1. Tactile fremitus – the power in your hand

As a simple one-liner, we can define tactile fremitus as the transmitted vibration of the patient’s voice to the chest wall, where we detect it by the hand

Fremitus, in general, is a vibration transmitted through the body and can be detected in a simple maneuver in physical examination. Yet it provides us with plentiful valuable information and nearly half the diagnosis. 

Sometimes it is named as vocal fremitus, as the vocal cords create the vibrations. When the vocal fremitus is felt/palpated with our hand, we call the phenomenon tactile fremitus or combining the two phrases: tactile vocal fremitus.

Tactile fremitus should be determined for all lung areas and symmetrically. We must compare the intensity of the vibrations detected by each hand during quiet breathing and speech as only asymmetrical tactile fremitus is an abnormal finding. We will see why, after we learn about the pathomechanisms involved. 

2. How to Assess

To evoke the most effective vibration, we ask the patient to say ‘blue balloons’. At the same time, we place the palm of the hand to the posterior chest wall of the patient, starting at the top and moving to the bottom, continuously comparing the vibration on both sides.

3. Mechanism

The transmission of the vibration depends on the media between the lung and the chest wall. Thick chest wall insulates the hand from the vibrating lung and may result in decreased or even absent tactile fremitus in healthy persons as well. It may also be decreased in high-pitched or soft voices, e.g. in women. However, in these cases, tactile fremitus is symmetrically reduced. 

Fremitus is more certainly abnormal when it is increased or decreased asymmetrically. 

Air, fluid, or tumor tissue can push the lung away from the chest wall in one location or side and decrease the fremitus. But sound waves are transmitted with less decay in a solid or fluid medium such as a consolidated lung. 

The following table shall be of help/guidance for your diagnostic considerations:

Normal tactile fremitus: 

  • Healthy persons
  • Several conditions cannot be ruled out, e.g., chronic bronchitis

Symmetrical decrease: 

  • Healthy persons with higher-pitched voices (e.g. women)
  • Chronic Obstructive Pulmonary Disease (COPD)
  • Asthma 

Asymmetrically decreased or absent:

Symmetrically increased: 

  • Healthy persons with lower-pitched voices (e.g. men)

Asymmetrically increased:

  • Lobar Pneumonia in the consolidation phase
  • Right upper lobe atelectasis

5. Differential diagnosis

Physical signs are not extremely helpful as individual tests for pneumonia but may be better in combination.

A combined strategy using the history and physical examination may have the highest diagnostic accuracy.

 To summarize, diminished breath sounds, diminished tactile fremitus, and diminished vocal resonance (either egophony or bronchophony) should support a diagnosis of a pleural effusion. 

Fremitus, loud breath sounds, or vocal resonance, if present, make pleural effusion very unlikely.

Sources 

  1. Lynn S. Bickley: Bates’ Guide to Physical Examination and History Taking Twelfth, North American Edition
  2. Scot Irwin, Jan S. Tecklin: Cardiopulmonary Physical Therapy: A Guide to Practice 4th Edition
  3. Karen J. Tietze: Clinical Skills for Pharmacists, Third Edition
  4. Richard A. Shellenberger, DO, Bathmapriya Balakrishnan, MD, Sindhu Avula, MD, Ariadne Ebel, DO and Sufiya Shaik, MD: Diagnostic value of the physical examination in patients with dyspnea, Cleveland Clinic Journal of Medicine December 2017, 84 (12) 943-950; DOI: https://doi.org/10.3949/ccjm.84a.16127