What are the key components of a physical examination for a patient with suspected emphysema?

Physical Examination for Suspected Emphysema

The physical examination for suspected emphysema should focus on detecting signs of hyperinflation and airflow obstruction, with the most reliable findings being a low, flat diaphragm position, prolonged expiratory phase, diminished breath sounds, and hyperresonance on percussion. 1

Essential Components of the Examination

Vital Signs and General Appearance

• Measure respiratory rate, oxygen saturation at rest and with exertion, weight, height, and body mass index (BMI) 1
• Assess for signs of respiratory distress, including use of accessory muscles and pursed-lip breathing 1
• Evaluate overall nutritional status, as weight loss is common in advanced disease 1

Inspection

• Look for evidence of hyperinflation: barrel chest configuration, increased anteroposterior diameter, and horizontal positioning of the ribs 1
• Observe for cyanosis, which indicates advanced disease with significant hypoxemia 1
• Note the breathing pattern, particularly a prolonged expiratory duration relative to inspiration 1
• Assess for use of accessory respiratory muscles (sternocleidomastoid, scalenes) 2, 3

Palpation

• Evaluate chest wall expansion symmetry during deep breathing 2, 3
• Assess for tactile fremitus, which may be decreased in emphysema due to hyperinflation 3, 4

Percussion

• Hyperresonance is a key finding in emphysema, reflecting increased air trapping and lung hyperinflation 1, 3
• Assess diaphragm position and excursion, which are typically reduced in emphysema 5, 3
• The combination of hyperresonance and diminished breath sounds has a positive likelihood ratio greater than 5.0 for COPD diagnosis 1

Auscultation

• Diminished or "quiet" breath sounds are characteristic and highly specific for emphysema 1, 4
• Listen for prolonged expiratory phase, which reflects airflow obstruction 1, 3
• Assess for wheezing, though its absence does not exclude emphysema 1, 4
• Note that wheezing can be an unreliable indicator and may be absent in severe disease 1

Critical Clinical Context

A normal physical examination is common in mild emphysema, with signs becoming progressively more apparent as disease severity increases 1. This is a crucial pitfall—the absence of physical findings does not exclude early emphysema.

The physical examination serves primarily to:

• Identify respiratory and systemic effects of COPD 1
• Detect complications such as cor pulmonale or pneumothorax 1
• Assess functional status and disease severity 1

Functional Assessment

• Perform functional capacity testing, such as timed walking distances or walking speed, as these predict mortality particularly well in COPD patients 1
• Measure breathlessness using the modified Medical Research Council (mMRC) dyspnea score 1

Important Caveats

The physical examination has significant limitations in detecting mild-to-moderate emphysema. Conventional physical examination detects only about 50% of patients with mild-to-moderate emphysema, though it performs better (65-80% accuracy) in severe disease 5. Therefore, spirometry and imaging are essential when clinical suspicion exists despite normal physical findings 1, 5.

The combination of diminished breath sounds and hyperresonance provides the strongest physical examination evidence for emphysema, but these findings typically manifest only in moderate-to-severe disease 1.