A type of fremitus that is possible to assess for during mechanical ventilation is rhonchal fremitus. 25 However, this technique is not possible during mechanical ventilation due to the presence of an artificial airway preventing phonation. Research surrounding inter-rater agreement has shown variability, with some studies showing poor inter-rater agreement 26 and others showing excellent inter-rater agreement. 24, 25 Tactile (vocal) fremitus assessments utilize chest wall palpation to detect the changes in the intensity of vibrations created with specific spoken words to indicate toward certain lung pathologies. In addition to auscultation, tactile respiratory assessments are often used to assess for pulmonary dysfunction. Moreover, it is not known whether the level of clinical experience affects inter-rater agreement in this ICU population. 23 However, the inter-rater agreement of auscultation in patients who are ventilator-dependent has not been established, despite its frequency of use in the ICU population. 1, 22 As such, the literature surrounding lung auscultation suggests that inter-rater agreement for this assessment modality is poor to moderate, irrespective of the level of clinical experience. 21 Furthermore, differences in nomenclature used for the lung sounds heard have led to discrepancies between clinicians and their clinical interpretations of auscultation. 1, 22 However, the ability to recognize, differentiate between, and associate these acoustic signatures with specific lung disorders via auscultation relies heavily on the experience of the clinician, the acuity of the clinician's hearing, and his or her personal interpretation of what is heard. 1 Breath sounds, both in the absence and presence of lung disorders, have been shown (via respiratory acoustic analysis) to have specific sound signatures that reflect the underlying dysfunction. 20, 21 This sound energy is then transmitted to the stethoscope via the chest wall but is filtered and altered by structures and fluid within the thorax and further altered by lung disorders. 19 Auscultation works on the concept that sound vibration is created and amplified by turbulent air flow in the major airways. 1, 18 This is because auscultation is a cost-effective, easily applied respiratory tool that can be used to assess changes in lung sounds that may be associated with certain respiratory pathologies or dysfunction. 1 One of the most common bedside respiratory assessments performed in clinical practice is lung auscultation, 1, 17 which is considered an integral part of the clinical reasoning process for qualified and training health-care professionals. 13, 14īedside respiratory assessments are most commonly performed by doctors, nursing staff, 15 physical therapists, 13 and respiratory therapists 16 to differentiate between a range of pulmonary disorders, including pulmonary edema, consolidation, atelectasis, interstitial lung disease, bronchospasm, and retained secretions. 12 This therefore warrants the need for other timely bedside assessment to support accurate monitoring and diagnoses of respiratory dysfunction and, in turn, supports clinical decision making in real time. 10 Imaging techniques such as radiography or computed tomography are considered more accurate modalities than most bedside assessments (such as auscultation) at providing information on pulmonary dysfunction 11 but lack the ability to provide temporal changes in pulmonary status, especially at the point of a clinical intervention or deterioration. 9 All these factors have the potential to cause respiratory impairment 8, 10 and exacerbate pre-morbid respiratory injury or disease. 1 Respiratory complications frequently occur in patients who are mechanically ventilated due to the presence of artificial airways 2, 3 and sedation, 4 inadequate airway humidification, 5, 6 impaired mucociliary clearance, 7 diminished cough, 8 and variable airway pressures. A bedside respiratory assessment of patients receiving mechanical ventilation in the ICU is considered a fundamental part of clinical practice.
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