RET 1024
Introduction to Respiratory Therapy
Module 4.3
Bedside Assessment of the Patient
— Palpation, Percussion, Auscultation
Bedside Assessment of the Patient
 Palpation
 The art of touching the chest wall to
evaluate underlying structure and
function
 Vocal and tactile fremitus
 Thoracic expansion
 Assess skin and subcutaneous tissues of the
chest
Bedside Assessment of the Patient
 Palpation
 Vocal Fremitus – vibrations created by the
vocal cords during speech
When the vibrations travel down the
tracheobrochial tree, through the lung, and are
felt on the chest wall, it is called tactile fremitus
Bedside Assessment of the Patient

Tactile Fremitus

Ask patient to say
“ninety-nine” or “one,
two, three” or “E” while
palpating the anterior,
lateral, and posterior
chest wall with either
the dorsal or palmar
aspects of the fingers,
or the ulnar aspect of
the hand
Bedside Assessment of the Patient

Tactile Fremitus

May be …

Increased



Decreased






Atelectasis
Pneumonia
Pneumothorax
Pleural effusion
Emphysema
Obesity
Muscular
Or Absent


Pneumothorax
Pleural effusion
Bedside Assessment of the Patient

Thoracic Expansion
Bedside Assessment of the Patient
 Palpation
 Thoracic Expansion


Normal chest wall expands symmetrically during
inhalation
Bilateral reduction in chest expansion


Both lungs affected
 Neuromuscular diseases
 COPD
Unilateral reduction in chest expansion

One lung affected
 Lobar consolidation
 Atelectasis
 Pleural effusion
 Pneumothorax
Bedside Assessment of the Patient

Thoracic Expansion

Posterior evaluation


Place hands over the posterolateral chest – thumbs extended
and meeting at the T-8 vertebra
Anterior Evaluation





Place hands over the anterolateral chest – thumbs extended
along the costal margin toward the xiphoid process
Instruct patient to exhale slowly and completely
Extend the tips of the thumbs toward the midline until they
are touching
Grasp the chest securely and instruct the patient to take a
full, deep breath
Note the distance that the thumbs separate

Normal: Each thumb moves an equal distance of 3 – 5 cm
Bedside Assessment of the Patient
 Palpation

Skin and subcutaneous tissues



General temperature
Condition of the skin
Subcutaneous emphysema

Air under the skin
 Produce a crackling sound
and sensation when palpated
– called crepitus
Subcutaneous emphysema
Bedside Assessment of the Patient
 Palpation
 Subcutaneous emphysema
 Bue circle: characteristic of
subcutaneous emphysema with
muscle bundles of pectoralis
muscle becoming visible.
 Red arrow : points to
subcutaneous emphysema in the
supraclavicular area.
 White arrow: points to streaky air
visible in the mediastinum
Bedside Assessment of the Patient
 Percussion

The art of tapping on the
surface of the chest to evaluate
the underlying structure

Produces a sound and palpable
vibration

Useful for patients with
suspected conditions for which
percussion could be helpful
(e.g., pneumothorax)
Bedside Assessment of the Patient
 Percussion

Place the middle
finger of the left hand
(right-handed people)
firmly against the
chest wall, parallel to
the ribs, within the
intercostal space
(palm and other
fingers off the chest)
Bedside Assessment of the Patient
 Percussion

Using the tip of the
middle finger on the
right hand, or the
lateral aspect of the
thumb to strike the
finger against the
chest near the base of
the terminal phalanx
and remove briskly
Bedside Assessment of the Patient
 Percussion

Systematically, consecutively test comparable
areas on both sides of the chest, excluding
bony structures and breasts of female patients
Bedside Assessment of the Patient
 Percussion

Percussion notes are evaluated by intensity
(loudness) and pitch

Normal Resonance

Normal lung fields – loud, long, moderately lowpitched sound heard over air-filled structures
Bedside Assessment of the Patient
 Percussion

Clinical Implications of decreased resonance




Pneumonia
Tumor
Atelectasis
Pleural fluid
Bedside Assessment of the Patient
 Percussion

Clinical Implications of decreased resonance




Pneumonia
Tumor
Atelectasis
Pleural fluid
Bedside Assessment of the Patient
 Percussion

Clinical Implications of decreased resonance

Dull
 Heard over a solid organ (e.g. liver) – medium
intensity, medium pitch, and a medium duration

Flat
 Heard over bone – soft intensity, high-pitched,
and a short duration
Bedside Assessment of the Patient
 Percussion

Clinical Implications of increased or
hyperresonance


Acute bronchial obstruction (asthma, COPD)
Pneumothorax
Air Trapping
(asthma)
Bedside Assessment of the Patient
 Percussion

Clinical Implications of
increased or hyperresonance

Tension Pneumothorax
 Tympani
 Hollow, air-filled
structures under
pressure - Loud, drumlike, high-pitched note,
usually heart with
tension pneumothorax
Bedside Assessment of the Patient
 Auscultation of the Thorax

Listening to thorax with a stethoscope for the
purposes of identifying both normal and
abnormal lung sounds
Bedside Assessment of the Patient
 Auscultation

Stethoscope

Bell


Low-frequency
heart sounds
Diaphragm

High-frequency
lung sounds
Bedside Assessment of the Patient
 Auscultation

Patient should be sitting up
when possible
Bedside Assessment of the Patient
 Auscultation

Patient should be
sitting up when
possible
Bedside Assessment of the Patient
 Auscultation

Instruct patient to breath more deeply than
normal through the mouth and then exhale
normally

Be careful not to let the tubing rub against any
objects, which may be mistaken for abnormal
lung sounds

Auscultate over bare skin when possible;
clothing can mask sounds
Bedside Assessment of the Patient
 Auscultation

Proper way to hold stethoscope


Between index and middle fingers
Stabilize the stethoscope firmly against the chest
Bedside Assessment of the Patient
 Auscultation

Must be systematic – all lobes

Posterior and anterior chest

Start at the bases and work upward; opposite to what
is indicated in this photo
Bedside Assessment of the Patient
 Auscultation

Must be systematic – all lobes

Lateral chest
Bedside Assessment of the Patient
 Auscultation


Listen to a complete breathing cycle;
inspiratory and expiratory in each location
Identify



Pitch
Loudness
Duration
Inhalation
Exhalation
Duration
Pitch
Diagram of normal breath sound
Thickness of line indicates loudness
Bedside Assessment of the Patient
 Auscultation

Normal Breath Sounds

Tracheal / Bronchial

Bronchovesicular

Vesicular
Bedside Assessment of the Patient

Normal Breath Sounds

Tracheal / Bronchial

Over the trachea
 Turbulent flow of gas through the upper airways
 Loud, harsh, hollow or tubular quality
 High-pitched
 Expiratory and inspiratory components are almost
equal
Diagram
Bedside Assessment of the Patient

Normal Breath Sounds

Bronchovesicular

Upper half of sternum and between scapulae
 Gas moving between the large airways and
alveoli
 Not as loud as tracheal / bronchial
 Slightly lower in pitch
 Expiratory and inspiratory components are almost
equal
Diagram
Bedside Assessment of the Patient

Normal Breath Sounds

Vesicular

Lung parenchyma
 Gas moving in/out of small bronchiole and
possibly the alveoli
 Soft and muffled
 Low in pitch
 Heard primarily during inspiration, with only a
minimal exhalation component
Diagram
Bedside Assessment of the Patient

Abnormal (adventitious) Breath Sounds
 Breath sounds that are different than what
is normally heard over a particular area of
the thorax

For example
 When bronchial breath sounds replace normal
vesicular breath sounds when alveolar
atelectasis or consolidation are present
Bedside Assessment of the Patient

Abnormal (adventitious) Breath Sounds

Bronchial

Replace normal vesicular breath sounds when
alveolar atelectasis or consolidation are present
Atelectasis
Consolidation
Bedside Assessment of the Patient

Abnormal (adventitious) Breath Sounds

Diminished (reduced)

Vesicular breath sound are softer than expected








Shallow breathing
Slow breathing
Complete absence of a breathing pattern
Obstructive airway disorders (e.g., emphysema)
Alveolar hyperinflation
Pleural effusion
Pneumothorax
Obesity
Bedside Assessment of the Patient

Abnormal (adventitious) Breath Sounds

Wheezes

Continuous, high-pitched, musical sounds heard
primarily on expiration; can be heard on both
inspiration and expiration in severe cases






Secretions
Bronchospasm
Mucosal edema
Bronchial tumor (unilateral wheezing)
Foreign objects (unilateral wheezing)
Note: The greater the bronchial narrowing, the higher the
pitch of the wheeze (mild, moderate, severe)
Bedside Assessment of the Patient

Abnormal (adventitious) Breath Sounds

Stridor

Commonly caused by inflammation and edema of
the larynx and trachea


Tracheal damage resulting from intubation
 Heard following extubation
Croup
 Barking cough
 Subglottic inflammation/edema
 Foreign body aspiration
Bedside Assessment of the Patient

Abnormal (adventitious) Breath Sounds
 Laryngeotracheobronchitis
 Croup

Stridor
Bedside Assessment of the Patient

Stridor

Electrical wire stuck in the larynx of an infant; minimal
stridor pre-operatively
Bedside Assessment of the Patient

Abnormal (adventitious) Breath Sounds

Crackles

Discontinuous, high-pitched, short, crackling,
popping, or bubbling sound that usually heard on
inspiration

Coarse crackles (rhonchi)
 Airflow causing movement of excessive
secretions or fluid in the airways, cleared with
coughing or suctioning

Fine Crackles (rales)
 Collapsed airways / alveoli popping open during
inspiration
Bedside Assessment of the Patient

Abnormal (adventitious) Breath Sounds

Crackles

Common causes
 Excessive secretions
 COPD
 CHF
 Pneumonia
 Atelectasis
 Pulmonary fibrosis
 Early tuberculosis
Bedside Assessment of the Patient

Abnormal (adventitious) Breath Sounds

Pleural Friction Rub

Creaking or grating sound that occurs when the
pleural surfaces become inflamed and the
roughened edges rub together during breathing, as
in pleurisy


Heard on inspiration and expiration
Usually localized to a certain site on the chest wall
Bedside Assessment of the Patient

Voice Sounds

Bronchophony

An increase in intensity and
clarity of vocal resonance
produced by enhanced
transmission of vocal vibrations


Heard during auscultation while
the patient is repeating the
words “one, two, three,” or
“ninety-nine”
Indicative of consolidation
Bedside Assessment of the Patient

Voice Sounds

Whisper Pectoriloquy



Auscultate while the patient is whispering “one, two,
three” or “ninety-nine, ninety-nine”
Sounds are heard more clearly over areas of
consolidation
Egophony

Auscultate while the patient is saying “EEEEE”

Sounds like “AAAAA” over consolidation
Bedside Assessment of the Patient

Auscultation

Chest Hair

A fine crackling sound may be heard over areas
with chest hair

May be eliminated by wetting the hair or pressing
down firmly with the stethoscope
Bedside Assessment of the Patient

Auscultation

Subcutaneous Emphysema

Crackling sound is heard when stethoscope is
pressed down over an affected area
Chest exam reveals
seatbelt region
bruising and
significant upper
thoracic, neck, and
facial subcutaneous
emphysema.
Bedside Assessment of the Patient

Auscultation

Bone Crepitus

A clicking sound heard when bone ends rub
together as in rib or sternal fractures
L. SCAPULAR FRACTURE
(arrow) obscured by
subcutaneous emphysema,
rib fractures, and pulmonary
contusion.