Sutton Andrew E., Modi Pranav
University of Rochester School of Medicine and Dentistry
North Mississippi Medical Center, Tupelo, MS
Chest inspection, palpation, and auscultation constitute essential components of the physical examination in patients with respiratory disease. Palpation confirms findings observed during inspection and evaluates pleural and pulmonary parenchymal conditions by assessing vocal fremitus. Tactile vocal fremitus is the palpation of the chest wall to detect variations in vibratory intensity generated by specific spoken words in a steady tone, providing information regarding underlying pulmonary pathology (see . Tactile Vocal Fremitus). Sound vibrations generated in the larynx during phonation are transmitted through the bronchi and lung parenchyma to the chest wall. The efficiency of this transmission depends on the physical properties of the underlying lung and pleural structures. Normal lung parenchyma consists of air-filled alveoli and solid tissue. Air is a poor conductor of low-frequency sound, whereas denser media enhance transmission at these frequencies. Vocal fremitus decreases in conditions that alter the density or integrity of the lung parenchyma, pleura, or chest wall. Vocal fremitus is reduced in bronchial asthma, emphysema, and bronchial obstruction due to air trapping and decreased parenchymal density. Pleural effusion and pneumothorax similarly diminish transmission of low-frequency vibrations by introducing fluid or air into the pleural space. Attenuation of vocal fremitus also occurs in individuals with increased subcutaneous tissue, such as those with obesity. Inflammation and consolidation increase tissue density, thereby enhancing the transmission of low-frequency sounds and the detection of vocal fremitus. Vocal resonance represents the auscultatory counterpart of vocal fremitus, with characteristic changes observed in various pulmonary conditions. Bronchophony is characterized by increased sound intensity over areas of consolidation. Whispering pectoriloquy occurs when whispered words, such as “one, two, three,” are auscultated clearly over consolidated lung regions, reflecting the same underlying phenomenon as increased vocal fremitus. Egophony, or the “E-to-A” change, denotes a qualitative alteration in vocal tone in which specific frequencies transmitted through consolidated tissue distort the vowel “E” into a sound perceived as “A” or “AAAH.” Additional types of fremitus include ronchial fremitus, corresponding to palpable rhonchi, and pleural fremitus, representing a palpable pleural rub.
胸部视诊、触诊和听诊是呼吸系统疾病患者体格检查的关键组成部分。触诊通过研究语音震颤来确定通过检查和评估胸膜及肺实质状态所提示的体征。语音（触觉）震颤是通过触诊胸壁来检测在恒定音调及声音下说出特定词语时所产生振动强度的变化，提示潜在的肺部病变。发声时在喉部产生的声音振动会传递至支气管和肺部，然后传导至胸壁。语音的传导取决于胸膜腔内潜在肺部实质的状态。正常肺实质是充满空气的腔隙与实性肺实质的混合。空气是低频声音的不良导体，而实性或致密介质会增加低频声音的传导。在影响肺实质、胸膜或胸壁的情况下，语音震颤可能会减弱。支气管哮喘、肺气肿或因气体潴留和肺实质密度降低导致的支气管阻塞时，语音震颤会减弱。在胸腔积液和气胸的情况下，空气/液体积聚在胸壁与肺实质之间的潜在腔隙中，会降低低频声音振动的传导。肥胖个体的语音震颤也可能减弱。另一方面，炎症和实变会形成致密介质，增加低频声音和语音震颤的传导。语音共振是语音震颤的听诊对应表现。可出现以下语音共振变化。在实变区域听到更大的声音。当检查者在肺野听诊时，要求患者轻声说“一、二、三”。在实变存在时，轻声话语能清晰听到。耳语音与增强的震颤具有相同意义，且并未给这些检查方法增添新信息。声音的定性改变类似于山羊的咩咩叫声。特定声音频率能够穿过实变区域，并倾向于使元音“E”的声音失真，从而使检查者将其感知为“A”或“啊啊”。支气管震颤——可触及的啰音。胸膜震颤——可触及的胸膜摩擦音。
