Respiratory Examination

A general inspection of the patient should be the starting point for the respiratory examination. Ideally the practitioner should stand in front of the patient and ask themselves the following questions: 1. Does the patient appear comfortable at rest? Patients will appear uncomfortable if they are in pain or are breathless. 2. Is the patient using their accessory muscles to help them breathe? 3. Does the patient look unwell or distressed? 4. Does the patient look pale or flushed? 5. Does the patient have any obvious abnormalities such as scarring, rashes, disfigurements? 6. Does the patient look alert or appear confused or sleepy? 7. Is the patient overweight or thin? 8. Do the veins in the neck appear engorged? 9. What is the general state of the skin? Breathing pattern The practitioner should look closely at how the patient is breathing. This includes counting the amount of times the patient breathes in one minute (respiratory rate). The normal respiratory rate for an adult is between 12–15 breaths per minute. Examination of the hands and limbs Hands The nurse should examine the patients’ hands, looking for tar staining on the fingers, an indication that the patient is or has been a heavy smoker. The hands should also be examined for signs of rheumatoid disease. This may affect the lung, producing pulmonary nodules or pulmonary effusion. The temperature of the hands should also be noted. Abnormally warm and cyanosed hands are a sign of carbon dioxide (CO2) retention. The most common sign in relation to the respiratory system is finger clubbing. Finger clubbing is a painless enlargement of the finger tips. It is accompanied by softening of the nail bed and loss of the nail bed angle. Inspection of the head and neck Eyes The patient should be asked to look up, the lower eyelid should be gently lowered and the colour of the mucous membrane noted. A pale mucous membrane may indicate anaemia, which may be the cause of breathlessness. Anaemia can only be conclusively diagnosed by measuring haemoglobin levels. Tongue The patient should be asked to open their mouth and put out their tongue. The nurse should observe the colour of the underneath of the tongue. It should be pink; if it appears blue, this may be a sign of central cyanosis. Neck The jugular venous pressure should be measured. The jugular venous pressure (JVP) and characteristics of the waveform gives the nurse important information about the fluid balance of the body (central venous pressure), as well as indicating the pressure in the right atrium of the heart.

Chest expansion The main purpose of palpation in the respiratory examination is to determine the degree of expansion of the lungs. This may be affected unilaterally or bilaterally by disease. Palpation is performed anterioraly and posterioraly. The nurse should place their hands symmetrically on either side of the upper sternum with the thumbs in the midline. The thumbs should be slightly lifted off the chest so that they are free to move with respiration. The patient should be asked to inhale and exhale deeply. The relative movement of the two hands and the separation of the thumbs reflect the overall movement of the chest and any asymmetry between the two sides. When assessing for expansion, the nurse should also feel for the rise and movement of their own hands on the chest wall, as well as judging the distance moved by the thumbs. If any abnormality is detected, the nurse should determine whether the expansion is reduced symmetrically or unilaterally, and the degree of reduced expansion present. Reduced expansion is indicated by an expansion of <1½ cm when the patient inhales. Chronic respiratory conditions that cause a pattern of symmetrically reduced expansion include: 1. COPD 2. Pulmonary fibrosis 3. Neuromuscular disease. Localized respiratory conditions that cause a pattern of unilateral or asymmetric expansion include: 1. Pleural effusion 2. Pneumothorax 3. Collapse of one or more lobes of a lung secondary to tumour, foreign body or sputum plug. Tactile vocal fremitus Tactile vocal fremitus refers to the ability to palpate vibrations set up by the voice in the large airways and transmit these to the chest wall. This involves the practitioner placing the edge of their hand in a systematic manner on the chest wall and asking the patient to say ‘99’. The vibration felt by the examiner is the key to interpreting the physical sign. The vibration is decreased or absent in cases where there is a greater distance for the sound waves to travel to reach the examiner’s hand. An example of this would be if the pleural space is filled with air or fluid, as in a pneumothorax or pleural effusion. Other causes of decreased vocal fremitus include pulmonary fibrosis and pneumonia.

Percussion is the technique of tapping the chest to produce sounds which indicate if the underlying structures are filled with air, fluid, or are solid. There are four common types of percussion note that may be heard: 1. Resonant: the note obtained when percussing a normal air-filled lung 2. Dull: abnormal dullness found over areas of lung consolidation (pneumonia) 3. Stony dull: the note obtained when a significant quantity of fluid, pus or blood is in the pleural cavity (pleural effusion, empyema, haemothorax). 4. Hyper-resonant: a large air-filled space such as a pneumothorax, or emphysema, may produce a hyper-resonant note. Percussion technique: 1. Place the non-dominant hand on the chest wall. 2. Separate the fingers and press the middle finger down firmly. 3. With the tip of the middle finger of the dominant hand, strike the middle finger of the non-dominant hand at the level of the middle phalanx. 4. The movement should come from the wrist of the dominant hand, not the elbow or upper arm. The nurse should percuss the anterior and the posterior chest wall in a number of areas in a symmetrical manner. The areas to percuss include the apices of the lungs, the axillae and the lung bases. All areas should be percussed, paying particular attention to comparison between the two sides. In healthy lungs there should be a symmetrical distribution of sounds.

Auscultation is the process of listening to the sounds of breathing via a stethoscope. The stethoscope contains a diaphragm and a bell. The bell of the stethoscope should be used during auscultation, as it is more sensitive to sounds of lower frequencies which characterize most breath sounds. The ear-tips of the stethoscope should closely fit the ear canal, and incline towards the nose, matching the angle of the ear canal, to block out external noise. Auscultation technique It is important to auscultate the chest in a quiet room, as some breath sounds have frequencies which are hard for the human ear to hear. It also helps to listen with the eyes closed, to focus attention on the sound. The stethoscope should be placed on the chest wall in the same positions used in percussion. Each location is matched symmetrically with the same location on the opposite side. Before commencing the examination: 1. Explain the technique to the patient Warm the end of the stethoscope. 2. Ask the patient to take deep breaths in and out of their mouth 3. Listen to a full inspiration and expiration at each position in both lungs. 4. If the breath sounds are faint, ask the patient to breath more deeply 5. Note the pitch, intensity and duration of inspiratory and expiratory sounds 6. Ensure that the stethoscope tubing does not touch any clothing or extra sounds may be heard 7. Do not listen through clothing as the breath sounds will be muffled. Vocal resonance Vocal resonance is the auscultatory equivalent of tactile vocal fremitus and has largely replaced it. The practioner again listens with the stethoscope in the same area, but asks the patient to say ‘99’. Transmission is increased over the presence of consolidated lung (solid conducts sound better than liquid or air), and decreased if the pleural space is occupied by fluid (pleural effusion) or air (pneumothorax).

Normal lung sounds are categorized as tracheal, bronchial, bronchovesicular and vesicular. As air moves through the bronchi, it creates sound waves that travel to the chest wall. The sounds produced by breathing change as air moves from large airways to smaller airways. Sounds also change as the air passes through fluid, mucus, and through narrow obstructed airways. The properties of breath sounds (loudness, frequency, pitch) are modified according to any disease which alters the lungs and airways. Certain conditions will therefore cause changes in the breath sounds heard with the stethoscope. 1. Wheeze A wheeze is a musical sound heard mainly on expiration. It is caused by air forcing its way through narrowed airways, causing it to vibrate, producing the characteristic high-pitched sound. Wheezes are classified as being monophonic (just one note) or polyphonic (of many different notes). A monophonic wheeze indicates that a single airway is partially obstructed; a polyphonic wheeze is often heard in patients with widespread airflow obstruction. Conditions causing wheeze are: Asthma COPD Infection Heart failure Tumour Foreign body. Patients should be asked when they wheeze. If the wheeze is worse first thing in the morning, the cause may be COPD. If the wheeze is worse during the night or when exercising, the cause may be asthma. 2. Stridor Stridor is an audible, high-pitched noise heard on inspiration. It is an indicator of partial obstruction of the upper, larger airways, such as the larynx, trachea, and main bronchus. Conditions causing stridor are: Tumour Inhalation of a foreign body Laryngeal spasm. Any patient with stridor requires urgent investigation so that the cause is identified. 3. Crackles Crackles are intermittent, non-musical sounds. The crackling sound is caused by collapsed or fluid-filled alveoli popping open. Crackles are classified as either fine or coarse. >>Fine crackles Fine crackles are distinguished by: 1. Occuring when the patient stops inhaling 2. Usually heard at the base of the lungs Sound like Velcro™ being pulled apart. 3. Fine crackles tend to occur in diseases such as: * Diffuse parenchymal lung disease. *Asbestosis *Silicosis *Atelectasis *Heart failure *Pneumonia. >>Coarse crackles Coarse crackles are distinguished by: 1. Occuring when the patient starts to inhale and sometimes present when the patient exhales 2. Being heard through the lungs and at the mouth 3. Sounding like bubbling or gurgling, as air moves through secretions in large airways. Coarse crackles tend to occur in diseases such as: *COPD *Bronchiectasis *Pulmonary oedema *Severely ill patients who cannot cough. 4. Pleural rub A pleural rub is caused by the two surfaces of the pleura (visceral and parietal) making contact. The sound produced resembles leather rubbing against leather. It is caused by the surfaces becoming abnormally inflamed. A pleural rub is heard on both inspiration and expiration and does not alter on coughing. It may be caused by any condition which causes inflammation of the pleural surfaces. These include: *Pulmonary embolism *Pneumonia *Connective tissue disease.