Case in Point
Bronchial Breathing and Resonant
Percussion—An Important
Combination of Signs in Pneumothorax
Andrew P.J. Olson, MD; Kevin C. Wang, MD, PhD; and Lawrence M. Tierney Jr, MD
This case discusses the possibility that the physical signs of pneumothorax
are commonly overlooked and that some simple, basic examination procedures
are easy, efficient tools in diagnosing this condition.
Pneumothorax is a common clinical problem encoun- tered by physicians in many clinical settings. Pneumothorax may be either primary
or secondary; primary pneumothorax occurs in patients without
underlying lung disease; whereas
secondary pneumothorax occurs
in patients with preexisting pulmonary disease, such as bullous
emphysema. 1 In most cases, pneumothorax results from a rent in
the alveolar membrane; an interruption in the parietal pleura following chest trauma or surgical
procedures may also be causative.
Pneumothoraces are readily diagnosed clinically by using several
techniques, including observation, percussion, and auscultation;
more recently, point-of-care ultra-sonography has been used with
high sensitivity and specificity. 1, 2
However, clinical suspicion must
be high when these maneuvers are
Dr. Olson is chief resident in the Department of
Medicine at the University of Minnesota in Minneapolis, Minnesota. Dr. Wang is an assistant
professor in the Department of Dermatology at
Stanford University in Stanford, California. Dr.
Tierney is a professor in the Department of Medicine at the University of California, San Francisco,
and an attending physician in the Medical Service
at the San Francisco VAMC, both in San Francisco, California.
being performed in order for the
examiner to determine that a pneumothorax may be present. Furthermore, plain chest radiography may
be unreliable in diagnosing pneumothorax. 2, 3 The authors describe
a combination of physical signs
that may be particularly useful as
a rapid, inexpensive, and simple
method to increase the examiner’s index of suspicion and pretest
probability of a pneumothorax.
CASE REPORT
A 40-year-old male presented to a
walk-in clinic with a chief concern
of shortness of breath for several
hours. The dyspnea was acute in
onset; the patient reported pleuritic right chest discomfort, but no
fever, chills, or cough were present. The patient was healthy and
did not have known lung disease,
although he reported smoking 5 to
10 cigarettes daily.
On physical examination, the
patient was uncomfortable and dia-
phoretic. He was afebrile, his heart
rate was 105 bpm, his blood pres-
sure was 110/80 mm Hg, and his
respiratory rate was 18 bpm. Car-
diac examination revealed tachy-
cardia with a regular rhythm; there
were no murmurs, gallops, or rubs
present. The jugular venous pres-
sure was not elevated. The left lung
field was clear to auscultation;
distant, bronchial breath sounds
were heard throughout the right
lung field. Percussion was not per-
formed nor was tactile fremitus as-
sessed.
DISCUSSION
Bronchial breath sounds are
thought to originate in large
and patent airways that are surrounded by a consolidated lung. 4
In the normal lung, these sounds
are poorly transmitted to the ex-
