Communications to the Editor |

Clavicle Tapping and Auscultation as an Alternative to Chest Percussion When Performing Thoracocentesis FREE TO VIEW

Robert S. Crausman, MD, MMS; Amanda R. Crausman
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Brown University School of Medicine Providence, RI

Correspondence to: Robert Crausman, MD, MMS, FCCP, Director, Internal Medicine Residency Program, Memorial Hospital of Rhode Island, 111 Brewster St, Pawtucket, RI 02860

Chest. 2001;120(1):322-323. doi:10.1378/chest.120.1.322-a
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To the Editor:

Thoracocentesis is a common procedure in medical practice. Chest percussion, however, seems to have become a lost art among medical trainees. Unfortunately, chest percussion remains an important component of assessment when performing thoracocentesis at the bedside, as it allows for the identification of the pleural fluid meniscus, and therefore, the procedure site. The importance of the accurate identification of the superior-most aspect of the pleural effusion when performing thoracocentesis cannot be overstated as inaccurate assessment may needlessly increase the risk of procedural complication, particularly for pneumothorax. The response of many medical centers to the loss of this physical diagnosis skill by clinicians seems to be an increase in the use of ultrasonography and the relegation of thoracocentesis to radiologists.

In recent years, we have developed an alternative approach when teaching to our housestaff trainees thoracocentesis that does not rely on chest percussion, namely, clavicle tapping with posterior chest auscultation. Stated simply, this technique takes advantage of the sound transmission characteristics of the inflated lung and the loss of sound transmission caused by the interposition of a layer of fluid between the air-filled lung and the chest wall. A steady tapping of the clavicle anteriorly by the examiner, who is positioned posteriorly reaching over the ipsilateral shoulder, generates a repeating sound that is well-transmitted through the lung to the posterior chest wall and that is readily appreciated via a stethoscope. The stethoscope then is moved slowly inferiorly from the apex to the base with each appreciated tap to the level below which no further conducted sound can be appreciated. This place represents the level of the superior aspect of the pleural effusion.

In our experience, this technique correlates well with chest wall percussion performed by experienced examiners, is readily taught and learned, and has increased the comfort of our housestaff with thoracocentesis.




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