Note the following characteristics of any abnormal breath sounds (if present): loudness, quality, duration, and whether they occur during inspiration or expiration ( i.e., timing in the respiratory cycle).

Note the presence and location of abnormal (adventitious) extra breath sounds, such as crackles, wheezing, rhonchi, stridor, or pleural friction rub ( Table 1).

Normal breath sounds are called vesicular breath sounds, which are low-pitched sounds louder on inspiration and softer on expiration.

Auscultate at five levels posteriorly and anteriorly, comparing side by side.

Place the diaphragm of the stethoscope on the patient's chest, and ask the patient to take deep breaths in and out through the mouth.

Asking the patient to fold arms or place hands on opposing shoulders also helps to get maximal exposure to the lung fields.

Position the patient: ask the patient to lean forward or sit upright in order to examine posteriorly.

A hyper-resonant percussion note is a pathological percussion sound indicative of hyper-inflated lungs from advanced COPD, emphysema, or a pneumothorax. It resembles the percussion note heard over the thigh and is indicative of a pleural effusion. A 'stony dull' or flat percussion note sounds duller than the 'standard' dull sound.

Note the presence of pathological percussion sounds.

Left pleural effusion produces a dull percussion sound over Traube's space.

Tympanic percussion note (a drum-like sound when percussing over hollow organs): over the Traube's space, an area overlying the gastric bubble and bordered by the sixth rib, anterior axillary line, and left costal margin.When percussion of the lungs elicits this sound, it is indicative of consolidation. Dull percussion note (the sound heard over solid tissues): over the liver in the right lower anterior chest and over the heart in the left anterior chest.Resonant percussion note: heard over a normal air-filled lung.

The normal findings on the chest percussion are: Appreciate the quality of percussion sounds.Percuss anteriorly and posteriorly, placing the finger on the chest in the intercostal spaces.On expiration, the lower border of the lungs is at the level of the sixth rib at the midclavicular line and the eighth rib at the midaxiallary line anteriorly, approximately at the level of the T10 spinous process posteriorly. Repeat the percussion at four and five levels, comparing each lung level side by side, working up to the chest wall, starting at the inferior lung borders.The sound should be hollow, representing an air-filled lung. Use the tip of the middle finger (plexor finger) of the dominant hand to tap firmly on the top third (middle or distal phalanx) of the pleximeter finger of the non-dominant hand at least twice (it is advisable to keep fingernails short).Make sure the other fingers and palm are not pressed against the patient's chest.The firmer the finger is pressed to the chest wall, the louder the percussion note tends to be. Place non-dominant hand with middle finger (pleximeter finger) pressed and hyperextended firmly on the patient's right or left mid-back area (lower levels of lungs posteriorly).Percuss both posteriorly and anteriorly, starting on the back.Examining the posterior of the lung requires the patient to be leaning forward or sitting on the edge of the bed. Position the patient on the examination table at a 30- to 45-degree angle and approach from the right side.Make sure the patient is undressed down to the waist.RUL - right upper lobe RML - right middle lobe RLL - right lower lobe LUL - left upper lobe LLL - left lower lobe. An approximate projection of lungs and their fissures and lobes to the chest wall anteriorly.

Anatomy of lungs with respect to the chest wall. The superior lobe of the left lung also has a separate projection known as the lingual.įigure 1. The left lung has two lobes: the superior and inferior lobes. The right lung has three lobes: the superior, middle, and inferior lobes. Each lung lobe can be pictured underneath the chest wall during percussion and auscultation ( Figure 1). The areas for auscultating the lungs correspond to the lung zones. Auscultation can provide an almost immediate diagnosis for a number of acute pulmonary conditions, including chronic obstructive pulmonary disease (COPD), asthma, pneumonia, and pneumothorax. Percussion is a useful skill that is often skipped during everyday clinical practice, but if performed correctly, it can help the physician to identify underlying lung pathology. Learning the proper technique for percussion and auscultation of the respiratory system is vital and comes with practice on real patients. Source: Suneel Dhand, MD, Attending Physician, Internal Medicine, Beth Israel Deaconess Medical Center

Resonance lung sounds