Percussion of the lungs Palpation of the chest

Inspection of the chest
(inspectio thoracis)
This is the objective method of examination based on visual evaluation of condition and pathological changes in thorax
Static inspection – based on revelation of thorax features without taking into the act of breathing
Dynamic inspection - based on revelation of thorax features with taking into the act of breathing

Static inspection
Physiological shapes :
Normosthenic,
Hypersthenic,
Asthenic
The asymmetry of the chest (enlarged volume of the half of the chest, decreased volume of the one part of the chest)
Pathological shapes :
emphysematous (barrel)
paralytic
rachitic or pigeon
funnel
foveated
scoliotic
kyphotic
kyphoscoliotic

Normosthenic chest:
The shoulders are under the right angle to the neck
Supra- and infraclavicular fossae feebly expressed
The ribs are moderately inclined
The interspaces are visible, but moderate expressed
Epigastric angle is near 90 degree
The lateral diameter is larger than anteroposterior
Scapulae closely fits to the chest and are on the same level

Hyperstenic chest
The shoulders are wide and the neck is short
Supra- and infraclavicular fossae are absent (level with the chest)
Direction of the ribs are nearly horizontal
The interspaces are narow and slightly expressed
Epigastric angle exceeds 90 degree
The lateral diameter is about the same as anteroposterior
The chest has form of a cylinder
Scapulae closely fit to the chest

Asthenic chest
The shoulders are sloping and are under the dull angle to the neck
Clavicles are well visible
Supra- and infraclavicular fossae are distinctly pronounced
The ribs more vertical, direct downward
The interspaces are wide and pronounced
Epigastric angle is less than 90 degree
Both lateral and anteroposterior diameter are smaller than normal

The shapes of the chest (cross - section and appearance)
а,б – thorax of healthy adult; в,г – barrel thorax.
д,е – funnel thorax; ж,з – rachitic thorax.

Dynamic inspection
Participation of the accessory muscles in act of breathing (bronchial asthma, respiratory insufficiency or heart failure)
Participation parts of the chest in breathing act (pleuritis, pleural commissure, complications after surgical operations on the lung, lung tumors)
Type of respiration :
thoracic (costal)
abdominal (diaphragmal)
mixed
Respiration rate:
Normal at rest 16-20 per 1 min.
Frequent (more than 20 per 1 min.) – tachypnoë
Slow (less than 16 per 1 min.) – bradypnoë
Respiration depth:
moderate
deep
superficial
Respiration rhythm:
regular, irregular

Palpation
Identification of tender areas (widespread or local, in Valle points )
Thorax resistance (normal, increased, decreased)
Tactile vocal fremitus (normal, increased, decreased)
Chest expansion (in addition to inspection)
Assessment of epigastrical angle (in addition to inspection)
This is the objective method of examination based on evaluation of condition and pathological changes in thorax during its feelings

Topographic regions of the chest
Supraclavicular region – above clavicles
Infraclavicular region – below clavicles
Suprascapular regoin – above scapulae
Interscapular region – between the scapulae
Infrascapular region – below scapular

Assessment of thorax elasticity ;
а – antero-posterior, б – lateral.

TACTILE VOCAL FREMITUS:
palpable vibrations transmitted through the bronchopulmonary tree to the chest wall when the patients speaks
Anteriorly - midclavicular line
Laterally - midaxillary line
Posteriorly - above scapula , parascapular “paraspinal”, below scapula

TACTILE VOCAL FREMITUS:

Increased TVF
Thin chest wall
Lobar pneumonia
Lungs infarction
Pulmonary tumor
Tuberculosis
Compressive atelectasis
Air cavity communicated with bronchus
Decreased TVF
Pleural effusion
Pleural fibrosis
Pneumothorax
Thick chest wall (edema, subcutaneous fat)
Vocal fremitus can be absent when significant amount of fluid or air are accumulated in the pleural cavity

Palpation of the chest

Palpation of the chest

(L.Auenbrugger, 1722-1809)
(Jean Nicholas Corvisart, 1755-1821)

Topographic regions and lines of the chest

The left and right midaxillary lines – linea axillaris media dextra and sinistra
The left and right posterior axillary lines – linea axillaris posterior dextra and sinistra
The scapular left and right lines – linea scapularis dextra and sinistra
The paraspinal lines dextra and sinistra – linea paravertebralis dextra and sinistra
The vertebral line – linea vertebralis – linea mediana posterior
Topographic regions and lines of the chest

Topographic regions and lines of the chest

Press The last 2 phalanges of your left middle finger firmly on on the area to be percussed and raise the second and fourth fingers off the chest surface; otherwise, both sound and tactile vibrations will be blunted
Percussion

Movement from wrist
The best percussion site is between the proximal and distal interphalangeal joints.
Use a two quick, sharp wrist motion

Comparative – revealing of percussion sound features on symmetrical areas of the chest:
Supraclavicularis
Clavicularis
Subclavicularis
Axillaris
Suprascapularis
Interscapularis
Subscapularis
Topographic - aimed to determining :
lower borders of the lungs
upper borders of the lungs
the width of Crenig’s area
active and passive mobility of lower borders of the lungs
width of Traube’s area
This is the objective method of examination based on evaluation of sound types during the knocking of the thorax
Percussion of the chest

Comparative percussion

Comparative percussion
Resonant - Clear pulmonary
Intermediate - pulmonary sound becomes duller
Dull
Hyperresonant – Tympanic
Bandbox sound - over the hyper inflated lungs of emphysema

The main symptoms based on comparative percussion
Percussion sound on the symmetric areas :
Clear pulmonary (in healthy persons)
Dullness (dulling)
Infiltration of lung tissue (tuberculosis, pneumonia, pneumosclerosis, lung cancer, abscess, lung gangrene)
Accumulation of liquid in pleural cavity Stony dull – large pleural effusion
pleural thickening
Tympanic
Increasing the air capacity of lung tissue (bronchial asthma, lung emphysema)
Formation the cavity with air in lung parenchyma (released form contents caverns, abscess, bronchoectasis)
Accumulation of air in pleural cavity (pneumothorax)

The main symptoms based on topographic percussion
1.Lower borders:
Removal down (lung emphysema, bronchial asthma, lower standing of diaphragm)
Removal upper (athelectasis, surgical ablation the part of lung, higher standing of diaphragm, subdiaphragmal abscess)
2.Upper borders:
Removal down (tuberculosis of lung apexes, pneumosclerosis, athelectasis of lung apexes)
Removal upper (lung emphysema, bronchial asthma)
3. Width of Traube’s area:
Increasing more than 6 sm - lung emphysema, bronchial asthma Decreasing less than 4 sm - tuberculosis of lung apexes, pneumosclerosis, athelectasis of lung apexes

Topographic percussion

Topographic percussion

Topographic percussion
lower borders of the lung

4. Active and passive mobility of the lungs – the significance of lung tissue elasticity state and the possible mobility of lower lung border:
Enough (6-8 sm) by linea axillaris media, scapularis – normal
Decreased (less than 6 sm) by linea scapularis - lung emphysema, bronchial asthma, pneumosclerosis, pleural commissural, sweating pleuritis
5. The Traube’s area – the area of tympanic sound under the left ribs arch. Diagnostically impotence –decreasing of area width:
Cancer of cardial part of stomach
Increasing of the liver
Increasing of the spleen
Left side sweating pleuritis

Determining of the mobility of lower borders of the lungs