Why is tactile fremitus increased in tension pneumothorax?

[footcloud]

But decreased in pneumothorax? I thought both cases had increased air in the pleural space?

Thanks!

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[Zoom-Zoom]

But decreased in pneumothorax? I thought both cases had increased air in the pleural space?

Thanks!

I'm speculating here -- but I'd guess that when you're getting solid stuff pushed over to one side of the chest cavity, that side will transmit vibration more effectively than a healthy chest would. You might also be getting some pleural friction.

 

[Superfrost]

I've never seen anyone do tactile fremitus to evaluate for pneumothorax in real life.

 

[xrevision]

If your pt is suffering from a tension pneumothorax he/she is NOT going to be happy if you're listening for vtf.

 

[MilkmanAl]

Just think about it intuitively. What resonates more: a drum (hollow chest cavity) or a block of wood (chest cavity filled with a lung)?

If your pt is suffering from a tension pneumothorax he/she is NOT going to be happy if you're listening for vtf.

But ICM says you're supposed to!

 

[lisichka]

i thought fremitus should be decreased in pneumothorax --gas(i.e. bleb)

fremitus low
breath sound low
resonance/percussion high.

tension PTX--trachea deviates away from the bad lung.
nontention PTX/obstruction--trachea deviates toward the bad lung.

may be i am missing something?

fremitus (say 1,2,3) increases over a solid tumor.

 

[username456789]

Just think about it intuitively. What resonates more: a drum (hollow chest cavity) or a block of wood (chest cavity filled with a lung)?

But what you just described has much more to do with percussing than with checking for fremitus. It's the "solid" in consolidations that allow for increased vibratory transmission.

My first question on this thread to the OP would be: Who told you a tension ptx results in increased fremitus?

 

[jdh71]

This would depend on which side of the thorax you're listening, would it not, my friends?

 

[username456789]

This would depend on which side of the thorax you're listening, would it not, my friends?

I wouldn't expect to appreciate increased tactile fremitus unless the mediastinum was severely displaced towards the side I was checking.

But what do I know.

 

[Smurfette]

If your pt is suffering from a tension pneumothorax he/she is NOT going to be happy if you're listening for vtf.

How many patients died for someone to determine this?

Seriously, if your patient has a tension pneumothorax and you stop to check for tactile fremitus and percuss and other such things, your patient is going to be dead. If a patient develops a tension pneumo, the clock is ticking to save their life. Do not waste time. Do NOT get a CXR. Needle decompress and place a chest tube.

For those of you who haven't yet started your clinical years, this is a classic surgery pimp question in trauma/critical care scenarios.

 

[username456789]

How many patients died for someone to determine this?

Seriously, if your patient has a tension pneumothorax and you stop to check for tactile fremitus and percuss and other such things, your patient is going to be dead. If a patient develops a tension pneumo, the clock is ticking to save their life. Do not waste time. Do NOT get a CXR. Needle decompress and place a chest tube.

For those of you who haven't yet started your clinical years, this is a classic surgery pimp question in trauma/critical care scenarios.

Surely you remember the idiocy of the preclinical curricula as they try to force the basic PD skills into awkward clinical scenarios.

"Question 14: You're carefully measuring jugular venous pressure in a healthy 7 year old for a school physical . . . "

 

[MilkmanAl]

I wish I could remember the exact wording, but we had an ICM question where a guy was just about to have a heart attack in the office and didn't want to get a heart cath. The correct answer was something along the lines of discussing why he didn't want to have the procedure.

 

[45408]

How many patients died for someone to determine this?

Seriously, if your patient has a tension pneumothorax and you stop to check for tactile fremitus and percuss and other such things, your patient is going to be dead. If a patient develops a tension pneumo, the clock is ticking to save their life. Do not waste time. Do NOT get a CXR. Needle decompress and place a chest tube.

For those of you who haven't yet started your clinical years, this is a classic surgery pimp question in trauma/critical care scenarios.

Uh, that's actually a pretty significant finding right there, and you can do it in about 10 seconds to compare both sides. Decreased breath sounds + hyperresonance = tension. Tracheal deviation is a pretty late finding. How would you diagnose a tension?

It was one of the exam findings that our trauma surgery attending had on a presentation she gave two weeks ago, so she certainly thought it was reasonable to do. Tactile fremitus though....not so much.

 

[Rendar5]

Uh, that's actually a pretty significant finding right there, and you can do it in about 10 seconds to compare both sides. Decreased breath sounds + hyperresonance = tension. Tracheal deviation is a pretty late finding. How would you diagnose a tension?

It was one of the exam findings that our trauma surgery attending had on a presentation she gave two weeks ago, so she certainly thought it was reasonable to do. Tactile fremitus though....not so much.

someone with tension ptx isn't gonna cooperate for checking fremitus. The only thing I would add to your picture is hypotension. It's quick and easy, but hard to hear percussion in a trauma bay with lots of stuff going on, so I'd go with needle decompression just for hypotension + decreased breath sounds. But if you can hear hyperresonance in that situation, all the power to you. It takes a couple seconds only.

I agree that you should never expect to see tracheal deviation in a true clinical situation. And if you are checking for fremitus or wait for a CXR, smack to the head for ya.

 

[lisichka]

what is the most common cause of Tension pneumothorax that you usually see? and how often? any interesting clinical scenarios?

 

[45408]

what is the most common cause of Tension pneumothorax that you usually see? and how often? any interesting clinical scenarios?

in the ER? probably penetrating trauma. In a medical ICU, probably barotrauma from the ventilator.

 

[kryptik]

FA says tactile fremitus is absent in tension pneumothorax

 

[Smurfette]

Uh, that's actually a pretty significant finding right there, and you can do it in about 10 seconds to compare both sides. Decreased breath sounds + hyperresonance = tension. Tracheal deviation is a pretty late finding. How would you diagnose a tension?

It was one of the exam findings that our trauma surgery attending had on a presentation she gave two weeks ago, so she certainly thought it was reasonable to do. Tactile fremitus though....not so much.

These patients are using crumping rapidly in front of your eyes. Hypotensive, dropping sats, labored breathing, tachypneic, etc. Usually there is a flurry of activity going on in the room due to the fact that the patient is decompensating or about to code. With all that going on, it is not reasonable to try to re-position the patient to facilitiate percussing, nor is it going to be easy to confidently hear hyper vs hyporesonance vs nl resonance. Sometimes it's hard to hear/distinguish anything, esp if the patient is on a vent, it's a large patient, or there's a lot of movement in the room/with the patient. My point is more that if you suspect a tension pneumothorax, treat it and don't screw around trying to find more physical exam findings.

I've seen multiple tensions, both from trauma and from ventilator barotrauma. The whistling of air through the needle is highly satisfying.

One of the more memorable ones: the patient with a sucking chest wound who EMS placed an occlusive dressing on---ripped off the dressing and ppfffttttt....air comes rushing out and patient's BP and HR immediately improved.

 

[45408]

FA says tactile fremitus is absent in tension pneumothorax

As I would expect with no parenchyma to transmit the vibrations.

 

[45408]

These patients are using crumping rapidly in front of your eyes. Hypotensive, dropping sats, labored breathing, tachypneic, etc. Usually there is a flurry of activity going on in the room due to the fact that the patient is decompensating or about to code. With all that going on, it is not reasonable to try to re-position the patient to facilitiate percussing, nor is it going to be easy to confidently hear hyper vs hyporesonance vs nl resonance. Sometimes it's hard to hear/distinguish anything, esp if the patient is on a vent, it's a large patient, or there's a lot of movement in the room/with the patient. My point is more that if you suspect a tension pneumothorax, treat it and don't screw around trying to find more physical exam findings.

I've seen multiple tensions, both from trauma and from ventilator barotrauma. The whistling of air through the needle is highly satisfying.

One of the more memorable ones: the patient with a sucking chest wound who EMS placed an occlusive dressing on---ripped off the dressing and ppfffttttt....air comes rushing out and patient's BP and HR immediately improved.

And my point is that how are you going to suspect a tension pneumothorax without any physical exam findings? Hypotension, dropping sats, and labored breathing could be due to more than just a tension (sepsis+ARDS, cardiac injury with tamponade, etc), so you need something that actually points you towards that diagnosis.

 

[kryptik]

And my point is that how are you going to suspect a tension pneumothorax without any physical exam findings? Hypotension, dropping sats, and labored breathing could be due to more than just a tension (sepsis+ARDS, cardiac injury with tamponade, etc), so you need something that actually points you towards that diagnosis.

history

 

[Droopy Snoopy]

And my point is that how are you going to suspect a tension pneumothorax without any physical exam findings? Hypotension, dropping sats, and labored breathing could be due to more than just a tension (sepsis+ARDS, cardiac injury with tamponade, etc), so you need something that actually points you towards that diagnosis.

In the ICU, by the time your backup arrives (fellow, upper level) you can usually get a portable CXR. I'm not poo-pooing a good physical exam, but a quick film will distinguish a barotrauma-induced pneumo, flash pulm edema, a big mucus plug, whatever much faster and more definitevely than a battery of (listener subjective) exam findings.

 

[footcloud]

Thanks for the replies! A classmate that that it was increased, which confused me. Now I'm not really sure whether it's increased for tension pneumothorax.

This is for an OSCE, and I agree that doing tactile fremitus in a clinical setting is probably not the way to go.

 

[Rendar5]

And my point is that how are you going to suspect a tension pneumothorax without any physical exam findings? Hypotension, dropping sats, and labored breathing could be due to more than just a tension (sepsis+ARDS, cardiac injury with tamponade, etc), so you need something that actually points you towards that diagnosis.

In the trauma setting, decreased breath sounds on one side with extremely sudden onset hypotension in the appropriate situation is enough to warrant a needle. Either they improve suddenly and dramatically, or you didn't do much damage and can proceed on to find they have cardiac tamponade + hemothorax. You CANNOT DO tactile fremitus in a patient in extremis. You CAN percuss, and I have no problem with it provided it does not take you more than 10 seconds to do it and be confident in what you heard, but I challenge you to find a situation in which you receive a trauma and have a quiet enough room to determine percussion sounds. And if they're more or less equal, are you not going to stick a needle by the 2nd rib? Based on that, only 2 physical exam findings + history are needed to treat for tension ptx.

 

[45408]

history

So is it tamponade or a tension from the penetrating trauma to the chest resulting in hypotension, dropping sats and dyspnea?


Edit - In addition, if you're doing a primary survey in a trauma, you shouldn't have obtained a blood pressure if you're still on airway and breathing.

 

[SouthernSurgeon]

So is it tamponade or a tension from the penetrating trauma to the chest resulting in hypotension, dropping sats and dyspnea?

I think you are getting somewhat stuck on this point. Everyone else has correctly pointed out that in the trauma/emergent setting the patient would get a needle decompression or chest tube before any fiddling around with percussion or tactile fremitus.

As a serious answer to your question - in the traumas I've seen? If the patient you described had decreased breath sounds on either side those findings would warrant a chest tube. If not, then they would shoot a portable to look for a pneumo and stick an ultrasound on the chest to look for tamponade. If the patient was truly unstable then they would get bilateral chest tubes before anyone tried percussing or fremitussing.

 

[45408]

I think you are getting somewhat stuck on this point. Everyone else has correctly pointed out that in the trauma/emergent setting the patient would get a needle decompression or chest tube before any fiddling around with percussion or tactile fremitus.

Yeah, and I'm saying percussion is not fiddling. I'm not saying it's necessary, but it's not a waste.

As a serious answer to your question - in the traumas I've seen? If the patient you described had decreased breath sounds on either side those findings would warrant a chest tube.

I just think it's ironic that people are saying you'd never hear hyperresonance in a "noisy ER" but you could somehow hear decreased breath sounds. Seems like 6 of one, half a dozen of the other.

 

[SouthernSurgeon]

I just think it's ironic that people are saying you'd never hear hyperresonance in a "noisy ER" but you could somehow hear decreased breath sounds. Seems like 6 of one, half a dozen of the other.

I've done the primary/secondary survey in trauma resuscitations and could hear breath sounds with enough accuracy to feel confident in my findings and my residents/attendings were confident enough in my findings to base clinical management off of that. I don't think I could say the same about percussion, so I wouldn't do it. I also think my chief resident would have looked at me like a freak if I'd tried.

 

[SouthernSurgeon]

Edit - In addition, if you're doing a primary survey in a trauma, you shouldn't have obtained a blood pressure if you're still on airway and breathing.

LOL this isn't a textbook or an OSCE. All this information comes to you essentially simultaneously; ABCDE just gives you a framework/algorithm for prioritizing and working through. The second a trauma patient rolls into the bay the nurses will hook them up to the monitor WHILE you do the rest of your primary survey - they won't wait for you to finish A&B to hook up the BP cuff. You will also have BPs from the field and have an awareness of their hemodynamic profile while you handle the airway and breathing.

 

[45408]

LOL this isn't a textbook or an OSCE. All this information comes to you essentially simultaneously; ABCDE just gives you a framework/algorithm for prioritizing and working through. The second a trauma patient rolls into the bay the nurses will hook them up to the monitor WHILE you do the rest of your primary survey - they won't wait for you to finish A&B to hook up the BP cuff. You will also have BPs from the field and have an awareness of their hemodynamic profile while you handle the airway and breathing.

Ours will wait, and they do, because the trauma surgeons here don't mess with the alphabet. They don't even check the BP with the machine the first time either - they do it manually, and only after the ABCs have been gone through.

 

[SouthernSurgeon]

Ours will wait, and they do, because the trauma surgeons here don't mess with the alphabet. They don't even check the BP with the machine the first time either - they do it manually, and only after the ABCs have been gone through.

Just goes to show the different approaches at different places. Our attendings (ED and trauma) don't "mess with the alphabet" either. But our resuscitations are a very fast process where all this data is getting collected nearly simultaneously by the various team members. The only times I have seen manual pressures get obtained in a trauma is when there is a suspected discrepancy between the clinical picture and the reading on the monitor.

 

[jdh71]

This discussion is getting ridiculous.

If the lung is all crammed up on one side, you will get increased fremitus on the side away form the pneumo. Technical brownie points to the people who write PDX textbooks. You will NEVER feel for it in regular practice.

The clinical scenarios have already been painted for you - either mechanical trauma or barotrauma from a vent. These are your non-zebra scenarios. You will see the patient is not doing well. You will see low blood pressure in the setting of hypoxia, tachypnia, and tachycardia. You will not hear breath-sounds on one side. You will place a large bore needle in the proper location and then place or arrange for a large-bore surgical chest tube.

ABCDE's are essentially done simultaneously. If someone is gushing blood, I promise you'll be holding pressure and dumping in fluid and blood (oh noes doing "C") while someone is assessing the airway and breathing.

 

[Rendar5]

Yeah, and I'm saying percussion is not fiddling. I'm not saying it's necessary, but it's not a waste.


I just think it's ironic that people are saying you'd never hear hyperresonance in a "noisy ER" but you could somehow hear decreased breath sounds. Seems like 6 of one, half a dozen of the other.

I agree with the first thing you said. But disagree with the irony that you mentioned. Stethoscopes mute down outside sounds if you have decent earpieces and a breath sound through a stethoscope tends to be louder than a percussion note anyway unless you have someone with distant breath sounds.

And as for the way trauma surgeons wont' allow nurses to assess vitals before a chest tube is properly positioned, just seems strange anda poor use of resources. I agree that you act in the order of ABCDE's, but that doesn't mean you don't let someone assess the vitals while you're intubating the patient. Especially when the blood pressure is going to be more informative than the percussion in differentiating ptx from tension ptx.

 

[Rendar5]

So is it tamponade or a tension from the penetrating trauma to the chest resulting in hypotension, dropping sats and dyspnea?

Tamponade does not tend to cause hypoxia like tension. Both cause hypotension though. Easiest way to differentiate? needle in chest. You either hear a woosh or not.