Physical Assessment of the Respiratory Tract II: Palpation

Physical assessment of the respiratory tract is critical in identifying potential health issues. One key component of this assessment is palpation, a technique healthcare providers use to assess the body for abnormalities. This content explores the method of palpation in evaluating the respiratory tract, focusing on thoracic palpation and tactile fremitus.

Thoracic Palpation

Thoracic palpation detects tenderness, masses, lesions, respiratory excursions, and vocal fremitus. The nurse assesses the patient in the anterior and posterior of the chest wall for range and symmetry of excursion. In this procedure, the thumbs are placed along the costal margin of the chest wall or adjacent to the spinal column at the level of the 10th rib for anterior and posterior assessments, respectively.

During inhalation and exhalation, the nurse observes the movement of the thumbs, which should be symmetric under normal conditions. Decreased chest excursion could indicate chronic fibrotic disease, while asymmetric excursion might suggest splinting secondary to fractured ribs, trauma, pleurisy, or unilateral bronchial obstruction.

The tracheal position is also evaluated during palpation. A normal trachea is midline, and any deviation to the left or right could indicate a tension pneumothorax, neck mass, pneumonectomy, or lobar atelectasis.

Tactile Fremitus

Tactile fremitus refers to the vibrations of the chest wall that result from speech and can be detected on palpation. This is most pronounced with consonant sounds and varies based on numerous factors, including the thickness of the chest wall, the pitch of the voice, and the proximity of large bronchi to the chest wall.

To assess tactile fremitus, the nurse places their hands on the patient's thorax and asks the patient to repeat phrases such as "ninety-nine" or "one, one, one." The vibrations are detected with the hands' palmar surfaces or the extended hands' ulnar aspect.

Fremitus is most pronounced where large bronchi are closest to the chest wall. It is more prominent on the right side and decreases or disappears over the anterior chest wall. However, patients with emphysema exhibit almost no tactile fremitus, whereas those with pneumonia may have increased fremitus over the affected lobe.

Increased fremitus can indicate conditions where the lung becomes fluid or denser, such as pneumonia, lung tumors, thick bronchial secretions, or pleural effusion. On the other hand, decreased fremitus may suggest lung hyperinflation (e.g., barrel chest) or pleural effusion, while absent fremitus could indicate pneumothorax or atelectasis.

In conclusion, both palpation (especially thoracic palpation) and tactile fremitus play an essential role in the physical assessment of the respiratory tract. By understanding these techniques, healthcare professionals can better diagnose and treat potential respiratory issues.