OnExam

This test, also known as tactile vocal fremitus, is used to assess for abnormalities in the lungs such as consolidation and effusion. It requires no equipment.

Performing the Test

  1. Place the bony aspects of the hand (ball or ulnar surface) on the patient's chest
  2. Using one or two hands at a time, palpate bilaterally in an L-shaped pattern as outlined:
    • Posterior chest: Start at level of T1 (in between scapulae), descend to areas of T4 and T6, then finish laterally at T8 area
    • Anterior chest: Start at the level of sternal angle, then between the nipple and sternum, and finish laterally along costal margin
  3. Ask the patient to repeat the words "ninety-nine" in a sufficiently deep and audible voice for each point on the chest
  4. Compare symmetry from side-to-side

Evaluating the Result

  1. Decreased fremitus is suggestive of impeded transmission of vibrations from larynx to chest surface (e.g., obstructed bronchus, COPD, pleural effusion)
  2. Increased fremitus is suggestive of alveolar consolidation (e.g., pneumonia)
  3. Note that fluid (compared to air) increases sound transmission but with pleural effusion, separation of pleural surfaces impedes transmission
  4. For evaluation of a pleural effusion, absence of tactile fremitus is a significant test:
    • Absence of reduced tactile vocal fremitus: LR- = 0.21 (95% CI 0.12-0.37)
    • Dullness to conventional percussion: LR+ = 8.7 (95% CI, 2.2-33.8)
    • Asymmetric chest expansion: LR+ = 8.1 (95% CI = 5.2-12.7)

References

  1. Bickley LS. The thorax and lungs. In: Bickley LS, Szilagyi PG. Bates' Guide to Physical Examination and History Taking. 10th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2009:283-321.
  2. Wong CL, Holroyd-Leduc J, Straus SE. The rational clinical examination: Does this patient have a pleural effusion? JAMA. 2009;301(3):309-317.