You are seeing a patient with suspected pneumonia. Your attending hears crackles but you do not hear them. Later the radiograph shows pneumonia right where the attending heard crackles. What can you do to improve your pulmonary examination?


Sit up and take a deep breath might be bad advice?


Increase signal

Sensitivity for auscultation of crackles is increased in the supine position. Should you always listen supine? No. That is hard to do because anterior is less helpful and posterior requires you to squeeze the stethoscope behind their supine back. But be aware it is an option if you need to increase the sensitivity for the physical examination.


You can make crackles more easily discerned by varying your exam. If it sounded too quiet have them take a deeper breath.


Decrease noise

Should they always take a deep breath? No. That can increase other noise if they make upper respiratory noises. Have the patient take a “full and quiet” breath. That might be best for minimizing noise and maximizing signal.


Take Home Points:

-“Sit up and take a deep breath” is not the only way to do a lung examination

-Increase signal by auscultating the supine back

-Decrease noise by asking the patient to breathe deeply, but quietly