RATTLES

From Big Medical Encyclopedia

HRYPY (rhonchi) — the additional respiratory noise arising in pneumatic space of respiratory tracts of lungs at pathology.

Rattles are formed in the presence in bronchial tubes, air cells or patol. cavities (cavities, bronchiectasias, etc.) liquid contents; at disturbance of bronchial passability (as a result of a spasm of a bronchial tube, swelling of his mucous membrane, obturation a tumor); as a result of a raspravleniye of the fallen-down parenchyma of a lung in a zone of its structural changes or prelums.

Rattles reveal and investigate by auscultation (see) a thorax in the course of breath of the patient. During the listening of rattles consistently apply a stethoscopic, then fonendoskoii-chesky head of a stetofonendoskop in the beginning, at the same time by means of a stethoscopic head rattles with the characteristic frequency range below 500 Hz, and a fonendoskopi-chesky head are better listened — it is higher than 500 Hz. At auscultation of the patient if his state allows, is in a standing position or sitting and if necessary changes position of a body. Listening of lungs (see) is made posegmentno, it is symmetric from each party, at randomly profound breath with breaks in order to avoid development in the patient of a hypocapny (see) owing to a hyperventilation. At difficulties in identification or assessment of rattles their research is supplemented with auscultation of lungs in the different modes of breath, before and after cough, and if necessary before introduction pharmakol. the means influencing mechanisms of formation of rattles.

On the mechanism of education and sound perception rattles subdivide on wet and dry. On the extent of listening over pulmonary fields rattles can be local, i.e. be defined over the certain limited site in a projection of one segment or a lung lobe (see Lungs); disseminated — over several certain sites of one or both lungs and extended — over extensive sites of a thorax in a projection of several shares. Rattles characterize on their caliber, a timbre, sonority, noting usually uniformity or heterogeneity of caliber and sonority in places of their listening, and also the number of rattles (single, multiple, plentiful) and change of these characteristics under the influence of depth of breath, cough, a postural change of a body. The versatile, including acoustic characteristic of rattles has important diagnostic value for recognition of various forms of bronchopulmonary pathology or pulmonary displays of heart failure.

Wet rattles are caused by accumulation in respiratory tracts or in reported with them patol. cavities of liquid (exudate, transudate, bronchial secret, blood). During a breath air passes through this liquid, forming bubbles, as if making foam it. The sound arising at a rupture of air traps on the surface of liquid is heard at auscultation as rattles. Wet rattles are listened preferential on a breath when foaming is promoted by not only high speed of an air flow, but also falling of intracavitary pressure. Sometimes wet rattles are listened also on an exhalation. The size of the formed air traps depends on caliber of bronchial tubes or the sizes ttatol. cavities, in to-rykh rattles are formed. As a result wet rattles differ on caliber and average are characterized as large, or small-bubbling. The timbre and sonority of wet rattles are defined by acoustic properties of space, in Krom they are formed, and also the Wednesday which is carrying out a sound on a chest wall. Sonorous rattles with a ringing timbre are formed, e.g., in resonant cavities, especially gladkosteniy, in the center which is located near a gas bubble of a stomach or in the condensed parenchyma of a lung.

Small-bubbling wet rattles arise in alveoluses, terminal bronchioles and the smallest bronchial tubes in the presence in them liquid. Frequency range of not sonorous small-bubbling rattles usually is in limits of 180 — 355 Hz; they are well listened and remind noise of the bursting bubbles in a glass of soda water. Characteristic frequency range of sonorous small-bubbling wet rattles makes 710 — 1400 Hz. They are defined at auscultation by means of a fonendoskopichesky head better. In epiphrenic sites easy small-bubbling rattles come to light sometimes only at the deep breath leading to the considerable shift of a diaphragm. It needs to be considered during the listening of bed patients, at to-rykh the volume of respiratory movements of a diaphragm it is reduced.

Srednepuzyrchaty wet rattles indicate availability of liquid in bronchial tubes of average caliber or small cavities (at an ectasia of distal small bronchial tubes). Aurally these rattles are perceived as noise of the bursting air traps, blown through liquid by means of very thin straw. As well as small-bubbling, these rattles can be not sonorous (the characteristic frequency range of 180 — 355 Hz) and sonorous (355 — 710 Hz).


Refer to the category of srednepuzyrchaty wet rattles also the majority of so-called bitter rattles — usually sonorous, reminding a crunch at hypodermic crepitation or a crash of the broken-off fabric. The mechanism of formation of bitter rattles is not connected with foaming of liquid during the passing

of air through it. These rattles are formed as a result of a razlipaniye on a breath of walls of respiratory bronchioles and the alveolar courses (acinus), to-rye on an exhalation are compressed by surrounding fabric (e.g., at a pneumosclerosis, fibrosis or an incomplete compression atelectasis).

Large-bubbling wet rattles are formed during the passing

of air through liquid, a soder

zhashchuyusya in bronchial tubes of large caliber, a trachea and large patol. cavities. Characteristic frequency range of these rattles is from 150 to 335 Hz; they remind the sound arising from blowing off of water air through a thick culm or even through a tubular stalk of a cane — the bubbling rattles. Large-bubbling rattles more often than small - and srednepuzyrchaty, are well listened also on an exhalation; the bubbling rattles are quite often heard at distance from the patient and are often more expressed on an exhalation when liquid (a bronchial secret or transudate) is forced out from branchings of a bronchial tree in primary bronchi and a trachea.

Definition and differentiation of wet rattles of different caliber and sonority usually does not cause difficulties. Sometimes small-bubbling wet rattles are similar to crepitation (see), edges are reminded by the gentle crash arising at height of a breath. Bitter rattles should be distinguished with a pleural rub (see), to-ry unlike rattles it is usually heard both on a breath, and on an exhalation; it is quite often listened at the closed glottis against the background of the respiratory movements of a diaphragm resulting from retraction and protrusion of a stomach and amplifies sometimes during the pressing by a stethoscope on a chest wall.

Diagnostic value of identification of wet rattles at assessment of all a wedge, the displays of a disease given to percussion of easy and other types of inspection of the patient (see) very important; sometimes their listening is more valuable to diagnosis, than results rentgenol. researches.

Small-bubbling wet rattles are most often listened at bronchial pneumonia (see Pneumonia), a heart attack of a lung (see Lungs), can be defined also at a bronchiolitis (see) and in an initial phase of auskultativny manifestations of a fluid lungs (see) — so-called congestive rattles. At bronchial pneumonia the rattles localized (usually in a projection of a segment), multiple or plentiful, are listened generally on a breath; their sonority depends on extent of consolidation of pulmonary fabric and on localization of the center of pneumonia — they more sonorous at a close arrangement of the center to a chest wall; the profuseness and sonority sometimes slightly change after deep breath and cough. At a bronchiolitis small-bubbling rattles not sonorous, scattered, are usually combined with the dry whistling rattles, their quantity and sonority considerably change after cough. Congestive rattles are listened in the most low located departments of lungs that depends on position of the patient, their localization changes at a postural change of a body (a symptom of transfusion). These rattles do not disappear after deep breath though the quantity them can decrease a little.

Srednepuzyrchaty not sonorous rattles (scattered, heterogeneous on sonority and caliber, considerably changing after cough) come to light at hyper secretory bronchitis (see) and at pneumonia with multiple small abscesses.

In the latter case rattles are defined over the center of a dullness, are localized and are usually listened along with plentiful small-bubbling rattles. At a fluid lungs srednepuzyrchaty rattles more sonorous, widespread, are listened over both lungs more behind (in position of the patient sitting) or preferential lateralno from that party, on a cut the patient lies. The Srednepuzyrchaty sonorous rattles listened over peripheral sites of lungs within borders of a segment or share (with one or from two parties), are characteristic of small bronchiectasias in the centers of a pneumosclerosis.

The Srednepuzyrchaty rattles with a bitter timbre defined over border of a pleural exudate most often are caused by a compression atelectasis (see) also arise in its fringe region where the lung is fallen down not completely; in such cases they come to light as a gentle crash (so-called subcrepitant rattles), are listened only at a deep breath, their quantity is proportional to depth of a breath. Local bitter sonorous rattles in places of the dulled percussion sound are listened over the centers of a pneumosclerosis (see), a pneumosclerosis. At diffusion intersticial pulmonary fibrosis (see Hammen — Rich a syndrome), a berylliosis (see Beryllium, professional harm), sometimes at, a sarcoidosis (see) bitter rattles have widespread character, are listened over extensive symmetric sites of a thorax usually as multiple; as a rule, they are homogeneous on sonority and caliber and almost do not change at cough, deep breath and a postural change of a body.

Large-bubbling local rattles are listened over rather large cavities containing liquid and which are reported with a bronchial tube (a cavity, abscess a lung go, large bronchiectasias), along with srednepuzyrchaty rattles of different sonority and bitter rattles. Large-bubbling rattles with big constancy come to light in the morning and differ in considerable variability after cough. The bubbling rattles appear in a late phase of edematization of lungs (see) and are listened against the background of plentiful average and small-bubbling rattles, quite often muffling them, and also at accumulation of a bronchial secret or liquid in primary bronchi and a trachea at patients with the weakened tussive reflex, in particular at a coma (see).

Dry rattles are formed in bronchial tubes and represent lingering sounds with various musical timbre. Emergence of dry rattles in large and average bronchial tubes is connected or with fluctuations of a uvula or a threadlike crossing point from a viscous phlegm in a gleam of a bronchial tube, or with turbulences of an air stream in places patol. changes of a form and cross-sectional area of a bronchial tube that can be caused by existence of a lump of a phlegm on its wall, local hypostasis of a mucous membrane of a bronchial tube, a prelum his tumor. In small bronchial tubes dry rattles are caused by fluctuations of a wall of a bronchial tube and turbulences of a current of air at its passing through a zone of narrowing. Thus, reduction of a gleam of bronchial tubes causes formation practically of all dry rattles. Preferential emergence of dry rattles in an expiratory phase since on a breath the gleam of bronchial tubes usually increases in proportion to expansion of lung volume is explained by it.

Depending on a timbre dry rattles subdivide on hooting and buzzing, formed in bronchial tubes of large and average caliber, and also whistling, arising in small bronchial tubes and bronchioles. Such division of dry rattles orients concerning caliber of a bronchial tube, in Krom they are formed, but does not reflect the real number of musical shades defined at auscultation since each of the allocated subgroups includes rattles with various tones and overtones.

As well as for the majority of wet rattles, the characteristic frequency of the listened dry rattles is in range of 180 — 710 Hz. The low (bass) hooting rattles have characteristic frequency within 180 — 355 Hz and are better listened by means of a stethoscopic head. The buzzing and whistling (diskantovy) rattles have characteristic strips of frequencies in the range of 355 — 710 Hz, is rare — more high frequency (thin peep) and depending on structure of overtones can be listened better or by means of a stethoscopic, or fonendoskopichesky head. In nek-ry cases the local dry rattles listened on a front surface of a chest wall should be differentiated with the cordial noise (see Noise cordial) having a musical timbre. The last unlike rattles have accurate communication with a certain phase of a cardial cycle and do not undergo essential changes during the change of the modes of breath, being listened at its delay better.

Diagnostic value of dry rattles is not limited to recognition of disturbances of bronchial passability and level of these disturbances (on caliber of bronchial tubes). The analysis of nature of rattles and their dynamics in time and in the course of auscultation, including under the influence of broncholitic means and drainage procedures — respiratory gymnastics, a postural drainage (see. Bronchial asthma, Bronchitis), promotes pathogenetic diagnosis of bronchial obstruction and in total with others a wedge, given to statement nozol. diagnosis. Dry rattles are listened at disturbances of bronchial secretion and a drainage of bronchial tubes as a result of impact on bronchial tubes of a dry air, after reception of antibechics, at shallow breathing at the weakened patients and elderly people (often single hooting and low buzzing rattles disappearing after effective cough), at acute and chronic bronchitis (see), a bronchiolitis (see), bronchial asthma (see), intersticial (peribronchial) pneumonia, a peribronchial pneumosclerosis (see), tumors of a bronchial tube (see Bronchial tubes). At the majority of these diseases the diverse functional mechanisms changing in time take part in formation of disturbances of bronchial passability (a bronchospasm, disturbances of bronchial secretion, a vermicular movement of bronchial tubes, a plethora of vessels and hypostasis of a mucous membrane of bronchial tubes, etc.). In this regard the listened dry rattles usually differ in considerable variability (by quantity, type, a timbre, sonority). Constancy of local dry rattles forces to assume a tumor of a bronchial tube, a focal pneumosclerosis, etc.


HRISANFOV 113


At diffusion bronchitis, a bronchiolitis and bronchial asthma dry rattles, as a rule, scattered or widespread for a long time, change during time, and also under the influence of cough, drainage procedures, broncholitic means. At a tracheobronchitis the hooting and buzzing rattles prevail, at an inflammation of small bronchial tubes and a bronchiolitis — whistling. The dry rattles with various musical shades («the playing accordion») which are often heard at distance (remote rattles) are characteristic of bronchial asthma in the period of an attack widespread and plentiful mixed (buzzing and whistling). At development of the asthmatic status the number of the listened rattles and their musicality decrease (due to reduction of the buzzing rattles), the whistling rattles begin to prevail, but also their sonority owing to speed drop of an air flow decreases, sometimes considerably. In such cases increase in number of the listened rattles after to lay down. influences (introduction of glucocorticoids, Euphyllinum, liquids, alkalis, etc.) it can be the favorable diagnostic character testimonial of the beginning of recovery of bronchial passability.

Bibliography: 3 and m about t and e in I. P., etc.

Spectral analysis of the major auskultativny signs, Klin, medical, t. 52, No. 5, page 97, 1974; F about of g and with s P. The functional basis of pulmonary sounds, Chest, v. 73, p. 399, 1978; Leblanc P., Mac k-lemP. T. a. RossW. R. Breath sounds and distribution of pulmonary ventilation, Amer. Rev. resp. Dis., v. 102, p. 10, 1970; N a t h A. R. a. CapelL. H. Inspiratory crackles and mechanical events of breathing, Thorax, v. 29, p. 695, 1974.

V. P. Zhmurkin.

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