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Fremitus: 8 Types of Fremitus Easily Explained

Fremitus is a quiver or vibration transmitted through the body and this vibration potency falls on the chest wall. Vibration in any part of your body is perceived by palpation and auscultation. Generally, fremitus refers to evaluate or assessment of lungs. Fremitus heard with the help of a stethoscope

  • The main content or material of this article is to increase your knowledge and conveying information in a simple or easier way.

What we will cover in this article?

  • What is fremitus and how to examine fremitus?
  • Condition that cause fremitus and its types
  • Voice transmission 
  • Physical examination by simple and easy way
  • Abnormal sound of lungs

. Fremitus further is subcategorized into the following types. These are,

Types of Fremitus

There are 8 types of fremitus in total, listed below:

  1. Vocal fremitus 
  2. Tactile fremitus
  3. Dental fremitus 
  4. Pleura fremitus
  5. Rhonchal fremitus
  6. Periodontal Fremitus
  7. Hydatid Fremitus
  8. Tussive Fremitus.

To assess the type of fremitus Physical or lungs examination is recommended by your doctor.

How to examine fremitus?

To examine the fremitus either its vocal, tactile, or any other type we firstly do chest examination and it may include inspection, palpation, percussion, and auscultation. To evaluate fremitus inspection is not necessary to perform but for the safe side or satisfaction, your examiner performs the whole chest examination step by step. 

  • Before examining the patient, you should explain to the patient that you are going to perform the lungs or chest examination.
  • Position the patient in sitting or upright position at a 40-45 degree angle.
  • Make Sure the patient must be undressed (Just down the waist) when you are going to perform the examination.
  • One thing you always remember is that you should approach the patient on the right side.
  • Firstly you look or assess the patient generally at that time of assessment you also record the patient’s respiratory rate and oxygen saturation.

Inspection of Fremitus:

Inspection is an organized examination to assess patients. During the inspection, the examiner should pay attention to the breathing pattern of the patient. How many times do patients breathe? Are the breathing patterns of patients normal or they are tachypnea (fast breathing) or bradypnea (slow breathing pattern)? Do the patients use accessory muscles during breathing?

The position of the patient should be noted while patients breath, they breathe normal or with any pulmonary dysfunction.  When a patient sits in an upright position also checks the ability to speak (Patients speak normally during breathing or they are unable to speak or they become dyspnea during speaking).

Skeletal and chest abnormality should be noticed during inspection. 

Palpation:

Palpation is a physical touch of the examiner during examination. It helps to detect abnormalities of the chest like is there any mass. Tenderness (softness) is present or not. At the time of palpation examiner also evaluate fremitus either it may be vocal, tactile, or any other type.

  • To evaluate tenderness, Examiners palpate the affected area to check any pain, bruise, or lesion.
  • To evaluate fremitus, the assessor places both hands-on patient’s back and a finger placed in parallel to rib and thumb at 10th of the rib by your expertise.
  • Instruct the patient to inhale and during patient, inhalation observes or notes the movement of your thumb which you placed on ribs. Repeat this process again and again.
  • For best assessment of fremitus place your palm around the border of patient scapulae and instruct the patient to say resonance producing words or alphabets example, “ninety-nine”, one-one-one” to Assiut type of fremitus.

Percussion:

Percussion is the act of tapping on the surface of the body. Examiners doing percussion to check resonance and lung movement and the placed finger on the area of interest. Percussion performed is systemic from the upper chest to the lower rib. By doing percussion we judge, resonance, dullness, hyper- resonance, and flatness.

Auscultation:

Lungs are divided into apical (upper), middle (center), and basal (lower) regions during auscultation. Movement of air generates breath sound through the airway. We instruct the patient to try to take a deep breath and listen to abnormal sounds carefully. The abnormal sound which mostly present in lung disorder or fremitus condition is,

  1. Ronchi: Ronchi is a low-pitch rattling (fast, unsteady) sound. Rhonchi sounds caused by secretion in the airway or any obstruction. Mostly rhonchi heard in pneumonia, chronic bronchitis, cystic fibrosis, COPD, and fremitus. The sound of rhonchi continuously heard when patients breathe but suddenly disappear when a person coughs. To treat rhonchi, an examiner performs vibration tests. This test helps to loosen the mucus to make coughing easier without any obstruction. In some cases, lung transplantation is an option to treat.
  2. Crackle: Crackle is louder or low pitch sound. Crackle sound refers to crackling or rattling the sound in the lungs (either it may be one or both). Usually, crackles heard by auscultation.

Crackle sound may be uni crackle, Bilateral crackle, Basal crackle (appear from the base of the lung), Bibasal crackle (sound appear at base of left and right both lungs). Crackle sound caused by excessive fluid in the airway, might be exudates (leakage of fluid around cells caused inflammation) or transudate (fluid pushes the capillary due to high-pressure build).

Stridor:

Stridor sound refers to grating or creaking sound. Stridor is a high-pitched sound and present in turbulent airflow in the larynx (voice box). Stridor caused by any obstruction, lodging in the airway, and mostly heard during inspiration and occurs in children. Sound of stridor is diagnosed on the basis of history and physical examination.

Wheezing:

Wheezing sound produces a musical, high pitched d whistling sound. This is common in lung diseases, especially asthma. Wheezing sound is generated by the narrowing of the airway and bronchial wall inflammation. This sound mostly heard when patients exhale. But in severe cases, it is heard during inspiration.

1. Vocal fremitus:

Vocal fremitus is palpation of the chest wall to perceive changes in the intensity of vibration. Sound vibration produced in the larynx (called voice box located on top of the neck) during phonation (produce of sound) transmitted to bronchi and lungs or license to the chest wall. The production of tone or sound depends on the condition of basic lung parenchyma (prominent structure of lung involved in gaseous exchange) in pleural space. Rember air is poor or less conductor of low-frequency sound. 

In what condition do vocal fremitus increase?

Increasing of vocal fremitus indicate consolidation of lung tissue, dense or inflamed lung tissues

1. Lung consolidation:

Lung consolidation  is a condition of the lungs due to fremitus. In lung consolidation air filled in small airway and this air replaced  with 

  • A fluid (known as pus, blood or water)
  • Aa solid (such as stomach content or may be cells).

Consolidation creates difficulty in breathing because air can not get through consolidation and lungs become unable to bring fresh air and remove the air which your body uses. Consolidation is treated easily. When to instruct your patient to say a resonance word normally the resonance word produces muffled sound but in consolidation, this resonance sound is cleared because when sound transmitted through consolidated tissue will be greater because dense tissue transmits sound normal fluffy.

In what condition vocal fremitus decreases?

Vocal fremitus decrease in bronchial asthma, empyema, bronchial obstruction, air trapping, pneumothorax.way but in asthma lining of the airway swell and cause difficulty in breathing. The cause of asthma attacks is exposure with allergy, any viral infection, genetically or due to fremitus.

2. Empyema:

 Empyema is also called pyothorax. In the empyema pus is gathered in the area of the lung and inner surface chest wall. Mostly empyema developed after pneumonia or any thoracic surgery. During the inflammatory process production fluid increase in the pleural cavity. Pleural spaces naturally have fluid but due to infection this fluid builds faster than normal and this fluid becomes more infected because of pneumonia. Symptoms of emphysema are shortness of breath, dry cough, fever, and chest pain.

4. Pneumothorax:

A pneumothorax is collapsing of lungs. It occurs due to leakage of air in space between lungs and chest wall.Pneumothorax is caused by any blunt, traumatic injury, medical procedures  or due to any lung diseases.Symptoms of pneumothorax include chest pain and shortness of breath. 

How can you check vocal fremitus?

Basically fremitus is a vibrating quiver or tremors that can be felt through chest palpation. To check vocal fremitus You may command the patient to say resonance words again and again (999, blue moon). When a patient speaks these words, palpate his chest from one side to another. Usually fremitus  presents  mainstem bronchi (upper and lower lobe of bronchi) near the clavicle.

As You move your hand slowly or gradually you may feel frets should decrease or increase.

What is voice transmission?

You may assess voice transmission  by palpation(tactile) and auscultation (vocal)method. Meanwhile, speaking observes intensity and quality of pitch (either low or high).

  • Normal voice transmission: The Sound produced by phonation is sharp, distinct over bronchi. The sound is generated in the larynx (voice box) and it is transmitted along tracheobronchial trees and becomes a muffled sound in alveoli.
  • Abnormal Voice Transmission: Normal sound heard sharp, loud and distinct. But in extreme conditions whispered words speak clearly and alteration in voice transmission is noted with sign of consolidation. The sound is like nasal twang (voice produced by nasal resonance) or goat bleating (sound produced like goat or sheep). 

2. Tactile fremitus:

Tactile fremitus is also known as pectoral fremitus tactile vocal fremitus. Tactile fremitus is normally enormous in the right second intercostal space as well as the interscapular region which is closest to bronchial trifurcation or bifurcation. Palpable changes or variations of chest wall result in vibration or speech fremitus and feel posteriorly and laterally at the level of bifurcation of bronchi. Sometimes tactile fremitus is absent in young patients who have a high-pitched frequency or soft voices with thick chest walls. Asymmetry tactile fremitus is abnormally found because of the accumulation of air, fluid, or any tumor that pushes the lung away from the chest wall.

3. Dental Fremitus:

Dental fremitus refers to when teeth are moved. For assessment of dental fremitus look the teeth and mouth (open and close). When upper anterior teeth (a group of front teeth includes incisor and canine) can be reclined and they can be intruded or encroaching envelope of function. Feasible teeth need a little liberation of movement in centric (situated at center)  and horizontal position. So arc or curve of closures comes, you just need to adjust centric. If you took your fingernail and put it on the front surface of the tooth and have the patient close together and tooth move

4. Pleural Fremitus:

Pleural fremitus is the vibration of the wall of the thorax. It is due to friction of the parietal and visceral pleura of the lung. Pleura fremitus is easily palpable and seen by pleural friction rub. 

Pleural friction rub:

It is a breathing sound due to the inflammation of tissues surrounding your lungs. Sound is creaky and compared with the sound of walking in fresh snow. Pleural friction rub usually sign of pleurisy. The life-threatening condition of pleural friction rub is pulmonary embolus or pleural effusion.

5. Rhonchal fremitus:

Rhonchal fremitus is mostly known as bronchial fremitus. Rhonchal fremitus is a palpable vibration which is produced during breathing. Rhonchal fremitus is caused by small or large airway obstruction. This obstruction is due to excessive mucus or any6 other secretion in the airway. For Evaluate rhonchal fremitus examiner assist the ronchi (ronchous) for auditory analog.

6.  Periodontal Fremitus:

Periodontal fremitus present in alveolar bones (thick bone contain tooth socket to hold teethy)due to trauma from occulsionPerodontal fremitus. It is due to little mobility of rubbing teeth against the socket and is expanded due to inflammatory response. To determine the test of periodontal fremitus instruct the patient to grind teeth slightly than placed finger in labial vestibule (space between lips and alveoli) against alveolar bone.

7. Hydatid fremitus:

Hydatid fremitus is a vibratory sensation which is felt on palpation of hydatid cyst (diseases which affect liver and lungs).

8. Tussive fremitus:

Tussive fremitus is a type of vocal fremitus and it feels the same chest palpation.

Summary:

Fremitus becomes abnormal when it’s increases or decreases to its normal range. The reason for this abnormal condition is sound transmitted strongly through non-air filled lungs because as you know air is poor or less conductor. Assessment of fremitus by physical or lung examination helps to diagnose the underlying cause of diseases.

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