Building Blocks of Clinical Practice
Helping Athletic Trainers Build a Strong Foundation
Issue #8:
Chest Percussion and Auscultations
General Considerations
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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
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Observe the rate, rhythm, depth, and effort of breathing. Note whether the expiratory phase is prolonged.
Listen for obvious abnormal sounds with breathing such as wheezes.
Observe for retractions and use of accessory muscles (sternomastoids, intercostals).
Observe the chest for asymmetry, deformity, or increased anterior-posterior (AP) diameter.
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 Normal
Hyper resonant Pleural Effusion or Lobar Pneumonia
Healthy Lung or Bronchitis
Emphysema or Pneumothorax
Auscultation
Use the diaphragm, which is larger, flatter side of the chest piece to auscultate breath sounds.
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Auscultate from side to side and top to bottom using the pattern shown in the illustration.
Omit the areas covered by the scapulae.
Compare one side to the other looking for asymmetry.
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
(Lippincott Williams & Wilkins) – 10th International Ed. (2008).
Lynn S Bickley & Peter G Szilagyi
NATA Research & Education Foundation
2952 Stemmons Freeway, Suite 200
Dallas, TX 75247
Phone: (214) 637-6282
www.natafoundation.org