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Report by Dr Saima Saeed, Clinical Fellow, St George's Hospital, London
Search checked by Rick Body, Specialist Registrar, Manchester Royal Infirmary
A short cut review was carried out to establish whether there is any evidence that auscultation is a reliable indicator for pneumonia. 292 papers were found using the reported search, of which five answered the clinical question. The authors, patient groups, outcomes results and key weaknesses of this evidence are presented. The clinical bottom line is that, in the Emergency Department, pneumonia cannot reliably be confirmed or excluded by auscultation, or indeed physical examination, alone.
In [adult patients presenting to the emergency department with suspected community acquired pneumonia] is [auscultation] reliable in [confirming the diagnosis]?
A 50‐year‐old lady presents with a fever and cough. Physical examination of her chest reveals crackles in the left base. You wonder whether this means that you can be confident of a diagnosis of pneumonia before the results of further investigations are obtained.
Medline 1966 to 2007 February Week 1 using OVID interface Embase 1980–2007 Week 7 using OVID interface [exp Pneumonia, Bacterial/ OR exp Pneumonia/ OR pneumonia.mp.] AND [exp Auscultation/ OR auscultat$.mp.] limit to humans and English language
110 papers were identified in Medline and 192 in Embase. Five were relevant to the three‐part question.
The stethoscope remains a hallmark of the physician's diagnostic armoury. However, the studies identified report it's limited diagnostic efficacy for acute pneumonia. Further, the studies reported high rates of interobserver variability. Other conditions, including the kind of stethoscope used, the conditions it is used in (noisy resuscitation room versus quiet cubicle) and the experience of the examiner, are likely to influence sensitivity and specificity. The studies identified suggest that auscultation has a limited role in the diagnosis of acute pneumonia in the emergency department. Of course, this does not mean that the stethoscope should be thrown away. A careful physical examination may guide the emergency physician in the formulation of differential diagnoses and selection of appropriate investigations.
In the Emergency Department, pneumonia cannot reliably be confirmed or excluded by auscultation, or indeed physical examination, alone.