1. What should make you suspect paradoxical or reversed splitting?
ANS: A split that widens on expiration and narrows on inspiration implies that the P2 comes first.
Inspiration | j
If the split narrows on inspiration, the P2 must come first, and the split S2 is reversed.
If the split is fixed at the left sternal border, it may be difficult to tell whether it has a normal or paradoxical sequence. Toward the apex, the component that becomes relatively softer must be the P2.
2. How can you confirm by auscultation that a wide split is reversed when the respiratory movements are so erratic that the respiratory changes cannot be used?
ANS: a. At the apex the A2 is either the only sound heard, or it is the loudest component of the S2 if both are heard there. Therefore, you should gradually move your stethoscope from the left sternal border toward the apex as you listen to the split second sound. The S2 component that either disappears or becomes softer at the apex will be the P2. If you hear the first component becoming softer or disappearing in relation to the second component, then the order is P2A2. Since the A2 is usually the only component of S2 heard at the second right interspace, the same maneuver can be used by gradually shifting your chest piece toward the second right interspace. If the split is also heard in the second right interspace, which is part of the aortic area, and the second component is louder than the first, then you know that you are listening to P2A2 or a reversed split. b. The component that increases in loudness with inspiration is the P2.
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