one.
- The plessimeter finger should lie parallel to the defined border, but move perpendicular to it.
- Hands should be relaxed. Percussion does not require significant effort.
And, of course, experience is very important. Practice builds self-confidence.
Summarize
Percussion is a very important diagnostic method of research. It allows you to suspect many pathological conditions of the chest organs. Deviation of the boundaries of the lungs from normal values, impaired mobility of the lower edge - symptoms of some serious illnesses, timely diagnosis which are essential for a successful treatment.
With the help of topographic percussion of the lungs determine:
a) the lower borders of the lungs;
b) the upper borders of the lungs, or the height of the tops of the lungs, as well as their width (Krenig fields);
c) mobility of the lower edge of the lungs.
Volume of one or both lungs various diseases may increase or decrease. This is detected during percussion by a change in the position of the lung edges compared to normal. The position of the edges of the lungs is determined during normal breathing.
Rice. 30. Determining the boundaries of the lungs:
a, b, c - lower front and back and its scheme;
d, e, f - upper front, back, and its measurement.
The lower borders of the lungs are set as follows. They are cut by moving the plessimeter finger along the intercostal spaces from top to bottom (starting from the 2nd intercostal space) until a clear pulmonary sound is replaced by an absolutely dull one. In this case, as noted, weak percussion is used. It is made along all identification vertical lines on both sides, starting from the peristernal and ending with the paravertebral (Fig. 30, a, b). It is rather difficult to determine the lower edge of the lung along the left mid-clavicular, and sometimes along the anterior axillary lines, since here it borders on the stomach containing air. Having determined the position of the lower edge of the lung along all lines and marking this place with dots at the level of each of them, the latter are connected by a solid line, which will be the projection of the lower edge of the lung onto the chest (Fig. 30, c). The lower edge of the lung healthy person on percussion in vertical position it passes along the parasternal line on the right - along the upper edge of the VI rib, on the left - along the lower edge of the IV (here is the upper limit of the absolute dullness of the heart), as well as along the right and left mid-clavicular lines - along the lower edge of the VI rib, along the anterior axillary - on the VII rib, the middle axillary - on the VIII, the posterior axillary - on the IX, the scapular - on the X rib and along the paravertebral lines at the level of the spinous process of the XI thoracic vertebra.
It should be remembered that in healthy people, some fluctuations in the position of the lower edge of the lung are possible. To a certain extent, this depends on the height of the diaphragm dome. The level of the latter is determined by the constitution, sex and age of the person. Compared with normosthenics, in hypersthenics the diaphragm is located higher, in asthenics it is lower; in older people - lower than in middle-aged people; slightly higher in men than in women.
The upper limit of the lungs is determined by the height of their tops. From the front, it is found as follows (Fig. 30, d): the finger-plessimeter is placed parallel to the clavicle in the supraclavicular fossa and percussed from the middle of the clavicle up along scalene muscles until the change of a clear pulmonary sound is dull. The tops of the lungs in front are located 3-4 cm above the clavicle (Fig. 30, e). To determine the upper border of the lungs from behind, a plessimeter finger is placed in the supraspinatus fossa parallel to the spine of the scapula and percussed from its middle to a point located 3-4 cm lateral to the spinous process of the VII cervical vertebra until a dull sound appears. In healthy people, the height of the tops standing behind (Fig. 30, f) corresponds to the level of the spinous process of the VII cervical vertebra.
Rice. 31. Determining the width of the Krenig fields.
Rice. 32. Borders of the right (a) and left (b) lungs and their lobes:
1 - top; 2 - bottom; 3 - medium (A - bone-diaphragmatic sinus).
Fields of Krenig are zones above the tops of the lung, where a clear pulmonary sound is percussed. To determine the width of the Krenig fields, the finger-plessimeter is placed in the middle of the trapezius muscle perpendicular to its front edge and percussed first medially to the neck, the place of transition of a clear lung sound to a dull one is marked with a dot; then - laterally to the shoulder and again with a dot mark the place where the clear pulmonary sound changes into a dull one. The distance between these points will be the width of the Krenig 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 larger than on the right.
The borders between the pulmonary lobes behind begin on both sides at the level of the spine of the shoulder blades. On the left side, the border goes down and outward to the mid-axillary line at the level of the IV rib and ends at the left mid-clavicular line on the VI rib. On the right, it passes between the pulmonary lobes, at first in the same way as on the left, and on the border between the middle and lower thirds of the scapula it is divided into two branches: the upper one (the border between the upper and middle lobes), which goes anteriorly to the point of attachment to the sternum of the IV rib, and lower (border between the middle and lower lobes), heading forward and ending at the right mid-clavicular line on the VI rib. Thus, the upper and middle lobes are located on the right front, the upper, middle and lower lobes are located on the side, the upper lobes are on the left front, the upper and lower lobes are on the side, the lower lobes are mainly on the back on both sides, and small sections of the upper lobes are on top (Fig. 32) .
In a healthy lung, percussion cannot establish boundaries between lobes. However, with inflammatory compaction, it can be determined whether its boundaries correspond to the boundaries of the whole lobe or only part of it.
At pathological conditions the borders of the lungs may be displaced downward or upward compared to normal. The displacement of the lower edges of the lungs downward is observed, for example, with emphysema, during an attack bronchial asthma, with the omission of the abdominal organs. An upward displacement may occur with wrinkling of the lungs, due to the growth of connective tissue in them (pneumosclerosis) with its subsequent scarring (pneumofibrosis). This is seen after an abscess or lung injury, after suffering pleurisy, especially purulent, as well as with the accumulation of fluid in the pleural cavity (fluid pushes the lung up); with ascites, pregnancy, flatulence (accumulation of gas in the intestines), when the lung is pushed upward by the diaphragm (due to increased pressure in the abdominal cavity). It is also possible that the apparent displacement of the lower edge of the lung upwards with its inflammatory compaction in the region of the lower edge.
The shift of the upper border of the lungs down and the decrease in the Krenig fields is observed with wrinkling of the tops of the lungs. Most often this happens with tuberculous lesions. The displacement of the upper border of the lungs upward and the increase in the Krenig fields is noted with emphysema, an attack of bronchial asthma.
There are two types of lung percussion: topographic and comparative.
Topographic percussion of the lungs
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 determination of the mobility of the lower lung edge, as well as the topography of the lung lobes.
From the front, percussion is carried out from the middle of the clavicle up and medially towards the mastoid process. Normally, the apex of the lung is 3-5 cm above the clavicle. In the presence of well-defined supraclavicular fossae, they are percussed along the nail phalanx. Behind the boundary is determined from the middle of the spine of the scapula towards the spinous process of the VIIth cervical vertebra, at the level of which it is normal.
The determination of the width of the apices of the lungs or Kroenig fields also has diagnostic value. They are determined from two sides, since it is important to evaluate their symmetry. Percussion is carried out along the upper edge of the trapezius muscle from its middle - medially and laterally. Normally, their value is 4–8 cm. When the apex of the lung is affected by a tuberculous process with the development of fibrosis, the value of the Kroenig field decreases on the side of the lesion, and with emphysema, it increases on both sides. The standards of the lower border of the lungs are shown in table 3.
Table 3
Standards of the lower border of the lungs
|
topographic lines |
On right |
Left |
|
By midclavicular |
not defined |
|
|
Along the anterior axillary | ||
|
On the middle axillary | ||
|
On the posterior axillary | ||
|
By scapular | ||
|
Perivertebral |
11th rib (or spinous process of XI thoracic vertebra) |
|
In pronounced hypersthenics, the lower edge may be one rib higher, and in asthenics, one rib lower.
The mobility of the lower pulmonary edge is determined by the method of percussion along each topographic line, always on inhalation and exhalation. At the beginning, the lower border of the lung is determined with calm breathing, then the patient is asked to take a deep breath and, while holding the breath, percuss further until the percussion sound becomes dull. Then the patient is asked to exhale completely and also percuss from top to bottom until the sound becomes dull. The distance between the borders of the resulting dullness on inspiration and expiration corresponds to the mobility of the pulmonary edge. Along 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 size, but also to symmetry. Asymmetry is observed in unilateral inflammatory processes (pneumonia, pleurisy, in the presence of adhesions), and a bilateral decrease is characteristic of pulmonary emphysema,
Comparative percussion of the lungs
Comparative percussion of the lungs is carried out sequentially along the anterior, lateral and posterior surfaces of the lungs. When conducting comparative percussion, the following conditions must be observed:
a) percussion should be carried out in strictly symmetrical areas;
b) observe the identity of the conditions, meaning the position of the finger-pessimeter, the pressure on chest wall and the strength of percussion. Percussion of medium strength is usually used, but when a lesion is located deep in the lung, strong percussion is used.
From the front, percussion begins with the supraclavicular fossae, with the plessimeter finger parallel to the clavicle. Then the clavicle itself and the areas of the 1st and 2nd intercostal spaces are percussed along the midclavicular lines, while the plessimeter finger is located along the intercostal spaces.
On the lateral surfaces, comparative percussion is carried out along the anterior, middle and posterior axillary lines, with the patient's arms raised. With percussion of the posterior surface of the lungs, the patient is offered to cross his arms on his chest, while the shoulder blades diverge and the interscapular space increases. First, the suprascapular space is percussed (the plessimeter finger is placed parallel to the spine of the scapula). Then the interscapular space is sequentially percussed (the plesimeter finger is placed parallel to the spine). In the subscapular region, they are first percussed paravertebral, and then along the scapular lines, placing the plessimeter finger parallel to the ribs.
Normally, with comparative percussion, clear lung sound basically the same in symmetrical parts of the chest, although it should be remembered that the percussion sound on the right is more muffled than on the left, since the top of the right lung is located below the left and the muscles of the shoulder girdle in most patients are more developed on the right than on the left and partially extinguish the sound.
Dull or blunted pulmonary sound is observed with a decrease in the airiness of the lung (infiltration of the lung tissue), accumulation of fluid in the pleural cavity, with a collapse of the lung (atelectasis), if there is a cavity in the lung filled with liquid contents.
Tympanic percussion sound is determined with an increase in the airiness of the lung tissue (acute and chronic emphysema), which is observed with various cavity formations: a cavity, an abscess, as well as an accumulation of air in the pleural cavity (pneumothorax).
Dull-tympanic sound occurs when the elasticity of the lung tissue decreases and its airiness increases. Similar conditions occur with pneumococcal (croupous) pneumonia (tide stage and resolution stage), in the area of the Skoda strip with exudative pleurisy, with obstructive atelectasis.
Topographic percussion of the lungs is a method of physical diagnosis based on tapping the chest and assessing the sounds that occur during the procedure. By the nature of sound vibrations determine physical state, size, location of the organ of the respiratory system.
Ways to measure the border of the lungs
Topographic percussion allows you to determine the position of the lungs in the chest relative to adjacent internal organs. This is achieved due to the difference in the sounds that occur when airy lung tissue is tapped and denser structures that do not contain air. The study includes a consistent refinement of the height of the tops, the width of the fields, the lower boundaries and the mobility of the lobar margins.
The topography of the lungs is carried out in several ways percussion:
- deep;
- superficial.
The method of deep tapping allows you to identify the parameters of the organ, pathological seals, breath sounds, neoplasms located deep in the parenchyma. The surface diagnostic method helps to distinguish between air-containing and airless tissues, to determine the localization of pathological foci, cavities.
Percussion Rules
The diagnostic procedure is performed by a pulmonologist according to the following rules: 
- topographic percussion is carried out in the direction from a clear pulmonary sound to a deaf one;
- the doctor has a finger-pessimeter parallel to the intended edge of the lungs;
- the limit line corresponds to the outer edge of the finger from the side of the internal organ, which gives a clear percussion sound;
- first superficial and then deep percussion is used.
Topographic percussion of the lungs is carried out in a warm room, the person should be completely relaxed, breathing should be calm. During the study, the patient is standing or sitting, with the exception of bedridden patients. The doctor applies the pessimeter finger tightly to the body, but does not allow the phalanx to sink too deep into soft tissues so as not to provoke an increase in the vibration of the sound.
Upper bound limits
To localize the height of the pulmonary apices, the plessimeter is placed in the supraclavicular fossa parallel to the clavicle. Apply a few blows with a finger-hammer, then raise the plessimeter so that the nail rests on the edge of the cervical sternocleidomastoid muscle. Continue topographic percussion along the clavicular line until the percussion sound changes from loud to dull. Using a centimeter tape or ruler, measure the gap from the middle of the clavicle to the tops determined during the study.
Reasons for shifting the upper bounds
The tops are raised above the norm with emphysema, bronchial asthma, and lowered with sclerosis respiratory organ, for example, with tuberculosis, the formation of foci of infiltration. The downward displacement of the tops is observed with a decrease in airiness, pneumonia, pneumosclerosis.
Determining the parameters of the lower boundaries begins with tapping right lung along the parasternal (parasternal) line.
For diagnostics, the topographic lines of the chest are examined: mamillary (mid-clavicular), scapular - under angulus inferior, axillary, located at the height of the armpit, paravertebral - in the projection of the spine of the scapula.
The parameters of the left lung are determined in an identical way, with the exception of tapping the peristernal and mid-clavicular line. This is due to the close location of the heart, the influence of the gastric gastric bubble on the dullness of the sound. When performing topographic percussion in front upper limbs the patient is lowered down, when tapping armpit- raised above the head.
The omission of the lower edges can be a symptom of low standing of the diaphragm, emphysema. Elevation is noted with wrinkling, scarring of the lung tissue against the background of lobar pneumonia, hydrothorax, exudative pleurisy.
High intra-abdominal pressure, pregnancy, flatulence, ascites, excessive deposition visceral fat may cause high standing diaphragm that raises the lower edges. The displacement of the lower edges also occurs when cancerous tumors, sharp increase liver sizes.
Normal location of the borders of the lungs
In a healthy person, the height of the apices from the front side of the body is fixed 3-4 cm above the clavicle, and from behind it corresponds to the level of the transverse spinous process of the seventh cervical vertebra - C7.
Normal indicators of the lower limits:
Measurement of the indicator, taking into account the characteristics of the physique
In hypersthenics with a large chest, a long torso, it is allowed to raise the lower edges of the lungs by one costal arch, and in asthenics, the lower edge is lowered by one rib below the physiological norm.
Video: Topographic percussion of the lungs
The purpose of the study is to determine the height of standing of the tops of the lungs in front and behind, the width of the Krenig fields, the lower borders of the lungs and the mobility of the lower edge of the lungs. Topographic percussion rules:
percussion is carried out from the organ that gives loud noise, to an organ that gives a dull sound, that is, from clear to dull;
the finger-plessimeter is located parallel to the defined border;
the border of the organ is marked along the side of the plessimeter finger, facing the organ, giving a clear pulmonary sound.
The determination of the upper boundaries of the lungs is made by percussion of the pulmonary apexes in front of the clavicle or behind the spine of the scapula. From the front, the pessimeter finger is placed above the clavicle and percussed upward and medially until the sound is dulled (the fingertip should follow the posterior edge of the sternocleidomastoid muscle). Behind percussion from the middle of the supraspinatus fossa towards the VII cervical vertebra. Normally, the standing height of the tops of the lungs is determined in front by 3-4 cm above the clavicle, and behind it is at the level of the spinous process of the VII cervical vertebra. The patient is in a standing or sitting position, and the doctor is standing. Percussion is carried out with a weak blow (quiet percussion). Topographic percussion begins with determining the height of the tops and the width of the Krenig fields.
Determination of the standing height of the tops of the lung in front: Plessimeter finger is placed in the supraclavicular fossa directly above the clavicle and parallel to the latter. With a hammer finger, 2 blows are applied to the plessimeter finger and then it is moved up so that it is parallel to the collarbone, and the nail phalanx rests against the edge of the sternocleidomastoid muscle (m. Sternocleidomastoideus). Percussion is continued until the percussion sound changes from loud to dull, marking the border along the edge of the plessimeter finger facing the clear percussion sound. With a measuring tape measure the distance from top edge the middle of the clavicle to the marked border (the height of the apex of the lung in front above the level of the clavicle).
Determination of the standing height of the apex of the lung behind: Plessimeter finger is placed in the supraspinatus fossa directly above the spine of the scapula. The finger is directed parallel to the spine, the middle of the middle phalanx of the finger is located above the middle of the inner half of the spine. With a hammer finger, weak blows are applied to the plessimeter finger. By moving the plessimeter finger up and inward along the line connecting the middle of the inner half of the spine of the scapula with a point located in the middle between the VII cervical vertebra and the outer edge of the mastoid end of the trapezius muscle, percussion is continued. When the percussion sound changes from loud to dull, percussion is stopped and the border is marked along the edge of the plessimeter finger facing the clear lung sound. The height of the apex of the lung behind is determined by the spinous process of the corresponding vertebra.
Determining the width of the margins: Kreniga: a plessimeter finger is placed on the anterior edge of the trapezius muscle above the middle of the clavicle. The direction of the finger runs perpendicular to the anterior edge of the trapezius muscle. With a hammer finger, weak blows are applied to the plessimeter finger. By moving the plessimeter finger inwards, percussion is continued. By changing the percussion sound from loud to dull, a border is marked along the edge of the plessimeter finger facing outward (the inner border of the Krenig field). After that, the finger-plessimeter is returned to its original position and percussion is continued, moving the finger-plessimeter outwards. When the percussion sound changes from loud to dull, percussion is stopped and the border is marked along the edge of the plessimeter finger, facing inwards (the outer border of the Krenig field). After that, the distance from the inner border of the Krenig field to the outer one (the width of the Krenig field) is measured with a centimeter tape. Similarly, the width of the Krenig field of another lung is determined. A downward shift in the standing height of the tops of the lungs and a decrease in the width of the Krenig fields are observed with wrinkling of the tops of the lungs of tuberculous origin, pneumosclerosis, and the development of infiltrative processes in the lungs. An increase in the height of the apices of the lungs and an expansion of the Krenig fields are observed with increased airiness of the lungs (emphysema) and during an attack of bronchial asthma.
The determination of the lower border of the right light percussion is carried out in a certain sequence along the following topographic lines:
along the right parasternal line;
along the right mid-clavicular line;
along the right anterior axillary line;
along the right midaxillary line;
along the right posterior axillary line;
along the right scapular line;
along the right paravertebral line.
Percussion begins with the determination of the lower border of the right lung along the parasternal line. The plesimeter finger is placed on the II intercostal space parallel to the ribs so that the right parasternal line crosses the middle phalanx of the finger in the middle. With a hammer finger, weak blows are applied to the plessimeter finger. By moving the finger-plessimeter sequentially down (toward the liver), percussion is continued. The position of the plessimeter finger each time should be such that its direction is perpendicular to the percussion line, and the parasternal line crosses the main phalanx in the middle. When the percussion sound changes from loud to dull (not dull, namely dull), percussion is stopped and the border is marked along the edge of the plessimeter finger facing upward (towards the lung). After that, it is determined at the level of which rib the lower border of the lung was found along this topographic line. To determine the level of the found border, angulus Ludovici is visually found (at this level, the second rib is attached to the sternum) and, having palpated with a large and index fingers II rib, sequentially palpate the III, IV, V, etc. ribs along this topographic line. Thus, at the level of which rib the found lower border of the lung is located along this topographic line. Such percussion is carried out along all the above topographic lines and in the previously indicated sequence. The initial position of the plessimeter finger for determining the lower border of the lung is: along the mid-clavicular line - at the level of the II intercostal space, along all axillary lines - at the level of the top of the armpit, along the scapular line - directly under the lower angle of the scapula, along the paravertebral line - from the level awns of the scapula. During percussion along the anterior and posterior topographic lines, the patient's arms should be lowered. During percussion, along all axillary lines, the patient's hands should be folded into a lock over his head. lower lung border along the parasternal, mid-clavicular, all axillary lines and along the scapular line, they are determined in relation to the ribs, along the paravertebral line - in relation to the spinous processes of the vertebrae.
Determination of the lower border of the left lung: percussion definition of the lower border of the left lung is similar to the definition of the borders of the right lung, but with two features. Firstly, its percussion along the peristernal and mid-clavicular lines is not carried out, since this is prevented by cardiac dullness. Percussion is carried out along the left anterior axillary line, left middle axillary line, left posterior axillary line, left scapular line and left paravertebral line. Secondly, percussion along each topographic line stops when a clear lung sound changes to dull along the scapular, paravertebral and posterior axillary lines and to tympanic along the anterior and middle axillary lines. This feature is due to the influence of the gas bubble of the stomach, which occupies the Traube space.
Table. Normal position of the lower borders of the lungs
It should be borne in mind that in hypersthenics, the lower edge may be one rib higher, and in asthenics, one rib below the norm. The displacement of the lower borders of the lungs down (usually bilateral) is observed with acute attack bronchial asthma, emphysema, prolapse of internal organs (splanchnoptosis), asthenia due to muscle weakness abdominals. The displacement of the lower borders of the lungs upward (usually unilateral) is observed with pneumofibrosis (pneumosclerosis), atelectasis (fall) of the lungs, accumulation of fluid or air in the pleural cavity, liver diseases, enlarged spleen; bilateral displacement of the lower boundaries of the lungs is observed with ascites, flatulence, the presence of air in the abdominal cavity (pneumoperitoneum). The boundaries of the lobes of the lungs in the norm with the help of percussion cannot be detected. They can only be determined with a lobar compaction of the lungs (croupous pneumonia). For clinical practice it is useful to know the topography of the shares. As you know, the right lung consists of 3, and the left - of 2 lobes. The boundaries between the lobes of the lungs pass behind the spinous process of the III thoracic vertebra laterally down and anteriorly to the intersection of the IV rib with the back axillary line. So the border goes the same for the right and left lungs, separating the lower and upper lobes. Then, on the right, the border of the upper lobe continues along the IV rib to the place of its attachment to the sternum, separating the upper lobe from the middle one. The border of the lower lobe continues on both sides from the intersection of the IV rib with the posterior axillary line obliquely downward and anteriorly to the point of attachment of the VI rib to the sternum. It separates the upper lobe from the lower lobe in the left lung and the middle lobe from the lower lobe in the right. Thus, to rear surface the lower lobes of the lungs are more adjacent to the chest, in front - the upper lobes, and on the side - all 3 lobes on the right and 2 on the left.