Percussion of the chest Puncture of the chest Dr Tünde Tarr 3rd Dept. of Internal Medicine Physical examination INSPECTIO PALPATIO PERCUSSIO AUSCULTATIO Hystorical background Johann Leopold Auenbrugger (1722-1809) He practised in Vienna. He was the son an innkeeper and had often whitnessed how his father tapped on the various wouden barrels to determine how they full were. He used this tapping method on people by affecting of lung disease, using the sound produced by the tapping to determine the netire of the contents of the chest cavity. He is today regarded as the Founder of „percussion”. TECHNIQUES OF PERCUSSION Souds of percussion Dullnes (muscle, liver, fluid) Resonant (normal lung) Hyperresonant (empysema) Thympany (bowel, stomach) The aim of percussion To determind the border of lung the movement of diaphragma infitration of the lung pleural fluid ptx Percusson of the chest Topographic (to determine the borders of the organs) Comperative (symmetric points of the chest, lung) Anatomy Anterior axillary line anterior, mid-, posterior axillary line Medclavicular line Parasternal line Anatomy Scapular line Paravertebral line Location of percussion Topographic percussion The borders of the lung: Paravert. and scapular line: XI. th. vertebra Midaxillary line: VIII. rib Midclav.: VI. rib (right side) Parasternal: IV. rib (left side) Changing of lung border Lower Emphysema Asthma Enteroptosis Superior: Elevated abdominal pressure Pleural fluid (virtualy) Comperative percussion Compere symmetric points of the chest Changing of the soud of the lung: Dullness Hyperresonance, deeper Thympany Causes of the dullness Something wrong with the lung tissue Infiltration (pneumonia, tumor) atelectasia Something wrong in the chest cavity Exudation Transudation Pus Blood Tumor Causes of thympany sound Pneumothorax Tuberculosis Puncture of the chest Causes of pleural fluid Pleuritis exudativa Pleuropleuritis Heart failure Nephrosis syndrome Empyema Haemothorax Tumor, carcinosis pleurae The aim of chest puncture Therapeutic Diagnostic Rivalta test Cytology Bakterial examination Contraindications No absolut contraindication Relative contraindiction: Uncertain fluid location by examination Minimal fluid volume Altered chest wall anatomy Pulmonary disease severe enough to make complications life threatening Bleeding diathesis or coagulopathy Uncontrolled coughing The technique of puncter Drainage the most deeper fluid Determine the border of the lung Drainage with 2-3 finger above the lung border Between scapular line and posterior axillary line Upper rib (above border) Pleural fluid Serosus (dilute, clear) transudatum exudatum Pus (consistent, cloudy) bloody Transudatum, exudatum Transudatum: dilute, clear, less than 30 g/L protein in it Causes: Heart failure, nephrosis syndrome Exudatum: more protein (40-50 g/L) Rivalta pozitíve!! (acetyl-acid) Causes: pleuritis, tumor Complications Pneumothorax Haemoptysis from lung puncture Re-expansion pulmonary edema or hypotension after rapid removal of large volumes of fluid Hemothorax from damage to intercostal vessels Puncture of the spleen or liver Vasovagal syncope