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Issue #8: Chest Percussion and Auscultations

General Considerations • The patient must be properly undressed and gowned for this examination. • Ideally the patient should be sitting on the end of an exam table. • The examination room must be quiet to perform adequate percussion and auscultation. • Observe the patient for general signs of respiratory disease (finger clubbing, cyanosis, air hunger, etc.). • Try to visualize the underlying anatomy as you examine the patient. Inspection 1. Observe the rate, rhythm, depth, and effort of breathing. Note whether the expiratory phase is prolonged. 2. Listen for obvious abnormal sounds with breathing such as wheezes. 3. Observe for retractions and use of accessory muscles (sternomastoids, intercostals). 4. Observe the chest for asymmetry, deformity, or increased anterior-posterior (AP) diameter. 5. Confirm that the trachea is near the midline. Palpation 1. Identify any areas of tenderness or deformity by palpating the ribs and sternum. 2. Assess expansion and symmetry of the chest by placing your hands on the patient’s back, thumbs together at the midline, and ask him/her to breathe deeply. 3. Check for tactile fremitus, a tremulous vibration of the chest wall during speaking that is palpable on physical examination. Tactile fremitus may be decreased or absent when vibrations from the larynx to the chest surface are impeded by chronic obstructive pulmonary disease, obstruction, pleural effusion, or pneumothorax. It is increased in pneumonia. Percussion

Proper Technique 1. Place the 3rd distal interphalangeal joint firmly against the patients chest making sure to keep the palm of the hand free from direct contact. 2. With the end (not the pad) of the opposite middle finger, use a quick flick of the wrist to strike first finger. 3. Categorize what you hear as normal, dull, or hyperresonant. 4. Practice your technique until you can consistantly produce a “normal” percussion note on your partner before you work with patients.

Posterior Chest 1. Percuss from side to side and top to bottom using the pattern shown in the illustration. Omit the areas covered by the scapulae. 2. Compare one side to the other looking for asymmetry. 3. Note the location and quality of the percussion sounds you hear. 4. Find the level of the diaphragmatic dullness on both sides. 5. After finding the diaphragmatic dullness on both sides, ask the patient to inspire deeply. 6. The level of dullness (diaphragmatic excursion) should go down 3-5cm symmetrically. Issue #8: Chest Percussion and Auscultations

Anterior Chest 1. Percuss from side to side and top to bottom. 2. Compare one side to the other looking for asymmetry. 3. Note the location and quality of the percussion sounds you hear.

Interpretation

Percussion Notes and Their Meaning Flat or Dull Pleural Effusion or Lobar Pneumonia Normal Healthy Lung or Bronchitis Hyper resonant Emphysema or Pneumothorax

Auscultation

Use the diaphragm, which is larger, flatter side of the chest piece to auscultate breath sounds.

1. Auscultate from side to side and top to bottom using the pattern shown in the illustration. 2. Omit the areas covered by the scapulae. 3. Compare one side to the other looking for asymmetry. 4. Note the location and quality of the sounds you hear.

Interpretation

Breath sounds are produced by turbulent air flow. They are categorized by the size of the airways that transmit them to the chest wall (and your stethoscope). The general rule is, the larger the airway, the louder and higher pitched the wound. Vesicular breath sounds are low pitched and normally heard over most lung fields. Tracheal breath sounds are heard over the trachea. Bronchovesicular and bronchial sounds are heard in between. Inspiration is normally longer than expiration (I > E).

Breath sounds are decreased when normal lung is displaced by air (Emphysema or Pneumothorax) or fluid (Pleural Effusion). Breath sounds shift from vesicular to bronchial when there is fluid in the lung itself (Pneumonia). Extra sounds that originate in the lungs and airways are referred to as “adventitious” and are always abnormal (but not always significant). Issue #8: Chest Percussion and Auscultations

Adventitious (Extra) Lung Sounds

Crackles Also known as rales, these abnormal breath sounds are usually caused by excessive fluid within the airways. This fluid could be due to an exudate, as in pneumonia or other infections of the lung, or a transudate, as in congestive heart failure. You will notice that crackles sound just as they are named, and are typically inspiratory. Dry crackles will sound more like rubbing hair together next to your ear or like the sound of opening Velcro.

Wheezes Wheezes are generally high pitched and “musical” in quality. They are characteristically an expiratory sound associated with forced airflow through abnormally collapsed airways with residual trapping of air. Although commonly associated with asthma, wheezes may also be due to other causes such as airway swelling, tumor, or obstructing foreign bodies.

Stridor is an inspiratory wheeze associated with upper airway obstruction (croup).

Rhonchi These often have a “snoring” or “gurgling” quality.

References:

http://www.wilkes.med.ucla.edu/lungintro.htm

Bates’ Guide to Physical Examination and History Taking NATA Research & Education Foundation (Lippincott Williams & Wilkins) – 10th International Ed. (2008). 2952 Stemmons Freeway, Suite 200 Lynn S Bickley & Peter G Szilagyi Dallas, TX 75247 Phone: (214) 637-6282 www.natafoundation.org