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Chest examination - Part 1 - chest palpation

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VOL: 102, ISSUE: 44, PAGE NO: 26

Phil Jevon, PGCE, BSc, RN, is resuscitation officer/clinical skills lead, Manor Hospital, Walsall

Chest examination is a key component of respiratory system assessment. 

It includes chest palpation (described here), chest percussion and chest auscultation (described in parts two and three). Chest examination should complement other investigations.

Position of the trachea

The trachea should be checked to see if it is in the normal central position. This means the distance between the trachea and the sternomastoid muscles should be equal on both sides. Slight displacement of the trachea to the right is fairly common in healthy people (Talley and O’Connor, 2001). Tracheal deviation is indicative of mediastinal displacement to one side, which can be due to:

- Large volumes of air in the pleural space that push the lung away from the chest wall, for example pneumothorax;

- Large volumes of fluid in the pleural space that push the lung away from the chest wall, for example pleural effusion;

- Collapse of a single lobe or the complete lung, drawing the trachea towards the affected lung space.

Position of the apex beat can confirm or exclude mediastinal displacement (Ford et al, 2005). This is not a reliable sign if there is cardiomegaly (Epstein et al, 2003).

Cricosternal distance

Measuring the cricosternal distance can help determine if the patient is hyperventilating. A distance of less than three of the patient’s finger-breadths indicates hyperventilation, usually evident as a visible ‘descent’ of the trachea during inspiration (tracheal tug) (Ford et al, 2005).

Chest expansion

Chest expansion must be assessed to determine the depth and quality of movement on each side of the chest. Both sides should be assessed for symmetry. Unilateral decreased chest expansion, which is easier to detect, indicates pathology on that side, for example pneumothorax, pleural effusion, pneumonia and collapsed lung. Bilateral decreased chest expansion, which is more difficult to detect, is often seen in asthma and COPD. The symmetry and degree of chest expansion can be more accurately evaluated by observing chest movement than by palpating the chest wall (Ford et al, 2005).

Vocal fremitus

Tactile vocal fremitus refers to the vibrations that can be felt on the chest wall when the patient speaks. This can be assessed by placing the palm of each hand on the two comparable positions on the patient’s chest (anterior and posterior), then checking for differences in vibration while asking the patient to repeat the words, ‘99, 99… ’ (Talley and O’Connor, 2001).

Sound (and subsequent vibrations) is normally transmitted well in solid structures but poorly in air. Being able to appreciate the differences between normal and abnormal vibrations requires patience, although comparing one side to the other is often helpful. In normal lungs, the vibrations felt on the two sides of the chest should be similar (except over the heart). The mechanism and alterations of vibrations in disease are the same as for vocal resonance (part three of chest examination) (Epstein et al, 2003). When the two sides of the chest are compared, increased vibrations can be detected in cases of lung consolidation and decreased vibrations in the presence of pneumothorax or fluid (Adam and Osborne, 2005).

Chest-wall palpation

Gentle chest-wall palpation is indicated if the patient has chest pain. Local tenderness can be identified, the causes of which include bone, muscle and cartilage disease, and pleurisy (Ford et al, 2005; Epstein et al, 2003; Talley and O’Connor, 2001).


Checking the position of the trachea

- Using the forefinger of the right hand, identify the suprasternal notch (Fig 1);

- Gently push forefinger upwards and back until the trachea is palpated (Fig 2);

- Check to see if the finger slots more easily into one side of the trachea;

- Check the position of the apex beat to confirm/exclude mediastinal displacement (take care where cardiomegaly is evident as this may render this check unreliable).

Checking the cricosternal distance

- Locate the cricoid cartilage (below the thyroid cartilage or Adam’s apple);

- Insert the fingertips between the cricoid cartilage and the suprasternal notch, measuring the distance following full inspiration (Fig 3).

Checking chest expansion

- Place the hands on either side of the patient’s anterior chest;

- Position the thumbs together just either side of the midline, ensuring to keep them off the chest (‘in the air’), so they can move freely with respiration;

- Advance the fingers around both sides of the chest as far as possible;

- Ask the patient to breath in and out as normal. During inspiration the thumbs should move apart (Fig 4); during expiration the thumbs should return together (Fig 5);

- Repeat the procedure to check the patient’s posterior chest.

Checking vocal fremitus

- Place the palm of each hand on either side of the patient’s anterior chest (symmetrical positions);

- Ask the patient to repeat the words ‘99, 99…’;

- Repeat the procedure to check the patient’s posterior chest.

This article has been double-blind peer-reviewed.

Professional responsibilities

- This procedure should be undertaken only after approved training, supervised practice and competency assessment, and carried out in accordance with local policies and protocols.

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