Percussion. Comparative and topographic percussion of the chest.

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• Percussion of the chest is one of the basic, informative methods of examination of the respiratory patients.

• It allows revealing diagnostic signs of the respiratory diseases without modern additional investigations.

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• Percussion is a method of objective study consisting in tapping the patient's body to evaluate the physical properties of the underlying organs according to the character of the artificially produced sounds.

• There are two types of percussion: immediate and mediate.

• Immediate (direct) percussion consists in tapping the patient's body with one or several fingers.

• In indirect (mediate) percussion the tapping is performed on some object applied to the studied area. The most frequent method of indirect percussion is tapping with a finger on the finger.

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Physical grounds of percussion• Percussion is based on obtaining a sound

wave from the tissues as a result of their shacking on striking. Vibrations of the sounding bodies are due to their elasticity (air, metallic plate) or are produced under the influence of elasticity obtained with the body strain (string, membrane).

• Three sounds - clear (pulmonary), dull (deadened) and tympanic can be heard on percussion.

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• Clear lung sound is heard on percussion of the chest areas over an unchanged lung tissue.

A clear sound is heard when the amount of air in the lungs, the tension of the lung tissue, and the thickness of the covering structures are normal.

A clear lung sound is loud, long, low-pitched and not tympanic.

It changes its properties depending on a number of conditions: the properties of the chest, development of the muscles, the amount of subcutaneous fat.

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• Dull sound is heard in the areas neighboring with dense parenchymatous organs (heart, liver, spleen).

• This sound is silent, short, high-pitched, resembles the sound produced by tapping on the wood.

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• Tympanic resonance is produced in the areas neighboring with the air-filled cavities. Tympanic resonance has a musical shade which occurs at beating a drum. In a healthy person, tympanic resonance is heard only in one area of the chest, on the left lower anterior portion, so-called Traube's semilunar space. The upper border of this space is limited by the lower edge of the liver, to the left - spleen, below - costal arch. In this area, the thoracic wall adjoins the fundus of the stomach with an air sac, which is the cause of the tympanic resonance in this area.

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• The rules of the percussion. To obtain clear percussion sound it is necessary to observe the following rules:

• 1. The middle or the point finger of the left hand plays the role of the plessimeter.

• 2. The percussion taps are made with a soft portion of the end phalanx of the right-hand middle finger on the middle phalanges of the plessimeter finger.

• 3. The hands of the physician should be warm not to produce unpleasant sensations.

• 4. The plessimeter finger is applied to the patient's body tightly but without excessive pressure. When the pressure is strong, even a weak percussion tap gets the properties of a strong one, which is not desired because its effect propagates to the depth and around the studied point. The point and the ring fingers should be kept apart, sliding apart the skin of the patient.

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• 5. The axis of the end phalanx of the tapping finger as well as the direction of the percussion strike should be strictly perpendicular to the surface of the plessimeter finger. Only in this case the force of the percussion strike will be used to penetrate deep inside, not around the studied place.

• 6. Percussion strike should be light and always of the same force. It is necessary to learn to bend the hand only in the radioulnar joint, without moving the arm on tapping.

• 7. Percussion strike should be short and elastic.• 8. Percussion of the lungs should be performed in an

upright position, when the patient stands or sits.• 9. The examination room should be warm.

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Percussion allows answering two important questions:

1. What changes has occurred in the studied organ?2. What are the borders, size, and shape of the organ.

The answer to the first question is obtained at the so-called comparative percussion, topographic percussion answers the second question.

• Topographic percussion is used to determine the lower border of the lungs, their mobility, the height of the lung apices and the width of Kronig's fields.

• Comparative percussion allows to evaluate the morphological state of the underlying tissue considering the changes in the character of the sound.

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• Anterior median line (I. mediana) going vertically through the middle of the chest.

• Right and left sternal lines (/. sternalis dextra at sinistra) going along the both edges of the breastbone.

• Right and left parasternal lines (I. parasternalis dextra et sinistra) going vertically between the two above mentioned.

• Right and left medioclavicular lines (I. medioclavuculare dextra at sinistra) going through the middle of the both collarbones.

• Right and left anterior axillary lines (I. axillare dextra et sinistra) going through the anterior edges of the armpits.

• Right and left middle axillary lines (I. axillare dextra et sinistra) going vertically through the middle of the both armpits.

• Right and left posterior axillary lines (I. axillare posterior dextra et sinistra) going vertically through the posterior edges of the armpits.

• Right and left scapular lines (7. scapulare dextra et sinistra) going vertically through the angles of the shoulder blades.

• Right and left paravertebral lines (7. paravertebral dextra et sinistra) going vertically between the scapular lines and the line going through the processes of the vertebrae.

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• Comparative percussion of the lungs allows determining the presence of pathological changes judging by the changes in the character of the percussion sound. The obtained percussion sound is compared with normal sounds.

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Technique of comparative percussion Comparative percussion is performed in the following order:

1) apices;

2) anterior surface of the lungs: along the intercostal spaces;

3) lateral surfaces: along the axillary lines;

4) posterior surface: along the scapular lines over the shoulder and above the angle of the scapula in the interscapular space.

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• Dullness of percussion sound is caused by reduction in the amount of air in the lung tissue, filling the pleural cavity with fluid, thickening of the pleura.

- pneumosclerosis, fibrous focal pulmonary tuberculosis, hepatization stage of lobular pneumonia, lung abscess, echinococcus cyst, tumor, lung infarction, complete atelectasis

- Dullness can be observed in pleura thickening, tumors, presence of fluid in the pleural cavity (hydrothorax, pyothorax, hemothorax, exudation pleuritis).

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Tympanic character of the sound is observed at increased amount of air or decreased elasticity of the lung tissue.

This may be observed at pneumothorax, at presence of an air-filled cavity (lung abscess, tuberculosis), when the cavity is large enough (>3—4 cm) and located close to the chest wall.

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Topographic percussion of the lungs

• Determining the borders of the lungs starts from the lower border of the right lung (pulmonohepatic border), percussion is done from the top (beginning with the subclavicular area) downward along the parasternal, medioclavicular, axillary, scapular and paravertebral lines.

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Lower borders of the lungsPlace of percussion Right lung Left lung

Along the parasternal line 5th intercostal space —

Along the medioclavicular line 6th intercostal space —

along the anterior axillary line 7th intercostal space 7th intercostal space

along the median axillary line 8th intercostal space 8th intercostal space

along the posterior axillary line 9th intercostal space 9th intercostal space

along the scapular line 10th intercostal space 10th intercostal space

along the paravertebral line 11th thoracic vertebra 11th thoracic vertebra

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• Determining the upper border of the lungs • The upper border of the lung is determined using

percussion of the lung apices over the collarbone and the spine of scapula (spina scapulae). The percussion is started from the middle of the supraclavicular fossa going upwards (silent percussion, the plessimeter finger is parallel to the studied border). On the back, the percussion is done from the middle of the fossa supraapinata to the process of the 7th cervical rib. With this method, the apex is 3—5 cm above the collarbone, and at the level of the 7th cervical vertebra on the back.

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Palpation of the heart Palpation of the apex beat

Technique. Place the palm of your right hand on the chest about at the level of and parallel to the 3r - 6th ribs. Flex the terminal phalanges of three fingers and slide them medially along the interspaces until the moderately pressing fingers feel the movement of the heart apex.

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• Location

• A normal apex beat is found in the 5 intercostal space 1-1,5 centimeters toward to the sternum from the left midclavicular line. If the patient slightly leans forward or during deep inspiration you can better detect apex beat, because in these positions the heart presses closer to the chest wall. When the patient lies on his left side, the beat is displaced 3-4 cm to the left, and on right side - 1-1,5 cm to the right. In about one third of cases the apex beat is impalpable: covered by rib.

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Causes of the apex beat displacement.

Physiological

Pathological

Noncardiac Cardiac

Respiration phases

Position on the left, right side, lying, standing position

Constitutional types

Changes of pressure in the chest and diaphragm level

Changes of pressure in the pleural cavities

Tumor of the lungs and mediastinum

Changes of the heart chambers size

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Percussion of the heart

• The right contour of the heart is formed by the right atrium at the bottom and by the superior vena cava to the upper edge of the 3r rib.

• The left contour is formed by the arch of the aorta, pulmonary trunk, auricle of the left atrium, and downward by the narrow strip of the left ventricle.

• Relative cardiac dullness - is the projection of its anterior surface onto the chest. The relative cardiac dullness corresponds to the true borders of the heart.

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• In order to determine the borders of the relative cardiac dullness the remotest points of cardiac contour are first found on the right, then at the top, and finally on the left.

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Borders Location Formed by

Right 4th intercostal space laterally of the right edge of the sternum

Right atrium

Upper 3rd intercostal space in the left parasternal line

Cone of the pulmonary artery, the auricle of the left atrium

Left 5th intercostal space medially of the left midclavicular line

Left ventricle

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Displacement of the relative cardiac dullness borders. Physiological and pathological causes.

Extracardiac Cardiac

Physiological Pathological

Position of the bodyConstitutional typesDiaphragm level(pregnancy)

Pulmonary pathologyFluid, air in the pleural cavityDiaphragm level (ascitis)

Changes of the heart chambers size and volume

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• Transverse width of the heart is the sum of distance from the right border of the relative cardiac dullness to the anterior median line (3-4 cm) and from the left border of the relative cardiac dullness to the median line (8-9 cm). The transverse width is measured by a measuring tape, and normally is 11-13 cm.

• Enlargement of the cardiac transverse width is observed in hypertrophy and dilation of the heart chambers.

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The borders of the vascular bundle are determined by light percussion in the 2nd

intercostal space from midclavicular line to the right and left toward the sternum. The borders of the vascular bundle are normally found along the edges of the sternum. The normal width of the vascular bundle is 4-6 cm.

The width of the vascular bundle is increased in:• Dilation of the pulmonary artery in elevated

pressure in it;• Aortic aneurysm;• Syphilitic mesoaortitis.

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• Absolute cardiac dullness is the projection of the anterior surface of the heart, which is not covered by the lungs onto the chest. Absolute cardiac dullness is formed by the right ventricle.

• Technique. The right border of the absolute cardiac dullness is first elicited. Place your pleximeter-finger on the right border of the relative cardiac dullness parallel to the sternum, and using light percussion stroke move it medially to dullness.

• To determine the upper border place pleximeter-finger on the upper border of the relative cardiac dullness and move downward to dullness.

• To outline the left border place pleximeter-finger slightly outside the left border of the relative cardiac dullness and move medially.

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Normal borders of the absolute cardiac dullness:

• The right - along the left edge of the sternum from 4th to 6th rib;

• The upper - lower edge of the 4th rib in the site of its connection with the left sternal edge;

• The left - 5th intercostal space 0.5 cm medially of the left border of the relative cardiac dullness.

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Changes of absolute cardiac dullness area

Decreasing Increasing

Low diaphragm level

Pulmonary emphysema

Left-sided pneumothorax

Pregnancy

High diaphragm level (ascitis, meteorism)

Tumor of mediastinum

Dilation, hypertrophy of the right ventricle

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