respiratory 3

Examination and
Assessment procedures
of Respiratory disorders
Examination and Assessment procedures of Respiratory disorders
Subjective Assessment
Patient Information,
Chief complaints,
Past Medical History,
Present Medical History.
Objective Assessment
On Inspection,
On Palpation,
On Percussion,
On Auscultation,
On Examination.
History taking is a very critical part of the examination
Most of the cases, you can actually be able make a diagnosis based on the history alone.
An ability to listen & ask common-sense questions that help define the nature of a particular problem.
 A Information can be obtained from
- History
2. - Medical chart
3. - Patient / Family interview
4. - Other members of the team treating the patient
What brings your here?
The patient describe the problem in their own words and the same should be recorded
Usually a single symptoms, occasionally more than one complaints like
Chest pain,
Palpitation ( Feeling of one’s own breath)
Shortness of breath (breathlessness),
Blood present in the sputum etc.,
Present complaint
The main respiratory symptoms are:
oDyspnea (Breathlessness).
oDyspnea on exertion
oSputum Production
oImproved work of breathing
oAudible Wheezing
oChest pain
Other systems
•Loss of appetite
•Significant loss of weight e.g. malignancy or tuberculosis.
•Upper gastrointestinal symptoms: gastro-oesophageal reflux is a common cause of chronic
•Heart disease may cause respiratory symptoms. Are there any indications of heart
failure or ischemic heart disease
•Severe anemia may cause breathlessness.
•Rheumatoid arthritis and other connective tissue diseases may cause respiratory symptoms.
•Neuromuscular diseases may cause respiratory symptoms, particularly dyspnea.
oPast health including Childhood illnesses, accidents or injuries.
oChronic illnesses and Hospitalization( If yes prognosis and Duration).
oMalignant disease (Pulmonary Metastases).
oInfections including Pneumonia, Tuberculosis and Whooping cough
oChest trauma (Fracture) and Surgeries.
oThromboembolic disease, specifically Deep vein thrombosis (DVT) and Pulmonary
oHistory of other system disorders like Cardiovascular, Neurological, Orthopedical .
Psychological disorders leads to respiratory problem.
Medications history
Drug history
Knowledge of the patient’s medications can provide
information about the patient’s present or recent
past medical history like medications for Hypertension, Heart failure,
Angina, Bronchospasm and Infections.
Use of inhalers (Assess compliance and technique).
Use of Steroids (Some measure of severity in asthma).
Other drugs which may have relevance in respiratory disease, e.g. angiotensinconverting enzyme (ACE) inhibitors for hypertension may cause Dry cough.
Allergic History
Ask about all allergies including, for example, food, inhaled allergens and drugs.
Occupational history
An occupational history may be very important in respiratory disease.
Extrinsic Allergic Alveolitis
Industrial Dust Diseases
Home environment / Family situation / Social history
Supportive family is important to the success of rehabilitation of any patient
family environment can deter the rehabilitation
Personal history / Smoking history
The type and number of cigarettes smoked currently and in the past. Ask also about
passive smoking.
Lifestyle and alcohol consumption are also very relevant to
respiratory diseases. Ask about illicit drugs.
Hobbies and pet animals may also be responsible for respiratory disease. (Extrinsic
Bronchial asthma)
Sexual history may be relevant to risk of HIV and AIDS.
Family history
•Respiratory diseases with a genetic component, e.g. Cystic fibrosis,
Emphysema (alpha-1-antitrypsin deficiency)
•Infectious diseases such as tuberculosis (remember high-risk groups).
•Atopic diseases such as asthma, hay fever and eczema.
Vital signs
1. Body Temperature (T)
2. Pulse (P)
3. Respiratory rate (RR)
4. Blood pressure (BP)
5. O2 saturation ( Spo2)
Body temperature
Normal range - 37˚C or 98.6˚ F
If more than normal – Pyrexia or Hyperthermia
If Temperature more than 41˚C or 105.8˚ F - Hyperpyrexia
If Temperature below 35.0 °C or 95° F - Hypothermia
A pulse is a rhythmic arterial blood pressure throb created by the
pumping action of the ventricular muscles. It is assessed by palpation.
 There are 9 common sites to palpate the pulse includes carotid, brachial,
radial, femoral, popliteal, dorsalis pedis, and posterior tibial area.
Normal Heart rate
Infants (0 to 1 year)
- 100 to 160 beats/mins
Toddler ( 1 to 3 years)
- 90 to 150 beats/mins
Preschooler ( 3 to 6 years)
- 80 to 140 beats/mins
Elementary school age ( 6 to 12 years) - 70 to 120 beats/mins
Adolescent ( 12 to 18 years)
- 60 to 100 beats/mins
Adult (18+ years)
- 60 to 100 beats/mins
- Bradycardia: HR < 60
- Tachycardia: HR > 100
The number of breaths a person takes during one minute.
Normal respiration rate at rest range from 12-20 breaths/ minute
Infants (0 to 1 year)
- 30 to 60 breaths / mins
Toddler ( 1 to 3 years)
- 24 to 40 breaths / mins
Preschooler ( 3 to 6 years)
- 22 to 34 breaths / mins
Elementary school age ( 6 to 12 years) - 18 to 30 breaths / mins
Adolescent ( 12 to 18 years)
- 12 to 16 breaths / mins
Adult (18+ years)
- 12 to 20 breaths / mins
Breathing patterns
1. Apnea
- Absence of Ventilation
2. Eupnea
- Normal rate, Normal depth, regular rhythm
3. Hyperventilation
4. Tachypnea
- Fast rate and increased depth.
- Faster rate, Shallow depth , regular rhythm
5. Bradypnea
- Slow rate, shallow or normal depth, regular rhythm
6. Orthopnea
- Difficulty breathing in postures other than erect
7. Dyspnea
- Rapid rate, Shallow depth, regular rhythm ; associated with accessory
muscle activity
8. Fish-mouth - Apnea with concomitant mouth opening and closing associated with neck
extension and bradypnea
9. Cheyne-stokes - Increasing then decreasing depth, period of apnea interspersed ;
somewhat regular rhythm ; associated with critically ill patients
Blood pressure( BP )
Blood Pressure- measurement of the force exerted by blood against the walls
of the arteries
Normal blood pressure- 120± 20 / 80± 10
Systolic blood pressure- the pressure in the large arteries when the heart is
Diastolic Blood pressure- the pressure in the large arteries when the heart is
If Pressure goes ABOVE 140 ( Systolic) or 90 ( Diastolic) – Hypertension
If Pressure goes BELOW 100 ( Systolic) or 70 ( Diastolic) - Hypotension
SpO2 Is a measurement of the amount of oxygen attached to the
hemoglobin cell in the circulatory system.
Normal percentage of SpO2 is 98% to 100%
Caution should be taken with patients who desaturate with activity
below 90 %
Exercise should not be continued of oxygen saturation drops to 88
1. Inspection
2. Palpation
3. Percussion
4. Auscultation of the lungs
5. Investigation
Is extremely important in patients with pulmonary dysfunction.
Level of consciousness – Alert, agitated, Confused, Semi comatose,
Observation of body type – Obese, normal, Cachectic
Posture and positioning - Their impact on pulmonary system.
Skin tone – It indicates the general level of oxygenation and
External monitoring and Support equipment
Face Inspection
Facial expression and effort to breathe
Facial signs of distress includes Nasal flaring, Sweating, Paleness, and
focused, or enlarged pupil
Pursed lip breathing ( Is a sign of COPD)
Central cyanosis.
Anemia (conjunctivae).
Horner's syndrome- Combination of drooping of the
eyelid(ptosis) and constriction of the pupil (miosis) (possible
apical lung cancer).
Neck Inspection
◦ Activity of the neck musculature during breathing – There may
be hypertrophy of sternocleido mastoid muscle (Indicates
chronic pulmonary condition)
◦ Adaptive shortening of sternocleido mastoid muscle and
clavicle appears more prominent (Indicates chronic forward bent
◦ Distended (Swelling)Jugular veins in sitting or recumbent
position with head elevated at least 45 degrees (Indicates
increased volume in the venous system – it may an early sign of
right side heart failure (Cor pulmonale)
◦ Goitre - It is a swelling in the thyroid gland
◦ Lymphadenopath
Chest inspection
The resting chest is evaluated for its symmetry, configuration, rib angles and intercostal
spaces and musculature.
There may be hypertrophy of scalenes, trapezius, and intercostals indicates diminished
work of diaphragm muscle.
Abnormal chest shapes and configuration
- Funnel chest (Pectus excavatum) - Depression of sternum
- Pectus carinatum(Pigeon chest) - Protrusion of the sternum
- Lordosis
- Anterior curvature of spine
- Kyphosis
- Posterior curvature of spine
- Scoliosis
- Lateral curvature of spine
Operation scars, Trauma , Chest drains and Tubes
THE MOVING CHEST WALL MUST BE EVALUATED for its Breathing pattern, rates,
inspiratory to expiratory ratios (I:E ratio), and symmetry of chest wall motion.
Breathing pattern – Movement of chest wall and paradoxical breathing pattern
(Breathing movements in which the chest wall moves in on inspiration and out on
expiration) can be noted with COPD and Neurological assault and respiratory distress
in child.
Respiratory rate – Should be assessed subconsciously for 1 full minute
I:E ratio – Normal is 1:2 ( With asthmatics it can be 1:4)
On Inspection – Phonation, cough and Cough production)
oDyspnea on phonation – When speech is interrupted for breath.
Should see how many words can be expressed before next breath.
oCough should be assessed for strength, depth, and length of cough.
oSecretions (Sputum) should be assessed for quantity, color, smell
and consistency
Extremities inspection
Digital clubbing-Loss of the normal ( less than165° )angle (Lovibond angle)
between the nail bed and nail. It indicates chronic tissue hypoxia.
 Cyanosis: is a bluish discoloration of the skin and mucous
membranes. (Common in :COPD, Pulmonary Hypertension, Pulmonary
embolism, Hypoventilation)
1. Central cyanosis -Seen on the tongue and mouth, is caused by hypoxemia
2. Peripheral cyanosis - Affecting the toes, fingers and earlobes may
also be due to poor peripheral circulation
Tobacco staining.
A tremor may indicate carbon dioxide retention.
(2)Palpation- 1- trachea
Firstly, the trachea is palpated to assess its position in relation to the
sternal notch.
Trachea can shifted due to disproportionate intra thoracic pressure or lung
volumes between two sides of thorax.
tracheal deviation indicates underlying mediastinal shift .
– contents shifts to unaffected side: Pleural Effusion, Untreated
Pneumothorax and tumor (when there is increased pressure on same side)
– contents shifts towards affected side: Lobectomy, Pneumonectomy,
Pulmonary fibrosis and large degree of Atelectasis ( When the lung volume
and pressure is decreased)
Palpation- 2- Chest excursion
Symmetrical reduction: Overinflated lungs (e.g. bronchial asthma,
emphysema), stiff lungs (e.g. pulmonary fibrosis, ankylosing spondylitis).
Asymmetrical reduction of chest wall expansion: absent expansion
(e.g. empyema and pleural effusion) or reduced expansion (e.g.
pulmonary consolidation and collapse).
Usual chest expansion in an adult is 2-3 Inches and should be
Take a Inch tape and encircle chest around the level of nipple.
Take measurements at the end of deep inspiration
and expiration.
Normally, a 2-3 Inches of chest expansion
can be observed.
Palpation-3- Tactile vocal Fremitus
Tactile vocal Fremitus : Fremitus is defined as the vibration that is produced by the voice
or by the presence of secretions in the airways and is transmitted to the chest wall and
palpated by the hand
 Whilst the examiner's hands are placed flat on both sides of the chest.
The hands are moved from apices to bases, anteriorly and posteriorly, comparing the
vibration felt. Each time asking the patient to say "ninety-nine“ (99).
Note how the sound is transmitted to the hand.
Tactile vocal Fremitus is INCREASED with the presence of secretions and over areas of
consolidation (E.g. Pulmonary fibrosis, Pulmonary edema, Atelectasis and Lung tumors)
Tactile vocal Fremitus is DECREASED or ABSENT with more air in that area and over
areas of effusion or collapse(E.g. Pleural effusion, Pneumothorax, COPD)
There are five main symptoms of respiratory disease:
1) Breathlessness (Dyspnea)
2) Cough
3) Sputum and hemoptysis
4) Wheeze
5) Chest pain.
Five Main Symptoms Of Respiratory Disease
With each of these symptoms:
1) Duration - both the absolute time since first recognition of the
symptom (months, years) and the duration of the present symptoms
(days, weeks)
2) Severity - in absolute terms and relative to the recent and distant past
3) Pattern - seasonal or daily variations
4) Associated factors - including precipitants, relieving factors, and
associated symptoms, if any.
Rate of perceived exertion (RPE) or Borg scale (Dyspnea scale)
Nothing at all
Very, very weak (just noticeable)
Very weak
Weak (light)
Somewhat strong
Strong (heavy)
Very Strong
Nothing at all
Very, very slight shortness of breath
Very mild shortness of breath
Mild shortness of breath
Moderate shortness of breath or breathing difficulty
Somewhat severe
Strong or hard breathing
Severe shortness of breath or very hard breathing
Extremely severe
Shortness of breath so severe you need to stop
Nonspecific cough (Running nose)
Acute lung infection
Productive Cough
Lobar pneumonia
Purulent sputum
Acute exacerbation of Chronic
Chronic bronchitis
Productive for at least 3 months of the year
for at least two consecutive years.
Foul smelling, Copious, layered sputum
Blood tinged sputum ( a month long)
Persistent, Non productive cough
Interstitial fibrosis
Persistent, Non productive cough
“Smokers cough”
- Clear watery fluid
- Opalescent or white
- Slightly discolored, but not frank pus
- Thick, viscous: Yellow Dark green/brown/Rusty Red currant jelly
Grading of sputum
* M1 - Mucoid with no suspicion of pus * M2 - Predominantly mucoid, suspicion of pus
* P1 - 1/3 purulent, 2 /3 mucoid
* P3 - More than 2 / 3 purulent
*P2 - 2/3 purulent 1/3 mucoid
Chest pain
Chest pain in respiratory patients usually originates from musculoskeletal, pleural
or tracheal inflammation, as the lung parenchyma and small airways contain no
pain fibers.
1- Pleuritic chest pain:
It is caused by inflammation of the parietal pleura, and is usually described as a
severe, sharp, stabbing pain which is worse on inspiration. It is not reproduced by
2- Tracheitis chest pain:
generally causes a constant burning pain in the center of the chest aggravated by
Chest pain
3- Musculoskeletal (chest wall) pain
May originate from the muscles, bones, joints or nerves of the
thoracic cage. It is usually well localized and exacerbated by chest
and/or arm movement. Palpation will usually reproduce the pain.
4- Angina pectoris
It is a major symptom of cardiac disease. Myocardial ischemia
characteristically causes a dull central retrosternal gripping or bandlike sensation which may radiate to either arm, neck or jaw.
Breath Sounds
Bronchial or
Broncho vesicular
Crackles (Rales)
Pleural rub
a. Normal Breath Sounds
Breath sounds are created by turbulent air flow.
In Inspiration, air moves into progressively smaller airways with
the alveoli as its final location. As air hits the walls of these airways,
turbulence is created and produces sound.
In Expiration, air is moving in the opposite direction towards
progressively larger airways, thus normal expiratory breath sounds
are quieter than inspiratory breath sounds.
1)Tracheal or Bronchial Breath Sound
Bronchial breath sounds are very loud, high-pitched.
There is a Pause (gap) between the inspiratory and expiratory phases of
respiration, and the expiratory sounds are longer than the inspiratory
Place of Auscultation - Over the trachea
2) Broncho vesicular Breath Sound
These are of Moderate intensity and softer pitch than bronchial
sounds. The inspiratory and expiratory sounds are equal in length.
Anteriorly, these sounds can be ascultated directly over the main
stem bronchi (Between 1 st and 2 nd ribs) and Posteriorly, they can
be ascultated between the scapulae ( Between 1 to 6 ribs)
3)Vesicular Breath Sound
The vesicular breath sound is the major normal breath sound and is
heard over most of the lungs. They sound soft and low-pitched.
The inspiratory sounds are longer than the expiratory sounds.
Broncho Vesicular sound
Vesicular sounds
b. Abnormal Breath Sounds
1. Absent or Decreased Breath Sounds
There are a number of common causes for abnormal breath sounds,
including: COPD, Pleural Effusion, Pneumothorax, Hypo inflation and
2. Bronchial Breath Sounds in Abnormal Locations or Increased
breath sounds
Bronchial breath sounds occur over consolidated areas.
c. Adventitious Breath Sounds
1.Crackles (Rales)
Crackles are discontinuous, nonmusical sounds like brief bursts of
popping bubbles. More commonly heard during inspiration.
The mechanical basis of crackles: Sudden opening of closed airways.
Atelectasis, Fibrosis, Bronchiectasis, Chronic bronchitis,
Consolidation, Pleural effusion, and Pulmonary edema
Adventitious Breath Sounds
2. Wheeze
Wheezes are continuous, high pitched, Whistling sounds most commonly
heard on expiration.
Wheezes are produced when air flows through airways narrowed by
secretions, foreign bodies, or obstructive lesions.
Conditions: Asthma, CHF, Chronic bronchitis, COPD and Pulmonary edema
3. Rhonchi
Rhonchi are low pitched, continuous, musical sounds that are similar to wheezes.
They usually imply obstruction of a larger airway by secretions.
Common in Cystic fibrosis and Pneumonia
Adventitious Breath Sounds
4. Stridor
Stridor is an musical sound heard loudest over the trachea during inspiration.
Stridor suggests an obstructed trachea or larynx.
This is common in Asthma, Laryngo spasm and Neoplasm
5. Pleural Rub
Pleural rubs sounds Like two pieces of leather or sand paper rubbing together.
Produced when the pleural surfaces are inflamed and rub against each other. It is
usually heard in lower lateral chest
Conditions: Pleural effusion, Pneumothorax
(4) percussion
Percussion is the FINAL component of chest examination
and is performed to further evaluate changes in lung
density and to evaluate the extent of Diaphragmatic
Percussion is performed with the middle finger of the Non
dominant hand placed flat on the chest wall along the
intercostal space between two ribs and other hand is
positioned with the wrist in flexion and do strike the finger.
1) Resonant sounds
It is low pitched, hollow sounds heard over normal lung tissue.
2) Dull sounds
It is normally heard over dense areas such as the liver or heart. It is
described as “THUD”
Dullness will be heard when fluid or solid tissue replaces aircontaining lung tissues, such as occurs with pneumonia, pleural
effusions, tumors, Atelectasis, and pleural thickening.
Hyper resonant sounds
That are louder and lower pitched than resonant sounds are normally heard when
percussing the chests of children and very thin adults.
Hyper resonant sounds may also be heard when percussing lungs
hyper inflated with air, such as may occur in patients with COPD, or patients
having an acute asthmatic attack. An area of hyper resonance on one side of the
chest may indicate a Pneumothorax.
Tympanic sounds These are hollow, high, drum like sounds.
Tympany is normally heard over the stomach, but is not a normal chest sound.
Tympanic sounds heard over the chest indicate excessive air in the chest, such as
may occur with Pneumothorax.
Diaphragmatic excursion
It is performed by asking the patient to exhale and hold it. The therapist
then percusses down their back in the intercostal margins, starting below
the scapula, until sounds change from resonant to dull (lungs are resonant,
solid organs should be dull). Mark the point with the pen.
Then the patient takes a deep breath in and holds it, marking the spot
where the sound changes from resonant to dull again.
Then measure the distance between the two spots. Repeat on the other
side, is usually higher up on the right side. Normal excursion is 3–5 cm.
Excursion of Diaphragm may be decreased with COPD.