The Stanford 25

An Initiative to Revive the Culture of Bedside Medicine

Pulmonary Exam with a focus on INSPECTION & PERCUSSION

After earning his MD in Galway, Ireland, Dr. Peadar Noone trained in Galway, Dublin, Boston, the UK and Chapel Hill, where he is now Associate Professor of Medicine and Medical Director of the Lung Transplant Program at the University of North Carolina, Chapel Hill. In addition to his specialized interest in CF and Lung Transplant, Dr. Noone takes a keen interest in general internal medicine and bedside medicine / clinical teaching. On this page, he provides us with a clinical pearl regarding the pulmonary exam.


Introduction: Though taught extensively in early medical training this is a part of the exam that is often neglected apart from auscultation.  We hope you will find this useful, particularly in resource poor areas.

[ Stanford 25 video forthcoming.]

1. Inspect: Recognize the signs of COPD.

  • Inspiratory descent of trachea.
  • Use of accessory muscles.
  • Pursed lips on exhalation (provided a small amount of PEEP).
  • Increased AP diameter (barrel chest).
    • Normal in infancy and increased with aging.
  • Prominent angle of Louis (or sternal angle).
  • Flaring of the lower costal margins.
  • Dahl Sign: Above the knee, patches of hyperpigmentation or bruising caused by constant ‘tenting’ position of hands or elbows.
  • Hoover’s sign: briefly, during inspiration a paradoxical medial movement of the chest.
    • The “subcostal angle” is the angle between the xiphoid process and the right or let costal margin. Normally, during inhalation the chest expands laterally, increasing this angle. When the diaphragms are flattened (as in COPD), inhalation paradoxically causes the angle to decrease.
  • Harrison’s sulcus: a horizontal grove where the diaphragm attaches to the ribs; associated with chronic asthma, COPD, & Rickets.

REMEMBER : “The side that moves less is the side of disease!”

  • Look for signs of volume loss (or gain) on the side that moves less (hollow supraclavicular fossae, intercostal spaces prominent, shoulder droopy, scapula outline more prominent).

A pearl from PEADAR NOONE MD:

  • Insert (in a normal individual) three fingers vertically in the space under the cricoid cartilage, and above the sternal notch.  As the person breathes in, the space may reduce to two fingers at most (ie the fingers get “squeezed” as the sternum rises with inspiration).
  • In a patient with severe hyperinflation, the crico-sternal distance is much shorter (because the sternum is elevated by the pocket of retro-sternal air), maybe 1-2 fingers at most, and with inspiration;  one’s fingers get “squeezed” out as the already “high” sternum rises up to the level of the cricoid, thus, in many cases, obliterating the crico-sternal distance altogether.  Some clinicians label this sign “tracheal shortening” but strictly speaking, the actual tracheal length does not get shorter.
  • Classically seen with severe emphysema / hyperinflation, or severe air trapping.  Often accompanied by reduced hepatic and cardiac dullness on percussion, a widened / flared costal angle, and Hoover’s sign.


  • Pride yourself on being able to percuss well.
    • Has great utility–from finding wall studs at home to finding a distended bladder, outlining anatomical boundaries, detecting fluid in the chest, detecting consolidation.

“There is no point percussing unless we know the boundaries of percussion.”

  • On the right side, you must know  the UPPER BORDER OF LIVER DULLNESS in order to decide if dullness you encounter in the lung is normal or not.
  • The “579 rule.”
    • The upper border of liver dullness is in the 5th space in the midclavicular line, the 7th space in the mid axillary line, the 9th space in the scapular line.
  • Be able to outline the area of “absolute” cardiac dullness– a fist sized area just to the left of the sternum. If it is not there it suggests emphysema.
  • Be able to outline the gastric bubble, i.e. “Traube’s space” (paper) and you will be surprised at how high it is, just as you will be surprised to see how high the liver is on the right.
  • Be able to demonstrate the diaphragm and “tidal percussion”–yes, I know it is controversial, but so is coronary bypass!  See if your percussing skills are good enough to do this.

Other Findings in the Chest

  • Pectus Excavatum (Funnel Chest): depression of sternum; in severe cases may compress heart and great vessels.
  • Pectus Carinatum (Pigeon chest): anterior displacement of sternum, usually benign.
  • Flail Chest: secondary to multiple rib fractures, depression of diaphragm causes injured area to cave inward producing a “paradoxical thoracic movement” in breathing.

Written by stanford25admin

June 7, 2010 at 3:20 pm

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