C.

TRACHEAL / MEDIASTINAL DEVIATION (Marcial)

● Position of the trachea above the suprasternal notch and the location of
the apex beat
→ Indicate the position of the mediastinum and the lungs
● Shifting caused by imbalance of forces between 2 sides of the lungs
● Caused by various intrathoracic pathologic processes on one side of the
lungs
→ Pneumothorax
→ Pleural effusion
● Will push the mediastinum and trachea to opposite side of thorax
● Representation for deviation:
→ Arrow is drawn at the tracheal area to represent the deviation
→ Also used when apex beat is displaced
● Causes:
→ Atelectasis or collapse: trachea deviates ipsilaterally (same side)
Figure 14. Tracheal and Mediastinal Deviation to the left and to the right
→ Air or fluid: trachea deviates contralaterally (opposite)

D. PERCUSSION NOTES (Marcial)

● Important clues in physical diagnosis

● Has four qualities:
→ TYMPANIC
▪ Normal percussion note heard when the abdomen is percussed
▪ e.g. Gas-filled stomach bubble
→ RESONANT
▪ Normal percussion note heard when the normal chest is percussed
▪ e.g. Solid tissue (chest wall) overlying an air-filled lung tissue
− Best appreciated throughout the periphery of the lungs
− During a pathology, for example in pneumothorax and
emphysema (more air inside the chest cavity), the percussion
note becomes more hollow or drum-like = Hyperresonance
→ DULL
▪ Thud-like quality
▪ See additional description under "Flat" percussion note
→ FLAT
▪ As the acoustic mismatching of the chest cavity (with its contents)
and the chest wall diminishes, the percussion note changes to a Figure 15. Lung Auscultogram of Dull Percussion.
thud-like quality which we term as “dull” to almost no acoustic The area of interest or change in the percussion note is drawn with a cross
hatching or crisscrossing lines and is labeled with an arrow as
contrast which we term “flat” either hyperresonant, resonant, dull or flat.

E. VOICE SOUND TRANSMISSION (Marcial)

● Tactile fremitus refers to vibrations felt by the examining hands over the
chest by asking the patient to say “tres, tres, tres..” or “ninety-nine, ninety-
nine..”
→ Vibrations felt are the transmitted sounds originating from the vocal
cords and traveling to the airways, lung tissue, and the chest wall
● VOCAL FREMITUS
→ Term used when a stethoscope is used to listen to the sound over the
chest instead of feeling for the vibrations with a hand
● Fundamental notes produced by voice sounds
→ 130 Hz in males
→ 230 Hz in females
→ Overtones of 400-3500 Hz
● Normal voice sounds heard through the normal chest are attenuated and
filtered
● Sound transmission from vocal cords is dependent on the acoustic
properties of the airways, lungs, and chest wall
→ Frequency of <200 Hz is usually well transmitted
→ Frequency of >200 Hz is attenuated
▪ Leads to filtration of most of the vowel formants
− Reason for incomprehensible low-pitched mumble sound heard
through a stethoscope from normal speech
● Various pathologies in the chest that can asymmetrically alter these
acoustic properties are best appreciated as uneven transmission of
vibrations or sounds
→ e.g. Pneumonia that causes a lobar consolidation facilitates the
transmission of sounds due to the increased density of the lung tissue.
▪ Can be appreciated as an increased tactile/vocal fremitus
OTHER TYPES OF VOCAL RESONANCE
● Bronchophony
→ Increase in intensity and clarity of vocal resonance
→ Indicates an increased lung tissue density therefore increased
transmission of sound through the chest
● Whisper Pectoriloquy
→ Elicited by asking the patient to whisper (rather than say with a
normal voice tone) “tres, tres, tres” or “ninety-nine..”
● Egophony
→ Increased intensity of voice sounds that has a nasal or bleating
(goat-like) character
→ Elicited by asking the patient to say “eee…” while you listen using
a stethoscope
▪ When present, the “eee..” sounds like “aay…”
FYI: To simplify the lung auscultogram, the proposal made by the
ACCP-ATS is used in which it is to use plainly the words "increased" or
"decreased" transmission of the voice sounds
● e.g. In Figure 9, the area of the chest with decreased or increased
sound transmission is drawn with cross-hatchings and labeled
accordingly

MED.3.08 TBL: Lung Sounds 9 of 26