It could be coarse crepitations or rhonchi.

Friction fremitus

These include palpable pericardial rub or pleural rub (e.g. dry pleurisy).

Tenderness:

Seen in

Empyema (intercostal tenderness)

Local inflammation of soft tissue

Osteomyelitis/rib fractures/costochondritis (Tietze syndrome)

Tumor infiltration

Amoebic liver abscess

Subphernic abscess

Detection of subcutaneous emphysema:

Spongy crepitant feeling on palpation

Injury to chest wall

Pneumothorax

Rupture of esophagus

Rib crowding/intercostal widening:

Stand behind the patient and place the fingers in the intercostal spaces simultaneously on both sides

as shown in Figure 3D.29.

Observe for the separation of the fingers

Rib crowding Intercostal widening

Unilateral Bilateral Unilateral Bilateral

Atelectasis

Collapse

Fibrosis

Pneumonectomy

Interstitial lung disease

Fibrosis (bilateral)

Pneumothorax

Pleural effusion

Emphysema

Fig. 3D.29: Examination of rib crowding.

Percussion (Lower Respiratory Tract)

Preferably done in sitting position, supine position is needed for demonstrating shifting dullness.

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Position of patient for percussion:

Anterior chest (Fig. 3D.30): Sits up straight with hands by his side

Axilla (Fig. 3D.31): Raise the arm over the head and place over the back of head

Posterior of chest (Fig. 3D.32): Sits up with hands crossed and placed over the opposite shoulders.

Rules of Percussion

Direction of percussion: Always percuss from resonant to non-resonant area.

Pleximeter is usually the middle phalanx of middle finger of left/nondominant hand and is firmly

placed on the surface while rest of fingers are slightly lifted off.

Plexor/plessor (percussing finger) is middle finger of the right/dominant hand.

The movement of the plexor hand should be sudden and originating from the wrist.

The pleximeter must be kept parallel to the border to be percussed.

Percuss around 2–3 times over each area.

Percussion has to be heard as well as felt.

Always percuss the identical areas of chest for comparison.

The distance between the pleximeter finger and the ear should preferably be maintained.

Types of percussion

Heavy percussion Light percussion

Posterior part of chest Anterior part of chest and abdomen

Fig. 3D.30: Demonstration of percussion of anterior chest.

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Fig. 3D.31: Demonstration of percussion of axillary area.

Fig. 3D.32: Demonstration of percussion over the posterior chest.

Direct

percussion

Indirect percussion Auscultatory percussion

Directly over the

bony structures

like clavicle

By percussing over the

pleximeter finger with

the plexor/plessor

Was first described by Laennec and used to delineate the size of organs by placing

the stethoscope directly above the structure to be outlined, followed by percussion

from the periphery towards the organ of interest

Direct percussion (Fig. 3D.33):

Percuss the middle third of the clavicle with plexor finger.

Stretch the skin over the clavicle using the left hand as shown in Figure 3D.33.

Normally middle third of the clavicle is resonant whereas the medial and lateral thirds are dull

(because of muscles attached).

Impaired note Heard in apical fibrosis

Dull note Mass lesion like pancoast tumor

Widening of zone of resonance Heard in pneumothorax or emphysema

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Fig. 3D.33: Demonstration of direct percussion over the clavicle.

Flicking percussion: Flicking using thumb and finger—done for percussion of the abdomen, cardiac

border and to check for metallic note of pneumothorax.

Guarino’s method of auscultatory percussion:

Examined with patient sitting up and examiner facing the back of the patient

Place the stethoscope around 3 cm below the last rib in the scapular line as shown in Figure 3D.34.

Now percuss with the free hand (by finger flicking or with pulp of the finger) along 3 or more parallel

lines from the apex of each hemithorax perpendicularly downward towards the base to note the

dullness.

Fig. 3D.34: Guarino’s method of auscultatory percussion in pleural effusion.

Lung Resonance

Normal:

Vesicular resonance

Front of chest more resonant

Lesion >5 cm from chest wall or <2–3 cm in size will not alter the percussion note.

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Abnormal types of percussion notes

Quantitative Qualitative

Tympanic note

Subtympanic note

Hyper-resonant note

Impaired note

Dull/woody dull note

Stony dull note

Crackpot

Amphoric

Bell tympany

Quantitative types

Tympanic note It is a drum-like note

Normally seen over the stomach, intestine—Traube’s space

In chest—superficial cavity, subcutaneous emphysema (metallic tympanic note)

Subtympanic (skodaic)

note

It is Boxy quality

Seen just above pleural effusion

Hyper-resonant note Intermediate between normal and tympanic note

Bilateral—emphysema

Unilateral—pneumothorax, compensatory emphysema

Large bullae

Impaired note Airless areas (fibrosis, collapse)

Dull note Consolidation

Thick pleura

Flat dull Can be elicited by percussing over the thigh

Seen in pleural effusion

Stony dullness Pain over the pleximeter finger with resistance felt by plexor

Large pleural effusion

Large solid tumor

Qualitative types

Cracked pot resonance Normally seen in chest of infants or child during the act of crying

Pathological lung cavity with communication with bronchus due to sudden expulsion of air form the

cavity to bronchus

Artificially imitated by beating clasped hands over the knee

Amphoric Low pitched hollow note

Normally seen in trachea and cheek distended with air

Pathologically seen in pneumothorax and large cavity

Bell tympany High pitched metallic or tympanic note

Seen in massive pneumothorax

Place coin on affected side of chest and percuss with another coin while simultaneously

auscultating the back

Dullness in presence of fluid in lung

Straight line dullness Hydropneumothorax

S-shaped curve of Ellis Pleural effusion

5-7-9 rule:

The upper border of liver dullness is at 5th intercostal space (ICS) in mid clavicular line, 7th ICS in the

midaxillary line and 9th ICS in the scapular line.

Topographical percussion of lung

Apical percussion:

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Kronigs isthmus: It is a band of resonance in the supraclavicular area bounded anteriorly by the

posterior border of the clavicle, medially by the neck muscles, posteriorly by the anterior border of

trapezius, extended laterally till the acromioclavicular joint.

Stand behind the patient, place the pleximeter finger over the neck and percuss from lateral to medial

as shown in Figure 3D.35.

On percussion there is dull zone medially and laterally, and only middle part is resonant.

Dullness in this area suggests apical tuberculosis, Pancoast tumor or apical fibrosis.

The zone of resonance may be widened in emphysema or apical pneumothorax.

Fig. 3D.35: Percussion of apical area (Kronig’s isthmus).

Tidal percussion:

Tidal percussion is a measure of diaphragmatic excursion

It is used to differentiate whether the causes of dullness are above the diaphragm (subpulmonic

effusion) or below (subphrenic collections)

With patient in, percuss the right side of the chest from above downwards till you get the liver

dullness. Normally, it is in 5th intercostal space.

Ask the patient to take a deep inspiration and hold his breath.

Now percuss the same area

Normally, dullness moves down by 1–2 intercostal spaces as shown in Figure 3D.34.

Tidal percussion is negative in right-sided subpulmonic effusion, diaphragmatic paralysis.

In emphysema, since the lung is already fully expanded tidal percussion will be negative (Figs.

3D.36A and B).

Percussion of Traube’s space (Fig. 3D.37)

It is a semilunar space in the left anterior chest bounded by:

Above by 6th rib

Below by left costal margin

Laterally by midaxillary line.

Normal Traube’s space percussion Tympanic note

Obliteration of Traube’s space Left sided pleural effusion

Pericardial effusion

Massive splenomegaly

Enlarged left lobe of the liver

Full stomach or fundic mass

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Upward shift of Traube’s space Left diaphragmatic paralysis

Left lower lobe collapse or fibrosis

Figs. 3D.36A and B: Demonstration of tidal percussion: (A) Expiration; (B) Inspiration (Note the change

in liver dullness from expiration to inspiration).

Fig. 3D.37: Percussion of Traube’s space.

Shifting dullness:

It is classically described for hydropneumothorax. It can also be demonstrated in pleural effusion.

Steps:

Percuss the anterior chest in sitting position, from above downward to get upper border of dullness.

You will get a level of straight line dullness perpendicular to long axis of body as shown in Figure

3D.38A. Mark this level.

Now, make the patient lie down in opposite lateral position/normal side (for around 5 minutes in case

of hydropneumothorax and around 30 minutes in case of pleural effusion). Percuss over the affected

side and note the change in the straight line dullness which will now be parallel to long axis of body as

shown in Figure 3D.38B. Shifting dullness may be absent in case of empyema or loculated pleural

effusion.

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Figs. 3D.38A and B: Right hydropneumothorax: (A) Sitting position; (B) Left lateral position.

Special findings in percussion:

Special finding Clinical condition

Shifting dullness Hydropneumothorax

S-shaped curve of Ellis (Damoiseau’s

curve)

Pleural effusion (moderate)

Obliteration of Traube’s space Pleural effusion (left sided)

Grocco’s triangle (Fig. 3D.39)

(Paravertebral triangle of dullness)

Boundaries of Grocco’s triangle:

Medially: The mid-spinal line from the level of the effusion to the level of the

tenth dorsal vertebra

Below: A horizontal line extending outwards from the tenth dorsal vertebra

along the lower limit of lung resonance

Laterally: A curved line connecting these two lines

Clinical condition:

Seen over the back of the chest, on the opposite side of effusion in moderate to massive pleural effusions

Garland’s triangle (Fig. 3D.39) Small area of resonance next to the spine found in patients with large unilateral

pleural effusions

Lower relaxed part of the lung in moderate or large pleural effusion is tympanic

or subtympanic

William’s tracheal resonance Description:

Area of tympany over the first or second intercostal space, close to sternum

Seen in:

Patch of consolidation or fibrosis interposed between the trachea or a major

bronchus and the chest wall

Referred to as “pulled trachea syndrome” in fibrotic apical tuberculosis

Wintrich’s sign Description:

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Percussion note over an area during inspiration appears clearer and higherpitched with the mouth open than with it closed

Seen in:

Lung cavity communicating with a bronchus, pneumothorax or mediastinal

tumor

Gerhardt’s sign Description:

Percussion note over an area appears lower pitched with the patient recumbent

than with him standing or sitting

Seen in:

Lung cavity containing both fluid and air.

Friedreich’s sign Description:

Percussion note over an area becomes higher in pitch during forced inspiration

than during expiration

Seen in:

Lung cavity

Fig. 3D.39: Special findings in percussion: (1) Effusion, (2) Rauchfuss-Grocco triangle, (3) Garland

triangle.

Auscultation (Lower Respiratory Tract)

Position of patient:

In upright position

Front Sitting or standing

Back Preferably sitting and leaning forward with neck flexed and arms crossed in front

In recumbent position Back Turn the patient sideways or slip the steth underneath the patient

Breathing advice:

Ask the patient to breathe through the mouth. If not cooperating ask the patient to count numbers or

cough successively and then observe during deep inspiration.

Normal physiology of breath sounds :

Mechanism of sound production

In larger airways (pharynx, large airways of

trachea and lung)

In smaller airways

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Sounds are generated due to turbulence Higher frequencies are lost due to dampening when they travel from higher

to smaller airways

They are the source of sound They are just filter sounds and not the source of sound

Sound frequencies are of range 200–2,000 Hz Sound frequencies are of range 200–400 Hz

Heard over the upper sternum Heard over most other areas of lung

Grading of breath sound intensity

0 Absent breath sounds

1 Barely audible breath sound

2 Faint but definitely audible breath sound

3 Normal breath sound

4 Louder than normal breath sound

Graphical representation of breath sounds

Upstroke Inspiratory element

Downstroke Expiratory element

Length Duration or timing

Thickness Loudness or intensity

Angle between upstroke and downstroke made with a vertical line Pitch of respiratory sound

Lower the angle higher is the pitch

Types of normal breathing

Vesicular breathing Most areas of chest

Tracheal/bronchial breathing Larynx

Trachea

Between C7 to T3

Bronchovesicular Anteriorly 1st and 2nd intercostal space

Posteriorly between the scapula

Vesicular breath sounds

Characteristics Rustling or breezy quality

Longer duration of inspiratory phase (which includes both tubular and alveolar phase)

Higher pitch of inspiratory sound

I:E = 4:1

Absence of pause between I and E

Distribution Most of chest

Intensity Louder: infraclavicular, axillary and infrascapular areas

Diminished: Lower margins of lung and over the scapular areas

Mode of production Distension and separation of alveolar walls by the in rushing current of air

Graphical representation

Tubular phase of inspiration

Alveolar phase of inspiration

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