Case in Point Bronchial Breathing and Resonant Percussion—An Important Combination of Signs in Pneumothorax

Andrew P.J. Olson, MD; Kevin C. Wang, MD, PhD; and Lawrence M. Tierney Jr, MD

This case discusses the possibility that the physical signs of pneumothorax are commonly overlooked and that some simple, basic examination procedures are easy, efficient tools in diagnosing this condition.

neumothorax is a common being performed in order for the sure was not elevated. The left lung clinical problem encoun- examiner to determine that a pneu- field was clear to auscultation; tered by physicians in many mothorax may be present. Further- distant, bronchial breath sounds Pclinical settings. Pneu- more, plain chest radiography may were heard throughout the right mothorax may be either primary be unreliable in diagnosing pneu- lung field. Percussion was not per- or secondary; primary pneumo- mothorax.2,3 The authors describe formed nor was tactile fremitus as- thorax occurs in patients without a combination of physical signs sessed. underlying lung disease; whereas that may be particularly useful as A chest radiograph was ordered secondary pneumothorax occurs a rapid, inexpensive, and simple due to a concern for a consolida- in patients with preexisting pul- method to increase the examin- tive process in the right lung: monary disease, such as bullous er’s index of suspicion and pretest specifically, pneumonia with para- emphysema.1 In most cases, pneu- probability of a pneumothorax. pneumonic effusion or empyema mothorax results from a rent in was suspected. Laboratory tests the alveolar membrane; an inter- Case Report were sent but were not initially ruption in the parietal pleura fol- A 40-year-old male presented to a available. The radiograph revealed lowing chest trauma or surgical walk-in clinic with a chief concern a pneumothorax comprising 100% procedures may also be causative. of shortness of breath for several of the right lung field; the lung had Pneumothoraces are readily di- hours. The dyspnea was acute in collapsed medially to the proximal agnosed clinically by using several onset; the patient reported pleu- right main stem bronchus. Per- techniques, including observa- ritic right chest discomfort, but no cussion performed later revealed tion, percussion, and auscultation; fever, chills, or cough were pres- resonant percussion over the right more recently, point-of-care ultra- ent. The patient was healthy and posterior lung field. The patient sonography has been used with did not have known lung disease, was admitted to the hospital, and high sensitivity and specificity.1,2 although he reported smoking 5 to a right chest tube was placed in the However, clinical suspicion must 10 cigarettes daily. patient. The patient recovered un- be high when these maneuvers are On physical examination, the eventfully and was discharged from patient was uncomfortable and dia- the hospital.

Dr. Olson is chief resident in the Department of phoretic. He was afebrile, his heart Medicine at the University of Minnesota in Min- rate was 105 bpm, his blood pres- Discussion neapolis, Minnesota. Dr. Wang is an assistant sure was 110/80 mm Hg, and his Bronchial breath sounds are professor in the Department of Dermatology at Stanford University in Stanford, California. Dr. respiratory rate was 18 bpm. Car- thought to originate in large Tierney is a professor in the Department of Medi- diac examination revealed tachy- and patent airways that are sur- cine at the University of California, San Francisco, cardia with a regular rhythm; there rounded by a consolidated lung.4 and an attending physician in the Medical Service at the San Francisco VAMC, both in San Fran- were no murmurs, gallops, or rubs In the normal lung, these sounds cisco, California. present. The jugular venous pres- are poorly transmitted to the ex-

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aminer’s stethoscope and are quiet have been in stark contrast to the dents (and attending physicians) will compared with the normal vesicu- expected dullness to percussion mention egophony, but when asked lar lung sounds that originate in in other processes; thus pneumo- what it is, few if any can describe it the lung parenchyma. However, thorax would have been suspected or the pathophysiology leading to the in consolidative processes, bron- earlier in the patient’s course. phenomenon. The authors believe chial breath sounds are appreciably The case discussed presents a that well in excess of 90% of patients louder. The loudness of the sound persuasive argument for the rou- admitted or seen in a clinic do not is due to the greater transmis- tine performance of chest percus- have the results of chest percussion sion of the sound produced in the sion in patients with dyspnea. mentioned in the documentation larger airways through water den- Percussion takes only a few sec- of the physician-patient encounter. sity rather than through air density. onds to perform and, as discussed, Moreover, when asked at bedside to Consolidation (accumulation of provides important information perform the maneuver, few know fluid in the pulmonary tissues) cre- to the examiner in making triage how, and fewer still know the signifi- ates more of a water density than decisions and changing his or her cance. The failure to perform percus- Percussion takes only a few seconds to perform sion at all in the present case is thus not surprising. One should and, as discussed, provides important information not expect in a nontension pneu- to the examiner in making triage decisions mothorax that there should be any change in the percussion note and changing his or her pretest probability of from the expected resonance; after pneumothorax before obtaining further imaging. all, the lung is an air-filled organ. When under tension, hyperreso- nance is a crucial physical sign, the near air density of the normal pretest probability of pneumotho- and patients with this are often in lung.5 rax before obtaining further imag- extreme respiratory distress and A softer variant of bronchial ing. Percussion does not rely solely hypotensive. The patient was un- breath sounds may be present in on auscultation of the percussion comfortable, indeed seemed as patients with pneumothoraces. by the examiner. Percussion is per- though he had an acute cardiopul- The finding of very distant breath formed by placing the distal inter- monary process, but not as criti- sounds and bronchial breathing phalangeal joint of the second or cally ill as a patient with tension would be identical on auscultation third digit of the examiner’s non- pneumothorax. to a patient with a pneumonia with dominant hand on the patient’s empyema; indeed, that is what the chest and striking the joint with Conclusion provider believed was the diagno- the distal phalanx of the second or The authors believe that this sis. The reason is that in a 100% third digit of the examiner’s domi- combination of physical signs in pneumothorax, the collapsed lung nant hand. The examiner then ap- patients with pneumothorax— is consolidated; it is just very dis- preciates the change in sensation distant bronchial breath sounds tant from the examiner’s stetho- as well as sound created by the per- with resonant percussion—may be scope and, therefore, produces cussion over tissues of various den- commonly overlooked by health markedly reduced, but bronchial, sities. care providers as bronchial breath breath sounds. Had the examiner The authors reviewed documenta- sounds and are quite common and done the most rudimentary of at- tion of examinations of thousands of usually associated with consolida- tempts at percussion, he or she patients in their clinical work. Their tive processes. Traditional exami- would have realized that there was overwhelming impression, verified nation findings discussed in most resonance or perhaps hyperreso- by a review of current inpatients at textbooks of physical diagnosis— nance; this could not have been the San Francisco VAMC is that the decreased chest wall movement possible in consolidated pneumo- examination of the chest as recorded and decreased or absent breath nia with empyema or with pleu- in the medical record consists only of sounds—are not appreciated in up ral effusion. This finding would auscultation. Often students and resi- to 30% of patients with pneumo-

22 • FEDERAL PRACTITIONER • JANUARY 2013 Pneumothorax

thorax.6 The lack of rapid diagno- pathologic processes. Although per- the U.S. Government, or any of its sis in patients with pneumothorax haps examination of the first cranial agencies. This article may discuss may lead to much morbidity and nerve is performed less often, the unlabeled or investigational use of even mortality, as 1% to 3% of authors are certain that percussion, certain drugs. Please review complete pneumothoraces may proceed to the funduscopic examination, and prescribing information for specific tension pneumothorax. Tension the otolaryngologic examination are drugs or drug combinations—includ- pneumothorax often leads to he- on the verge of clinical extinction. ing indications, contraindications, modynamic stability and, if un- The authors strongly believe that warnings, and adverse effects—be- treated, death. the thorough examination, when fore administering pharmacologic Further, this simple part of the mastered, is of value to patient and therapy to patients. physical examination is seldom provider alike. ● performed today, and that simple ReFeRenCes 1. Sahn SA, Heffner JE. Spontaneous pneumothorax. examination, in conditions like a Author disclosures N Engl J Med. 2000;342(12):868-874. large pneumothorax, can lead more The authors report no actual or po- 2. Blaivas M, Lyon M, Duggal S. A prospective com- parison of supine chestradiography and bedside rapidly to the diagnosis and proper tential conflicts of interest with re- ultrasound for the diagnosis of traumatic pneumo- treatment for the reasons noted ear- gard to this article. thorax. Acad Emerg Med. 2005;12(9):844-849. 3. Gordon R. The deep sulcus sign. Radiology. lier. Maintenance of this skill is im- 1980;136(1):25-27. portant in determining the proper Disclaimer 4. Bickley LS. Bates’ Guide to Physical Examination and History Taking. 8th ed. Philadelphia, PA: Lippincott use of imaging and contributes to The opinions expressed herein are Williams & Wilkins; 2003:223-226. the physician’s ability to use physi- those of the authors and do not nec- 5. McGee S. Evidence-Based Physical Diagnosis. Phila- delphia, PA: Saunders; 2001:311-364. cal examination to alter the pretest essarily reflect those of Federal Prac- 6. Weissberg D, Refaely Y. Pneumothorax: Experience probability of various pulmonary titioner, Quadrant HealthCom Inc., with 1,199 patients. Chest. 2000;117(5):1279-1285.

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