PERCUSSION OF THE CHEST

What is percussion Rules of percussion

Is tapping of the body structure to produce audible sound & 1. From resonant to dull or less resonant area except in Kronig’s isthmus.
palpable vibration. 2. The pleximeter finger should be in firm contact with chest wall.
Aims of percussion 3. The long axis of the pleximeter finger should be parallel to the edge of the organ to be per
 To determine limits of lung resonance. cussed and the line of percussion should be perpendicular to the edge.
 To determine state of lungs as regard to quantity of air. 4. Light percussion is meant for the lungs.
 To determine any fluid or gas in pleural cavity or thickened 5. Heavy or deep percussion is meant for deeper organs e.g. liver.
pleura. 6. The chest is percussed along the mid- clavicular, the mid axillary and the scapular lines space
by space and rib by rib comparing both sides on front and back.
Types and technique of percussion
Immediated percussion (Direct percussion) 5. The right middle finger (plexor) should be partially flexed,
Strikes the chest either by the palmer aspect of the middle finger or tips of four fingers relaxed and ready to strike.
held tightly together. Clavicles & Sternum 6. With a quick, sharp but relaxed wrist motion strike the left
middle finger with the right middle finger
Mediated percussion (Indirect percussion) 7. Striking at distal interphalangeal joint.
1. Hyperextension of the middle finger of the left hand (the pleximeter finger). 8. We use the tip of the plexor finger not the finger pad.
2. Press its distal interphalangeal joint firmly on the surface wanted to be per cussed. 9. The striking finger should be at right angles with the pleximeter
3. We must avoid contact by any other part of the hand. finger.
4. The right forearm quit close to the surface with the hand cocked upward. 10. Thump about twice in one location and then move to another.

Percussion notes
Intensity Pitch Location Pathology
Flatness Soft High Thigh Large effusion
Dullness Medium Medium Medium Liver
Resonance Loud low Lung Bronchitis
Hyper-resonance Very loud lower None normally Emphysema Pneumothorax
Tympany Loud High Over stomach Large Pneumothorax

Steps of chest percussion

1. Upper border of the liver 2. Heart
 Heavy percussion on the right MCL. Right border Base of heart Left border
 The upper border of the liver 1. Starting by ICS above the upper border of the  started from a left position away from the
normally present in the 5th ICS liver. In the 2nd right apex beat and towards it.
2. Percuss from outside inwards towards the heart. and 2nd left  Also, from a left position away from the left
Emphysema: encroachment on liver 3. Normally no dullness is found to the right of the spaces border of the heart and towards it for each
dullness. sternum. intercostal space.

Thug’s
 3. Percussion of the chest proper
Patient lying down Patient sitting
Direct percussion of clavicles normally: resonant note. Percuss the lateral chest wall along anterior, mid and posterior axillary lines
Direct percussion of the sternum & manubrium normally cancellus resonance. while the patients raises his hands above his head and compare both sides.
Percuss the lung anteriorly along parasternal and midclavicular lines and Percuss posterior chest wall while the patient sit sits with his arms folded
comparing both sides. across the front of the chest.
Percuss Traube’s area. Percuss Kronig’s isthmus.
Percuss bare area of the heart. Tidal percussion
Special Areas
Kronig’s isthmus Bare area of the heart Traube’s area
Resonance Impaired note Hyper-resonance (tympanitic resonance)
 supra clavicular band By light percussion give over 4th and 5th spaces. It’s a lozenge Shaped area of tympanitic
 apex of the lung Part of heart not covered by lung on the left basal region overlying the fundus of the stomach.
 In emphysema there is encroachment on bare area.
 In cardiomegaly there is broadening of the area
which is referred to as ‘superficial dullness’
 Sternoclavicular joint to  Rt border: middle line  Rt border: Lt 6th ribs – Lt 8th costal cartilage
7th cervical  Lt border: middle line opposite 4th rib to 6th rib in  Lt border: Lt 9th – 11th in MAL
 Jx of medial 2/3 & lat 1/3 parasternal line  Upper Border: Lt 9th to Lt 6th rib in MCL
of clavicle to spine of  Inf border: concave border joining 4-6 ribsth
 Lower Border: Lt 8th costal cartilage – 11th rib in MAL
scapula
Dullness Widened resonance
Apical TB RVH & pericardial effusion Splenomegaly Left basal lung collapse
Apical Fibrosis Hyperresonant Hepatomegaly After basal pneumonectomy
Apical pneumonia  Emphysema Left pleural effusion Splenectomy
Apical Tumor(pancoast)  Pneumpthorax Pericardial Effusion Liver cirrhosis
Apical pleural thickening  Pneumomediastinum Full stomach & gastric tumor Dilatation of the stomach
Massive pleural effusion  Compensatory emphysema of left lung Infradiaphragmatic causes: ascites, Pneumothorax
Collapsed rt upper lobe pregnancy & subphrenic abscess

Tidal percussion
The lower border of lung resonance at the back is carefully noted in full inspiration and full expiration.
The distance between both represents approximately the range of movement of the diaphragm.
Normally around 4cm to 7cm or about 2 spaces.

Thug’s