Main goals and objectives of the method
Palpation of the chest wall serves several important diagnostic purposes in propedeutics of internal diseases. First of all, the physician aims to detect asymmetry of respiratory movements, which may indicate unilateral lung or pleural involvement.
In addition, palpation is necessary for:
- Determining resistance, i.e., the elasticity and compliance of the chest wall under mechanical compression.
- Assessing the vocal fremitus phenomenon, which reflects the physical properties of the lung tissue.
- Precisely localizing areas of tenderness, for example, in the intercostal spaces.
Assessment of respiratory excursion and resistance
To detect asymmetry of respiratory movements, the physician places their palms on the lateral (side) surfaces of the patient's chest wall. Afterwards, the patient is asked to take as deep a breath as possible. At this moment, the specialist closely monitors the synchrony with which their hands move apart. If one half of the chest lags behind in the act of breathing, this is a clear sign of a pathological process.
Determining resistance consists of assessing the resistance that the chest wall offers when compressed by the examiner's hands. Normally, it should be sufficiently elastic. If resistance increases (the chest wall becomes rigid, stiff), this has important diagnostic significance. Such rigidity typically occurs with marked consolidation of the lung tissue or with an accumulation of fluid in the pleural cavity, which clinically is called hydrothorax.
Examination of vocal fremitus
Vocal fremitus (fremitus vocalis or fremitus pectoralis) is a palpatory sensation of specific resonant vibration of the chest wall that occurs during phonation (speaking words).
The physical basis of this phenomenon lies in the propagation of predominantly low-frequency sound vibrations. These waves originate at the level of the vocal cords, descend through the structures of the bronchial tree, and are transmitted to the surface of the chest wall.
Execution Technique:
- The physician firmly applies their palms to strictly symmetrical areas of the patient's chest wall.
- The patient is asked to pronounce words rich in low-frequency sounds (most often with the letter "R"). Classic examples are the phrases "thirty-three" or "thirty-four".
- The specialist compares the intensity of vibration under both hands.
It is important to consider topographic features: in a healthy person, vibration is most clearly felt precisely in the upper parts of the chest. This is explained by their anatomical proximity to the trachea and large bronchi, which are the main pathways for conducting sound vibration.
Clinical interpretation of vocal fremitus
Any change in the intensity of the conducted sound indicates that the physical properties of the lung tissue itself or the pleural cavity have changed.
Enhancement of vocal fremitus occurs due to consolidation of the lung tissue. When the tissue loses air content and becomes more homogeneous, it begins to conduct sound waves much better. This symptom is characteristic of such diseases as pneumonia, pulmonary infarction, and compression atelectasis.
Weakening of vocal fremitus is observed when a peculiar obstacle to sound forms (the emergence of a heterogeneous medium) or with a pathological increase in the air content of the lung tissue. This condition is diagnosed in:
- Accumulation of fluid (hydrothorax) or gas (pneumothorax) in the pleural cavity.
- Increased air content of the lungs themselves, which is typical for emphysema.
Additional capabilities of palpation
Palpating the chest wall is not limited to checking vocal fremitus and excursion. The physician may also detect a number of other important clinical symptoms:
- Pleural changes. In inflammation of the pleural leaves (dry pleurisy), their friction against each other can be felt by palpation.
- Assessment of the lymphatic system. Peripheral lymph nodes are carefully palpated — cervical, axillary, and cubital. Their pathological enlargement may be a sign of tuberculosis infection or the presence of tumor processes in the respiratory system.
- Condition of superficial tissues. Skin turgor and moisture, the condition of subcutaneous tissue and muscles are assessed. Local pain points are also identified, especially in the intercostal spaces.
- Subcutaneous emphysema. If air pathologically penetrates into the subcutaneous adipose tissue, upon pressing the skin with fingers, the physician will feel a specific crackling or "crunching" sensation — crepitation.
Briefly: answers to topical questions
Which groups of peripheral lymph nodes are palpated during the examination of the respiratory system?
When examining the respiratory system, the condition of the following groups of peripheral lymph nodes is assessed by palpation:
- Cervical — superficial (anterior to m. sternocleidomastoideus).
- Axillary — deep within the axillary fossae (fossa axillaris).
- Cubital — on the anterior surface of the forearm (along the course of v. basilica).
Their enlargement may indicate tuberculosis or tumor processes in the lungs.
In what diseases is local tenderness in the intercostal spaces detected?
Local tenderness in the intercostal spaces upon palpation is directly indicated for intercostal neuralgia: sharp tenderness is noted along the intercostal spaces, at the nerve exit points near the spine and at the sternal margin.
To check vocal fremitus, words with the letter "R" ("thirty-three") are always used, because it is precisely rolling, low-frequency sounds that create the best vibration for conduction through the bronchial tree.
Class and exam questions
Why is vocal fremitus normally stronger in the upper sections?
This is due to the anatomy of the airways. The upper parts of the chest are closer to the trachea and large bronchi, which are the main source of conducting sound vibrations from the vocal cords.
Under what conditions does the chest become rigid?
Chest resistance (rigidity) increases with massive consolidation of the lung tissue or in the presence of fluid in the pleural cavity (hydrothorax).
What is the difference between the mechanisms of enhancement and weakening of vocal fremitus?
Enhancement occurs when a dense, homogeneous medium appears (e.g., in pneumonia), which conducts sound excellently. Weakening occurs when a barrier of fluid or gas appears (hydrothorax, pneumothorax) or with excessive tissue air content (emphysema).
How to determine subcutaneous emphysema by touch?
When air enters the subcutaneous tissue during palpation, a characteristic crackling or crunching sensation called crepitation is determined under the fingers.
What else to study on this topic
- Mechanisms of formation and clinical picture of hydrothorax and pneumothorax
- Diagnosis of dry pleurisy: pleural friction rub
- Compression atelectasis: causes of lung tissue consolidation
- Pathological changes in peripheral lymph nodes in tuberculosis and tumors
- Physical syndromes of increased lung air content (emphysema)
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