What is the proper procedure for performing a physical exam of the lungs?

How to Perform a Proper Physical Exam of the Lungs

The proper lung physical examination follows a systematic four-step sequence: inspection, palpation, percussion, and auscultation, performed with the patient preferably seated upright for safety and optimal results. 1, 2

Patient Positioning and Preparation

• Position the patient seated upright in a chair with arms and without wheels to prevent falls from syncope during the examination 3
• If using a wheelchair, lock the wheels before beginning the examination 3
• Have the patient remove or loosen tight-fitting clothing that restricts chest and abdominal expansion 3
• Ensure the patient is relaxed, as anxiety can affect respiratory patterns and findings 3

Common pitfall: Standing position may be used but increases fall risk; always have a chair positioned behind the patient if examining while standing 3

Step 1: Inspection

• Observe the patient's respiratory rate and pattern, noting any tachypnea or irregular breathing 4
• Assess for use of accessory muscles of respiration, which indicates respiratory distress 1
• Look for chest wall deformities such as kyphoscoliosis, barrel chest, or asymmetry 3
• Note any cyanosis, particularly central cyanosis of the lips and tongue 4
• Observe for paradoxical chest wall movement or unilateral chest lag during breathing 1

Step 2: Palpation

• Palpate the chest wall for tenderness, masses, or subcutaneous emphysema 1, 2
• Assess chest expansion by placing hands on the posterior chest wall at the level of the 10th rib, with thumbs meeting at the midline, and asking the patient to take a deep breath 1
• Check for tactile fremitus by placing the ulnar aspect of your hand on symmetric areas of the chest while the patient repeats "ninety-nine" or "one-one-one" 1, 2
• Increased fremitus suggests consolidation; decreased fremitus suggests pleural effusion, pneumothorax, or emphysema 1

Step 3: Percussion

• Percuss systematically across all lung fields, comparing side-to-side in a ladder pattern from apex to base 1, 2
• Normal lung produces a resonant sound; dullness indicates consolidation or pleural effusion 1, 4
• Hyperresonance suggests pneumothorax or emphysema 1
• Percussion dullness increases the probability of pneumonia, though its absence does not exclude it 4

Important caveat: Percussion has poor interobserver reliability and should always be combined with other examination findings 4, 5

Step 4: Auscultation

• Use the diaphragm of the stethoscope and listen systematically over all lung fields, comparing side-to-side 2, 5
• Have the patient breathe deeply through an open mouth to maximize airflow and sound generation 2
• Listen for at least one complete respiratory cycle at each location 2

Normal Breath Sounds

• Vesicular sounds: soft, low-pitched sounds heard over most lung fields 1, 2
• Bronchial sounds: loud, high-pitched sounds normally heard only over the trachea 1, 2

Abnormal Breath Sounds

• Bronchial breath sounds heard over peripheral lung fields indicate consolidation 4, 5
• Decreased or absent breath sounds suggest pleural effusion, pneumothorax, or severe emphysema 1, 4

Adventitious Sounds

• Crackles (rales): discontinuous sounds that increase probability of pneumonia, particularly when heard in the lateral decubitus position 4, 5
• Wheezes: continuous musical sounds indicating airway narrowing, as in asthma or COPD 1, 2
• Rhonchi: low-pitched continuous sounds suggesting secretions in larger airways 1
• Pleural friction rub: grating sound heard in both inspiration and expiration, indicating pleural inflammation 1

Critical point: The most valuable examination findings for detecting pneumonia are unilateral crackles and crackles in the lateral decubitus position, with kappa values around 0.5 for interobserver agreement 5

Special Examination Techniques

• For suspected pleural effusion, have the patient lie in the lateral decubitus position with the affected side down and re-auscultate 5
• This position allows better detection of crackles and helps differentiate atelectasis from consolidation 5
• Egophony (E-to-A changes): ask the patient to say "eee" while auscultating; if it sounds like "aaa," this suggests consolidation 1, 2
• Whispered pectoriloquy: whispered words heard clearly through the stethoscope indicate consolidation 1, 2

Diagnostic Accuracy Considerations

• Physical examination alone has sensitivity of 47-69% and specificity of 58-75% for diagnosing pneumonia 5
• No single physical finding has very high predictive value; always combine multiple findings to increase diagnostic accuracy 4, 5
• The absence of abnormal findings does not exclude significant lung pathology 4, 5
• Interobserver agreement for lung examination findings is generally poor due to lack of standardization 4, 5

Documentation

• Record the patient's position during examination (sitting or standing) 3
• Document specific findings by lung zone (upper, middle, lower) and side (right, left) 5
• Note any limitations to the examination, such as patient inability to cooperate or body habitus restrictions 3

Final consideration: While physical examination remains fundamental, it should be complemented with chest imaging when pneumonia or other significant lung pathology is suspected, as examination findings alone are insufficient to confirm or exclude disease 4, 5, 6