Terms Associated with Respiratory Percussion & Palpation

• Dullness — Associated with lobar pneumonia, where the alveoli are filled with fluid . It has a medium intensity, pitch and duration (e.g., normal liver).  The dullness replaces the normal resonance because fluid or tissue has filled the lung or pleural air space. Other pathological examples of dullness include, pleural effusion (accumulation of serous fluid in the pleural space), hemothorax (blood), empyema (pus), and other changes like fibrosis or malignancy.
  Because pleural fluid sinks to the lowest part of the pleural space, it may be very difficult to percuss anterior dullness in a supine patient; unless it is a very large effusion.
  Right middle lobe pneumonia typically occurs behind the right breast. In a female patient, it is very important to displace the breast in order not to miss the related dullness.
• Flatness — Associated with a large pleural effusion. It has a soft intensity, high pitch and short duration (e.g., thigh).
• Fremitus —  Palpable vibrations transmitted through the bronchopulmonary tree to the chest wall when the patient speaks. Use the bony part of your palm to feel the chest for vibrations. Ask the patient to repeat the words "ninety-nine." Fremitus is more prominent in the interscapular area, and more on the right than the left side. Examine midclavicular 2nd & 4th intercostal spaces, and anterior axillary 4th intercostal space.
  Fremitus is decreased when the vibrations are not transmitted from the larynx to the chest wall. May be due to an obstructed bronchus, COPD, pleural effusion, fibrosis, pneumothorax, or an infiltrating tumor.
  Fremitus is increased when there is increased transmission of vibrations. This is most often associated with the consolidated lung of lobar pneumonia. 
• Hyperresonance — A generalized/bilateral hyperresonance is associated with an over inflated lung, as seen with emphysema or asthma (not very reliable). On the other hand, a unilateral hyperresonance is associated with a pneumothorax (see tympany). This sound quality can not be percussed over any normal body part. It has a very loud intensity, very low pitch, and long duration.
  In emphysema, the hyperresonance may completely replace normal cardiac dullness.
• Resonance — Associated with either a normal lung or a simple chronic bronchitis. It has a very loud intensity, low pitch and long duration.
• Tympany — Associated with a very large pneumothorax. It has a loud intensity, high musical pitch, and long duration (e.g., gastric air bubble or puffed cheeks!).

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