Methods for performing topographic percussion of the lungs. Normal location of the lower boundaries of the lungs in normosthenics How to determine the boundaries of the lungs

Includes sequential determination of their lower border, mobility of the lower pulmonary edge, standing height and width of the apexes. The determination of each specified parameter is carried out first on one side, and then on the other. In all cases, the pessimeter finger is placed parallel to the determined border of the lung, and the middle phalanx of the finger should lie on the line along which percussion is carried out, in a direction perpendicular to it.

Using quiet percussion blows, they percussion from the area of ​​clear pulmonary sound to the place where it becomes dull (or dull), which corresponds to the border of the lung. Fix the found boundary with a pessimeter finger and determine its coordinates. In this case, the edge of the pessimeter finger facing the area of ​​​​clear pulmonary sound is taken as the border of the organ. In cases where it is necessary to take measurements, it is convenient to use the previously known length or width of the phalanges of your fingers.

The lower border of the lungs is determined by vertical identification lines. The determination begins along the anterior axillary lines, since along the right midclavicular line the lower border of the lung was already found earlier before percussion of the right border of the heart, and the heart is adjacent to the left anterior chest wall.

The doctor stands in front of the patient, asks him to raise his hands behind his head and sequentially percusses along the anterior, middle and posterior axillary lines. The pessimeter finger is placed in the axillary fossa parallel to the ribs and percusses along the ribs and intercostal spaces in the direction from top to bottom until the boundary of the transition of a clear pulmonary sound into a dull one is detected (Fig. 39a).

After this, the doctor stands behind the patient, asks him to lower his arms and similarly percusses along the scapular line, starting from the lower angle of the scapula (Fig. 39b), and then percusses along the paravertebral line from the same level.

It should be borne in mind that determining the lower border of the left lung along the anterior axillary line may be difficult due to the close location of the tympanic sound area in Traube's space.

To indicate the location of the found lower borders of the lungs, ribs (intercostal spaces) are used, which are counted from the collarbone (in men - from the nipple lying on the V rib), from the lower angle of the scapula (VII intercostal space) or from the lowest freely lying XII rib. In practice, it is possible, having determined the localization of the lower border of the lung along the anterior axillary line, to mark it with a dermograph and use this mark as a guide to determine the coordinates of the lower border of this lung along other lines.

The localization of the lower border of the lungs along the paravertebral lines is usually designated relative to the spinous processes of the vertebrae, since the back muscles interfere with palpation of the ribs. When counting the spinous processes of the vertebrae, they are guided by the fact that the line connecting the lower corners of the shoulder blades (with arms down) crosses the VII thoracic vertebra.

Normal location of the lower borders of the lungs in normosthenics

In hypersthenics, the lower borders of the lungs are located one rib higher than in normosthenics, and in asthenics - one rib lower. Uniform descent of the lower borders of both lungs is most often observed with emphysema, less often with pronounced pubescence of the abdominal organs (visceroptosis).

The prolapse of the lower borders of one lung can be caused by unilateral (vicarious) emphysema, which develops as a result of cicatricial wrinkling or resection of the other lung, the lower border of which, on the contrary, is shifted upward. A uniform upward displacement of the lower borders of both lungs is caused by cicatricial wrinkling of both lungs or an increase in intra-abdominal pressure, for example, with obesity, ascites, flatulence.

If fluid accumulates in the pleural cavity (exudate, transudate, blood), the lower border of the lung on the affected side also shifts upward. In this case, the effusion is distributed in the lower part of the pleural cavity in such a way that the boundary between the zone of dull percussion sound above the fluid and the overlying area of ​​​​clear pulmonary sound takes the form of an arcuate curve, the apex of which is located on the posterior axillary line, and the lowest points are located in front - at the sternum and behind - at the spine (Ellis-Damoizo-Sokolov line). The configuration of this line does not change when changing body position.

It is believed that a similar percussion picture appears if more than 500 ml of fluid accumulates in the pleural cavity. However, with the accumulation of even a small amount of fluid in the left costophrenic sinus above Traube's space, instead of tympanitis, a dull percussion sound is determined. With a very large pleural effusion, the upper limit of dullness is almost horizontal or continuous dullness is determined over the entire surface of the lung. Severe pleural effusion can lead to mediastinal displacement. In this case, on the side of the chest opposite to the effusion, in its posteroinferior section, percussion reveals an area of ​​dull sound in the shape of a right triangle, one of the legs of which is the spine, and the hypotenuse is the continuation of the Ellis-Damoiso-Sokolov line to the healthy side (Rauchfuss-Grocco triangle ).

It should be taken into account that unilateral pleural effusion in most cases is of inflammatory origin (exudative pleurisy), while effusion simultaneously into both pleural cavities most often occurs when transudate accumulates in them (hydrothorax).

Some pathological conditions are accompanied by simultaneous accumulation of fluid and air in the pleural cavity (hydropneumothorax). In this case, during percussion on the affected side, the boundary between the area of ​​boxed sound above the air and the area of ​​dull sound above the liquid defined below it has a horizontal direction. When the patient's position changes, the effusion quickly moves to the underlying part of the pleural cavity, so the boundary between air and liquid immediately changes, again acquiring a horizontal direction.

With pneumothorax, the lower border of the box sound on the corresponding side is located lower than the normal border of the lower pulmonary border. Massive compaction in the lower lobe of the lung, for example in lobar pneumonia, can, on the contrary, create a picture of an apparent upward displacement of the lower border of the lung.

The mobility of the lower pulmonary border is determined by the distance between the positions occupied by the lower border of the lung in a state of full exhalation and deep inhalation. In patients with pathology of the respiratory system, the study is carried out along the same vertical identification lines as when establishing the lower boundaries of the lungs. In other cases, we can limit ourselves to studying the mobility of the lower pulmonary edge on both sides only along the posterior axillary lines, where the excursion of the lungs is maximum. In practice, it is convenient to do this immediately after finding the lower boundaries of the lungs along the indicated lines.

The patient stands with his hands raised behind his head. The doctor places a pessimeter finger on the lateral surface of the chest approximately a palm width above the previously found lower border of the lung. In this case, the middle phalanx of the pessimeter finger should lie on the posterior axillary line in a direction perpendicular to it. The doctor asks the patient to first inhale, then exhale completely and hold his breath, after which he percusses along the ribs and intercostal spaces in the direction from top to bottom until the border between a clear pulmonary sound and a dull sound is detected. Marks the found border with a dermograph or fixes it with the finger of the left hand located above the pessimeter finger.

Next, he asks the patient to take a deep breath and hold his breath again. In this case, the lung descends and below the border found on exhalation, an area of ​​​​clear lung sound again appears. Continues to percuss from top to bottom until a dull sound appears and fixes this boundary with a pessimeter finger or makes a mark with a dermograph (Fig. 40).

By measuring the distance between the two boundaries found in this way, the amount of mobility of the lower pulmonary edge is found. Normally it is 6-8 cm.

Reduced mobility of the lower pulmonary border on both sides in combination with drooping of the lower borders is characteristic of pulmonary emphysema. In addition, a decrease in the mobility of the lower pulmonary edge can be caused by damage to the lung tissue of inflammatory, tumor or scar origin, pulmonary atelectasis, pleural adhesions, dysfunction of the diaphragm, or increased intra-abdominal pressure. In the presence of pleural effusion, the lower edge of the lung, compressed by fluid, remains motionless during breathing. In patients with pneumothorax, the lower limit of the tympanic sound on the affected side during breathing also does not change.

The height of the apex of the lungs is determined first from the front and then from the back. The doctor stands in front of the patient and places a pessimeter finger in the supraclavicular fossa parallel to the collarbone. It percusses from the middle of the clavicle upward and medially towards the mastoid end of the sternocleidomastoid muscle, displacing the pessimeter finger by 0.5-1 cm after each pair of percussion blows and maintaining its horizontal position (Fig. 41a).

Having discovered the border between the transition of a clear pulmonary sound into a dull one, he fixes it with a pessimeter finger and measures the distance from its middle phalanx to the middle of the clavicle. Normally, this distance is 3-4 cm.

When determining the standing height of the apexes of the lungs from behind, the doctor stands behind the patient, places a pessimeter finger directly above the spine of the scapula and parallel to it. It percusses from the middle of the spine of the scapula upward and medially towards the mastoid end of the sternocleidomastoid muscle, displacing the pleximeter finger by 0.5-1 cm after each pair of percussion blows and maintaining its horizontal position (Fig. 41b). The found boundary of the transition of a clear pulmonary sound into a dull sound is recorded with a pleximeter finger and the patient is asked to tilt his head forward so that the most posteriorly protruding spinous process of the VII cervical vertebra is clearly visible. Normally, the apexes of the lungs behind should be at its level.

The width of the apexes of the lungs (Kroenig's fields) is determined by the slopes of the shoulder girdles. The doctor stands in front of the patient and places the pessimeter finger in the middle of the shoulder girdle so that the middle phalanx of the finger lies on the anterior edge of the trapezius muscle in a direction perpendicular to it. Maintaining this position of the finger-pessimeter, he first percusses towards the neck, shifting the finger-pessimeter by 0.5-1 cm after each pair of percussion blows. Having discovered the boundary of the transition of a clear pulmonary sound into a dull one, he marks it with a dermograph or fixes it with a finger of the left hand located more medially finger-pessimeter.

Then, in a similar way, he percusses from the starting point in the middle of the shoulder girdle to the lateral side until a dull sound appears and fixes the found border with a plessimeter finger (Fig. 42). By measuring the distance between the internal and external percussion boundaries determined in this way, one finds the width of Krenig’s fields, which is normally 5-8 cm.

An increase in the height of the apex is usually combined with an expansion of Kroenig's fields and is observed with pulmonary emphysema. On the contrary, the low standing of the apices and the narrowing of Kroenig's fields indicate a decrease in the volume of the upper lobe of the corresponding lung, for example, as a result of its scarring or resection. In pathological processes leading to compaction of the apex of the lung, a dull sound is detected above it already with comparative percussion. In such cases, determining the height of the top and the width of the Krenig fields from this side is often impossible.

When examining the respiratory organs, the tasks of topographic percussion are as follows:

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

1. Percussion should be done moving from a clear pulmonary sound to a dull one. Beginners should percussion only along the intercostal spaces, since percussion along the ribs increases the percussion area and complicates the examination. With the accumulation of experience, you can percussion in a row - both along the intercostal spaces and along the ribs, moving the plessimeter finger 1 - 1.5 cm or a finger's width down.
2. The pessimeter finger is always positioned parallel to the edge of the lung being examined.
3. Given the superficial location of the edge of the lung and its small thickness, quiet percussion is used. The exception is percussion of the apexes of the lungs from behind and determination of shi
   rins of Kroenig fields, where loud percussion is used due to the thick layer of muscle.
4. The determination of the lower borders of the lung begins with the installation of a palid-pessimeter 2-3 ribs above (the width of the palm) the expected position of the edge, taking into account the data of comparative percussion.
5. Moving the finger down ends at the level of an absolutely dull sound, and the mark of the border of the lung is made on the side of the finger from the side of the pulmonary sound, that is, along the upper edge of the plessimeter.
6. The patient's position during percussion should be standing or sitting; if the study is performed lying down, then one must remember about the passive displacement of the lower borders of the lungs.

Rice. 295. Determination of the lower boundaries of the lungs from the front.
Percussion is carried out along vertical topographic lines, on the right it starts from the third intercostal space, on the left - from the second intercostal space.

Rice. 296. Determination of the lower borders of the lungs from behind and determination of the mobility of the lower border of the lungs on the left and right
Percussion starts from the level of the middle or lower third of the scapula. Mobility of the lower edge is determined along the scapular and posterior axillary lines

air and airless organs (lungs - liver), and this greatly facilitates the detection of the difference in percussion sound at the border of the organs. Then the left side is percussed. The boundaries of the lungs are determined along all topographic lines; the pessimeter finger is installed so that the middle of the second phalanx falls on the line.
Determining the lower borders of the left lung, especially along the midclavicular and anterior axillary lines, is difficult due to adjacent organs containing gas - the stomach, intestines, which give a tympanic sound upon percussion. It is difficult to establish the boundary between pulmonary sound and tympanitis; fine hearing and great skill are required. Determination of the lower border on the left usually begins with the anterior axillary line, then moves from the lateral surface to the posterior surface of the chest. However, one must learn to determine the edge of the lung along the parasternal line, remembering that due to the cardiac notch it lies on the 4th rib, while on the right it is on the 6th rib.

Having completed percussion along a certain topographic line, the found border is marked with a dot with an iodine swab, chalk or felt-tip pen. By connecting the dots along all the lines, you can get a holistic picture of the position of the lower borders of the lungs on both sides.
The position of the lower borders of the lungs depends on the type of constitution. In table 9 we present data for normosthenics.
Table 9. Position of the lower fania of the lungs in a normosthenic

In persons with a hypersthenic constitution, the level of the edges of the lungs lies one rib higher, in asthenics - one rib lower than in normosthenics.
With obesity, pregnancy, and bloating, the lower boundaries of the lungs shift upward. In women who have given birth many times, in women who are thin, and also due to weakness of the abdominal wall, decreased intra-abdominal pressure and prolapse of internal organs, the lower borders of the lungs descend.
Pulmonary and other diseases accompanied by a decrease or increase in lung volume lead to a displacement of their boundaries up or down. This is possible on both sides, or on one side, or in a limited area.
Bilateral drooping of the borders is observed with swelling of the lungs - an attack of bronchial asthma, chronic pulmonary emphysema, as well as with visceroptosis. One-sided downward displacement of the fans is observed in vicarious emphysema, that is, swelling of a healthy lung after the removal of another or its exclusion from the act of breathing for various reasons.
us* inflammation, collapse, sclerosis, wrinkling. False displacement of the lower border of the lung on the affected side is possible with pneumothorax.
A shift of the lower borders of the lung upward on one side is caused by shrinkage of the lung, accumulation of fluid in the pleural cavity, lobar inflammation, atelectasis, and scarring in the pleura. Bilateral upward displacement of the boundaries occurs with ascites, a large tumor or cyst of the abdominal cavity, paralysis of the diaphragm, and severe bloating.
In addition to changes in the position of the lower edges of the lungs, displacement of the edge of the lung in the area of ​​the cardiac notch is possible. When the lungs are inflated, the edge moves down, the area of ​​the cardiac notch decreases. Wrinkling of the lung, an increase in the size of the heart, accumulation of fluid in the pericardium leads to an upward displacement of the edge of the lung, and the area of ​​the cardiac notch increases.
Percussion of the apexes of the lungs. It presents some technical difficulties due to their small size and the thick layer of muscles above them at the back. The height of the tops in front and behind and their width are determined. Quiet percussion is used in front, loud percussion is used in back. Patient xuyi! or sitting. When performing an examination from the front, the plessimeter finger can be installed in three ways (Fig. 297).

Rice. 297. Determination of the height of the apex in front, on the right - by the method of fan-shaped percussion, on the left - by percussion along the midclavicular line.

First (left tip) - the finger is placed above the collarbone parallel to its edge, the middle of the phalanx should be at the level of the middle of the collarbone. During percussion, the pessimeter finger gradually (0.5-1 cm) moves upward to the slope of the shoulder, adhering to the midclavicular line, until a dull sound appears. The mark is made on the side of the clear pulmonary sound.
The second option (right apex) - the pessimeter finger is installed in the same position, but only the final phalanx should be directed outward, both to the left and to the right. Further, during percussion, the finger gradually moves upward towards the outer edge of the sternocleidomastoid muscle, that is, up and slightly inward from the midclavicular line (like a fan). The pole of the apex is located here. The measurement is taken from the found pole to the collarbone. The height of the apex on the right is 3-4 cm above the collarbone, on the left - 3-5 cm, yes, the right apex is normally located slightly lower than the left.
The third option for determining the front height of the apex is shown in Fig. 298.
When percussing the apexes from behind, it is better to sit the patient down. Loud percussion is used due to the large thickness of the muscles. The plessimeter finger is installed in the middle of the supraspinatus fossa with the terminal phalanx outward (Fig. 298). By moving 0.5-1 cm, it moves in the direction of the VII cervical vertebra, the location of which is easy to determine by tilting the patient’s head forward. But it is better to mark an approximate point of 3-4 cm before percussion


Rice. 298. Determination of the standing height of the apexes of the lungs. In the front - percussion is similar to a fan-shaped one, but the position of the finger is horizontal, parallel to the collarbone. Posteriorly - placing the finger in the supraspinatus fossa parallel to the spine, then perpendicular to the slope of the shoulder

away from the apex of the VII cervical spinous process and percussion towards it until a dull sound appears. Normally, the posterior pole of the apex is located at the level of the VII cervical vertebra,
at the same time, the right top, as in the front, is slightly lower than the left. The position of the apexes, as well as the level of the lower edges of the lungs, depends on the type of constitution.
Upward displacement of the apexes of the lungs is most often observed in pulmonary emphysema and bronchial asthma. Elevation of the diaphragm (pregnancy, obesity, bloating, ascites) has little effect on the level of the apex.
A decrease in the height of the apex is often unilateral and is associated with shrinkage of the lung, inflammation, tumor, obstructive atelectasis, surgical intervention on the lung - resection of a lobe, lung.
A more complete picture of the condition of the tops can be obtained by examining the Kroenig fields (Fig. 299). The Kroenig field is a projection of the apexes onto the surface of the body. It is a strip of pulmonary sound 3-8 cm wide, narrower on the right than on the left by 1 - 1.5 cm. Usually they limit themselves to determining the width of the Kroenig field, examining it along the upper edge of the trapezius muscle in the patient’s sitting position. The doctor is behind during percussion. The pessimeter finger is placed across the edge of the trapezius muscle, in the middle of the apex, and loud percussion is used. First, the finger moves in the medial direction until a dull sound is obtained, then from the starting point towards the shoulder joint, also until a dull sound appears.

Rice. 299. Determination of the width of the Krenig field.

The level of the tops and the width of the Krenig fields are interconnected; a high position of the tops leads to an expansion of the fields, a low position leads to a narrowing of the fields.
Determination of mobility of the lower edges of the lungs. There are active and passive mobility. Active mobility is the displacement of the edges of the lungs due to their elasticity during deep inhalation and full exhalation. Passive mobility is a downward displacement of the edge of the lung in a horizontal position of the body due to a decrease in intra-abdominal pressure and compression of the abdominal organs.
During the active mobility study, the patient and the doctor are in the same position as when determining the lower edge of the lung. Quiet percussion is used. The determination of active mobility is carried out along all topographic lines, however, after developing the research technique, for practical purposes it is enough to limit oneself to three lines - midclavicular, middle axillary and scapular, and as an indicative study - in the places of greatest mobility of the edges, that is, along the middle or posterior axillary lines where mobility is most often limited due to adhesions in the pleural cavity
The pessimeter finger is placed on the softly found border of the lower edge of the lung. The patient is asked to inhale as much as possible, hold his breath and immediately percuss downwards until a dull sound appears, moving 0.5-1 cm. Having stopped at the level of the dull sound, a mark is made at the finger on the side of the pulmonary sound. If you have sufficient percussion skill, then immediately after determining the boundary, the patient is commanded to exhale as much air as possible, after which the doctor immediately continues to percussion upward until a pulmonary sound appears. Once you have finished percussing, remember to tell the patient to breathe as usual. The described technique requires quickness, clear and quick movements.
However, during the period of mastering the technique, it is better to use the following technique. After determining the downward displacement of the edge of the lung and establishing a mark, the patient is immediately allowed to breathe as usual. At this time, the pessimeter finger moves upward above the previously found border of the lungs to the width of the palm. Next, the patient is asked to take 2-3 moderately deep breaths, and then exhale deeply and hold his breath as much as possible. From the moment of exhalation, the doctor percusses downwards from a clear pulmonary sound until
stupidity. A mark is made at the finger on the side of the clear pulmonary sound, then the distance between the marks is measured. This technique is more convenient in that you have to percuss from a clear pulmonary sound to a dull one, the boundary between which the ear perceives better than when moving from dull to pulmonary. Here are the figures for the general (inhalation + exhalation) mobility of the lower edges of the lungs along the main lines:
midclavicular - 5-6 cm, middle axillary - 6-8 cm, scapular - 4-6 cm.
Passive mobility of the lower edge of the lungs is examined in 2 stages. First, the position of the lower edge of the lung is determined during quiet breathing while standing, and a mark is made. Then the patient is placed on the couch and the border of the lower edge of the lung is again determined from the initial level. With the patient lying on his back, the edge of the lung along the midclavicular line drops by about 2 cm; in the position on his side, with percussion along the mid-axillary line, the edge drops by 3-4 cm.
High rates of mobility of the lower edges of the lungs indicate a good condition of the respiratory system and good elasticity of the lungs. Restricted mobility of the lower edges of the lungs, and sometimes complete absence, indicate trouble due to either extrapulmonary or pulmonary causes. Poor mobility of the lung edge can be detected on both sides or on one side.
Extrapulmonary causes include pathology of the chest wall, pleura, respiratory muscles and high intra-abdominal pressure. Restricted mobility of the lower edge of the lungs is often associated with impaired ventilation of the lungs due to pain from chest trauma, rib fractures, myositis, intercostal neuralgia, and also due to inflammation of the pleura (dry pleurisy). Poor ventilation of the lungs occurs with ossification of the costovertebral joints, with weakness of the respiratory muscles (myasthenia gravis), diaphragmatitis, and paralysis of the diaphragm. Restriction of the mobility of the lower edges of the lungs occurs when the diaphragm is high due to high intra-abdominal pressure (obesity, flatulence, ascites).
The mobility of the lower edges of the lungs becomes limited as a result of pulmonary processes manifested by:

• impaired elasticity of the alveoli (acute swelling of the alveoli, chronic emphysema);
• decreased lung compliance due to diffuse or local pulmonary fibrosis;
• a decrease in the respiratory surface of the lungs with lobar pneumonia, tuberculosis, obstructive atelectasis, tumor, cystic hypoplasia of the lungs, after lobectomy.

• about the presence of interpleural adhesions;
• about the accumulation of fluid in the pleural sinuses;
• pneumothorax;
• about the pathology of the diaphragm.

Using topographic percussion, the standing height (upper borders) of the apexes of the lungs, the width of the Krenig fields, the lower borders of the lungs and the mobility of the lower edges of the lungs are determined.

To determine the height of the apexes (front and back) and the width of the Krenig fields, quiet percussion is used, since with loud percussion of the apices of the lungs, which have a small volume, the percussion blow will spread to the lower parts of the lungs, as a result of which the zone of clear pulmonary sound will be larger than In fact.

When determining the height of the apex of the lungs from the front, a pessimeter finger is placed in the supraclavicular region parallel to the clavicle. Percussion is carried out from the middle of the collarbone, gradually moving the finger up and inward (along the scalene muscles of the neck) until a clear pulmonary sound transitions into a dull one. A mark about the found boundary is made with a special dermograph (and not a ballpoint pen) along the edge of the pessimeter finger facing towards the clear sound (i.e., along the bottom). Normally, the apexes of the lungs are located in front 3–4 cm above the level of the collarbone, and the apex of the left lung protrudes above the collarbone somewhat more than the apex of the right lung.

When determining the height of the posterior apexes of the lungs (in relation to the level of the spinous process of the VII cervical vertebra), the pessimeter finger is placed horizontally in the supraspinatus fossa and percussion is carried out from the middle of the scapula. Here, students often make a mistake in determining the direction of percussion, choosing the spinous process of the VII cervical vertebra as a guide. Meanwhile, percussion should be directed not to the spinous process of the VII cervical vertebra, but towards a point located 3–4 cm lateral to the spinous process. A mark about the found boundary is made at the place where the clear pulmonary sound transitions into a dull sound, also along the edge of the finger facing towards the clear sound. Normally, the apexes of the lungs should be located approximately at the level of the spinous process of the VII cervical vertebra (slightly lower on the right than on the left).

Kroenig's fields are peculiar zones (“stripes”) of clear pulmonary sound located between the clavicle and the spine of the scapula, divided into anterior and posterior parts by the upper edge of the trapezius muscle. When determining them, stand behind the patient, place the plessimeter finger perpendicular to the middle of the upper edge of the trapezius muscle and percussion along it to the medial (towards the neck) and lateral (towards the head of the humerus) sides, marking along the edge of the finger facing the side of the clear sound, the place where the clear pulmonary sound transitions to dull. Normally, the width of Kroenig’s fields averages 5–6 cm.

Determination of the lower boundaries of the lungs (first the right and then the left) is carried out as follows. The lower border of the right lung in front is determined along the parasternal and midclavicular lines, starting from the second intercostal space. After this, the patient turns on his right side and puts his right hand behind his head. In this position, starting from the armpit, percussion is continued sequentially along the anterior, middle and posterior axillary lines. Another slight turn of the patient makes it possible, starting from the angle of the scapula, to complete the determination of the lower border of the right lung from behind (along the scapular and paravertebral lines). A mark about the found boundary is made at the point where the clear pulmonary sound transitions into a dull sound along the edge of the finger facing towards the clear sound.

The lower border of the left lung, established on the basis of the transition of a clear pulmonary sound into a dull sound of splenic dullness, begins to be determined along the anterior axillary line, since along the left parasternal line the lower border of the left lung seems to “break off” on the IV rib due to the dullness of the heart appearing here, and the precise determination of the lower border of the lung along the left midclavicular line is hampered by the tympanic sound of Traube’s space, adjacent here to the diaphragm. The tympanic shade of percussion sound, caused by the Traube space zone, sometimes makes it difficult to accurately determine the lower border of the left lung, even along the anterior axillary line. Determination of the lower border of the left lung along the remaining lines is carried out in the same way as determining the lower border of the right lung.

Topographic percussion, carried out with the aim of determining the lower boundaries of the lungs only along the intercostal spaces, will in itself give a very large error, since each subsequent insertion of a finger into the next intercostal space (i.e., a kind of “percussion step”) has, so to speak, a “price” divisions" of at least 3 - 4 cm (unacceptably high for topographic percussion). For example, by determining the lower border of the lungs only along the intercostal spaces, we will never be able to obtain the border of the right lung in the fifth intercostal space or along the upper edge of the VI rib (the normal position of the lower border of the right lung along the right parasternal line), since for this purpose the finger-pessimeter at the moment of termination percussion should be located directly on the VI rib. Therefore, starting from the level of the possible location of the lower border (for example, from the level of the fourth intercostal space when percussing along the right parasternal line), you need to percussion, going down each time by the width of a pessimeter finger. Such a small “percussion step” is the key to obtaining correct results with topographic percussion in general.

When determining the lower boundaries of the lungs, it is also necessary to ensure that the patient’s breathing during percussion is even and shallow. Often patients, sometimes without noticing it themselves, hold their breath, believing that by doing so they make it easier to find the desired boundaries. Depending on what phase of breathing (inhalation or exhalation) the delay occurred, the lower boundaries of the lungs may appear respectively higher or lower than the true ones. When assessing the results obtained, the patient’s body type must also be taken into account.

Determination of the mobility of the lower edges of the lungs is carried out on the right along three lines (midclavicular, middle axillary and scapular), and on the left - along two (middle axillary and scapular). After establishing the lower border of the lungs along the corresponding topographic line with quiet breathing, ask the patient (if his condition allows) to take the deepest possible breath and hold his breath, after which they continue percussion along the same line from top to bottom until the clear pulmonary sound transitions into a dull one and make a new mark along the edge of the pessimeter finger facing towards the clear sound (i.e. along the upper edge of the finger). Without lifting the pessimeter finger, ask the patient to exhale as deeply as possible and percussion along the same line, but in the direction from bottom to top until the dull sound transitions into a clear pulmonary sound. The third mark is made along the edge of the finger facing the dull sound (i.e., along the lower edge of the finger).

The distance (in cm) between the middle and lower marks will correspond to the mobility of the lower edge of the lungs during the inhalation phase, and the distance between the middle and upper marks will correspond to the mobility of the lower edge of the lungs during the exhalation phase. By adding up the found values, we will find the total (maximum) mobility of the lower edge of the lungs.

It should be noted that when determining the mobility of the lower edges of the lungs, we are faced with a rare exception to the rule, according to which topographic percussion is carried out in the direction from dull sound to clear sound with a boundary mark along the edge of the finger facing towards the dull sound. This exception was made to a certain extent in order to save time and more quickly conduct this study, taking into account that the patient (especially in the exhalation phase) cannot hold his breath for a very long time. In this regard, all actions to determine the mobility of the lower edge of the lungs and apply the appropriate marks must be very clear and prompt. If for some reason an unexpected hitch occurs, it is better to ask the patient to “catch his breath” and then continue the study.

Topographic percussion of the lungs is normal:

Lower borders of the lungs:

Parasternal line Upper edge of the 6th rib –

Midclavicular line Lower edge of the 6th rib –

Anterior axillary Lower edge of the VII rib

Middle axillary Upper edge of the VIII rib

Posterior axillary Lower edge of the VIII rib

Scapular line IX rib

Paravertebral Spinous process of the XI thoracic vertebra

Mobility of the lower 6 – 8 cm

In hypersthenics, the lower borders of the lungs are located one rib higher than in normosthenics, and in asthenics - one rib lower. Uniform prolapse of the lower borders of both lungs is most often observed with emphysema, less often with pronounced prolapse of the abdominal organs (visceroptosis). A drooping of the borders of one lung can be caused by unilateral (vicarious) emphysema, which develops as a result of cicatricial wrinkling or resection of the other lung, the lower border of which, on the contrary, is shifted upward. A uniform upward displacement of the lower borders of both lungs is caused by cicatricial wrinkling of both lungs or an increase in intra-abdominal pressure, for example in obesity, ascites, and flatulence.

If fluid accumulates in the pleural cavity (exudate, transudate, blood), the lower border of the lung on the affected side also shifts upward. In this case, the effusion is distributed in the lower part of the pleural cavity in such a way that the boundary between the zone of dull percussion sound above the fluid and the overlying area of ​​​​clear pulmonary sound takes the form of an arcuate curve, the apex of which is located on the posterior axillary line, and the lowest points are located in front - at the sternum and behind - at the spine (Ellis-Damoizo-Sokolov line). The configuration of this line does not change when changing body position. It is believed that a similar percussion picture appears if more than 500 ml of fluid accumulates in the pleural cavity. However, with the accumulation of even a small amount of fluid in the left costophrenic sinus above Traube's space, instead of tympanitis, a dull percussion sound is determined. With a very large pleural effusion, the upper limit of dullness is almost horizontal or continuous dullness is determined over the entire surface of the lung. Severe pleural effusion can lead to mediastinal displacement. In this case, on the side of the chest opposite to the effusion, in its posteroinferior section, percussion reveals an area of ​​dull sound in the shape of a right triangle, one of the legs of which is the spine, and the hypotenuse is the continuation of the Ellis-Damoiso-Sokolov line to the healthy side (Rauchfuss-Grocco triangle ). It should be taken into account that unilateral pleural effusion in most cases is of inflammatory origin (exudative pleurisy), while effusion simultaneously into both pleural cavities most often occurs when transudate accumulates in them (hydrothorax).

Some pathological conditions are accompanied by simultaneous accumulation of fluid and air in the pleural cavity (hydropneumothorax). In this case, during percussion on the affected side, the boundary between the area of ​​boxed sound above the air and the area of ​​dull sound above the liquid defined below it has a horizontal direction. When the patient's position changes, the effusion quickly moves to the underlying part of the pleural cavity, so the boundary between air and liquid immediately changes, again acquiring a horizontal direction.

With pneumothorax, the lower border of the box sound on the corresponding side is located lower than the normal border of the lower pulmonary border. Massive compaction in the lower lobe of the lung, for example in lobar pneumonia, can, on the contrary, create a picture of an apparent upward displacement of the lower border of the lung.

Mobility of the lower pulmonary border determined by the distance between the positions occupied by the lower border of the lung in a state of full exhalation and deep inhalation. In patients with pathology of the respiratory system, the study is carried out along the same vertical identification lines as when establishing the lower boundaries of the lungs. In other cases, we can limit ourselves to studying the mobility of the lower pulmonary edge on both sides only along the posterior axillary lines, where the excursion of the lungs is maximum. In practice, it is convenient to do this immediately after finding the lower boundaries of the lungs along the indicated lines.

The patient stands with his hands raised behind his head. The doctor places a pessimeter finger on the lateral surface of the chest approximately a palm width above the previously found lower border of the lung. In this case, the middle phalanx of the pessimeter finger should lie on the posterior axillary line in a direction perpendicular to it. The doctor asks the patient to first inhale, then exhale completely and hold his breath, after which he percusses along the ribs and intercostal spaces in the direction from top to bottom until the border between a clear pulmonary sound and a dull sound is detected. Marks the found border with a dermograph or fixes it with the finger of the left hand located above the pessimeter finger. Next, he asks the patient to take a deep breath and hold his breath again. In this case, the lung descends and below the border found on exhalation, an area of ​​​​clear lung sound again appears. Continues to percuss from top to bottom until a dull sound appears and fixes this boundary with a pessimeter finger or makes a mark with a dermograph (Fig. 7). By measuring the distance between the two boundaries found in this way, the amount of mobility of the lower pulmonary edge is found. Normally it is 6-8 cm.

Rice. 7. Scheme of percussion determination of the mobility of the lower pulmonary edge along the right posterior axillary line: arrows indicate the direction of movement of the pessimeter finger from the initial position:

- the lower border of the lung during full exhalation;

- lower border of the lung during deep inspiration

Reduced mobility of the lower pulmonary border on both sides in combination with drooping of the lower borders is characteristic of pulmonary emphysema. In addition, a decrease in the mobility of the lower pulmonary edge can be caused by damage to the lung tissue of inflammatory, tumor or scar origin, pulmonary atelectasis, pleural adhesions, dysfunction of the diaphragm, or increased intra-abdominal pressure. In the presence of pleural effusion, the lower edge of the lung, compressed by fluid, remains motionless during breathing. In patients with pneumothorax, the lower limit of the tympanic sound on the affected side during breathing also does not change.

Height of the apex of the lungs determined first from the front and then from the back. The doctor stands in front of the patient and places a pessimeter finger in the supraclavicular fossa parallel to the collarbone. It percusses from the middle of the clavicle upward and medially towards the mastoid end of the sternocleidomastoid muscle, displacing the pessimeter finger by 0.5-1 cm after each pair of percussion blows and maintaining its horizontal position (Fig. 8, a). Having discovered the border between the transition of a clear pulmonary sound into a dull one, he fixes it with a pessimeter finger and measures the distance from its middle phalanx to the middle of the clavicle. Normally, this distance is 3-4 cm.

When determining the standing height of the apexes of the lungs from behind, the doctor stands behind the patient, places a pessimeter finger directly above the spine of the scapula and parallel to it. It percusses from the middle of the spine of the scapula upward and medially towards the mastoid end of the sternocleidomastoid muscle, displacing the pleximeter finger by 0.5-1 cm after each pair of percussion blows and maintaining its horizontal position (Fig. 8, b). The found boundary of the transition of a clear pulmonary sound into a dull sound is recorded with a pleximeter finger and the patient is asked to tilt his head forward so that the most posteriorly protruding spinous process of the VII cervical vertebra is clearly visible. Normally, the apexes of the lungs behind should be at its level.

Rice. 8. Initial position of the pessimeter finger and the direction of its movement during percussion determination of the height of the apex of the right lung in front (a) and behind (b)

Width of the apices of the lungs (Kroenig fields) determined by the slopes of the shoulder girdles. The doctor stands in front of the patient and places the pessimeter finger on the middle of the shoulder girdle so that the middle phalanx of the finger lies on the anterior edge of the trapezius muscle in a direction perpendicular to it. Maintaining this position of the finger-pessimeter, he first percusses towards the neck, shifting the finger-pessimeter by 0.5-1 cm after each pair of percussion blows. Having discovered the border between the transition of a clear pulmonary sound into a dull one, he marks it with a dermograph or fixes it with a finger of the left hand located more medially finger-pessimeter. Then, in a similar way, he percusses from the starting point in the middle of the shoulder girdle to the lateral side until a dull sound appears and fixes the found border with a plessimeter finger (Fig. 9). By measuring the distance between the internal and external percussion boundaries determined in this way, one finds the width of Krenig’s fields, which is normally 5-8 cm.

Rice. 9. Initial position of the pessimeter finger and the direction of its movement during percussion determination of the width of the Krenig fields

An increase in the height of the apex is usually combined with an expansion of Kroenig's fields and is observed with pulmonary emphysema. On the contrary, the low standing of the apices and the narrowing of Kroenig's fields indicate a decrease in the volume of the upper lobe of the corresponding lung, for example, as a result of its scarring or resection. In pathological processes leading to compaction of the apex of the lung, a dull sound is detected above it already with comparative percussion. In such cases, determining the height of the top and the width of the Krenig fields from this side is often impossible.

It is used to determine the boundaries of the lungs, the width of the apexes of the lungs (Kroenig's fields), and the mobility of the lower edge of the lungs. First, the lower boundaries of the lungs are determined. Percussion is carried out from top to bottom along symmetrical topographic lines on the left and right (Fig. 23). However, on the left it is usually not determined by two lines - parasternal (parasternal) and midclavicular. In the first case, this is due to the fact that the border of relative cardiac dullness begins from the third rib on the left and, thus, this level does not reflect the true border of the lung. As for the midclavicular line, determining the lower border of the lung along it is difficult due to tympanitis above Traube’s space (a gas bubble in the area of ​​the vault of the stomach). When determining the lower boundaries, a plessimeter finger is placed in the intercostal spaces parallel to the ribs, moving it down until the sound is dull. The latter is formed during the transition from the lower edge of the lung to the diaphragm and hepatic dullness. The boundary mark is drawn along the edge of the finger facing the clear sound.

In normosthenics, the lower border of the lungs has the following location.

Since percussion is carried out along the intercostal spaces, to clarify the border of the lungs it is necessary to double-check it along the ribs.

To determine the height of the apex in front, a finger-pessimeter is placed in the supraclavicular fossa parallel to the clavicles and, along the course of percussion, is moved upward and medially towards the scalene muscles. Normally, the height of the apex in front is 3-4 cm above the collarbones, while the left apex is often located 0.5-1 cm higher than the right.

Rice. 23. Determination of the lower border of the right lung.

To determine the height of the apexes from behind, a finger-pessimeter is placed parallel to the spines of the scapula and percussed upward and inward towards the spinous process of the VII cervical vertebra (Fig. 24).

Normally, the apexes at the back are on a line passing through this process. The width of the apexes, or Krenig's fields, is determined by percussion along the anterior edge of m. trapecius. To do this, a plessimeter finger is placed in the middle of this muscle perpendicular to its edge, and then percussed inward and outward until dull. Normally, the width of Krenig’s fields is 5-6 cm, but can vary depending on the type of constitution from 3 to 8 cm.

The height and width of the apices most often increases with emphysema, while their decrease is noted with shrinking processes in the lungs: tuberculosis, cancer, pneumosclerosis.

Rice. 24 Determination of the standing height of the apexes of the lungs from behind and in front.

Most often, changes occur in the lower border of the lungs. Its bilateral descent occurs during an attack of bronchial asthma or chronic pulmonary emphysema. A unilateral downward displacement can occur with replacement emphysema of one lung against the background of the other being switched off from the act of breathing. This happens with exudative pleurisy, hydrothorax, pneumothorax.

An upward displacement of the lower border is often unilateral and occurs when: shrinkage of the lung due to pneumosclerosis or cirrhosis; obstructive atelectasis due to complete blockage of the lower lobe bronchus by a tumor; accumulation of fluid or air in the pleural cavity, which pushes the lungs upward; a sharp enlargement of the liver or spleen. With severe ascites and flatulence, at the end of pregnancy there may be a confusion of the lower border of the lungs on both sides.

The mobility of the lower edge of the lung is determined by percussion of the lower border of the lung during deep inspiration and deep exhalation. This is usually done along three topographic lines on the right (midclavicular, middle axillary and scapular) and two lines on the left (middle axillary and scapular). First, the lower border of the lungs is determined along the indicated lines during quiet breathing, then after a deep inhalation and breath-holding, percussion continues downward until dullness and a second mark is made. After this, the patient is asked to hold his breath while exhaling deeply (in this case, the edge of the lung moves upward) and the new position of the lower edge of the lung is also determined by percussion from top to bottom. This means that in any situation it is better to determine the lower edge of the lung by percussing from a clear lung sound to dullness or dullness. Normally, the mobility of the lower edge of the lung along the right midclavicular and scapular lines is 4-6 cm (2-3 cm each on inhalation and exhalation), along the middle axillary lines - 8 cm (3-4 cm each on inhalation and exhalation).