UWE Bristol
Respiratory Examination
Anna Neary
Respiratory Examination
Introduction
This activity looks at a systematic approach to respiratory examination.
You will need to have completed learning activities consultation models
and history taking before undertaking this learning activity.
In this activity, you will:
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Discover the anatomy of the thorax and lungs
Consider a systematic approach to respiratory examination
including inspection, palpation and auscultation
Consider the elements of a general survey
Identify some normal and abnormal breath sounds
Respiratory Examination
Anatomy
The respiratory system consists of the airways, lungs, bony thorax and
respiratory muscles all working together . The Lungs are covered in a
lining called the visceral pleura. There are three lobes on the right side of
the chest (upper, middle and lower). There are two lobes on the left side
of the chest (upper and lower) to accommodate the heart.
The lower airways start with the trachea and then sub divide into the right
and left main bronchi. These bronchi divide into lobar bronchi, then
secondary bronchi, tertiary bronchi, terminal bronchioles , respiratory
bronchioles and finally alveolar ducts. The bronchioles sub divide into
several alveolar ducts, which in turn will have a number of alveolar sacs.
The alveoli consists of alveolar cells, which are simple squamous
epithelial cells, this is the main site for gas exchange.
Anatomy of the chest wall, the chest consists of 12 ribs with intercostal
spaces, a sternal angle adjacent to 2nd rib, costal cartilage from rib 1-7
articulate with sternum. Ribs 8-10 articulate with the costal cartilage just
above them and ribs 11 and 12 have no anterior attachments.
Respiratory Examination
Anterior axillary
line
Anterior axillary line
Vertebral line
Mid clavicular line
Sternal line
Mid-axillary line
Posterior axillary
line
Use the vertical anatomical lines as shown
above to describe your findings.
Left scapular line
Respiratory Examination
Inspiration and expiration
Normal inspiration uses the diaphragm that goes down and flattens, this
is an active process. The intercostal muscles raise the sternum and ribs
and in turn air enters the lungs. Negative alveolar pressure is created. Air
moves into the lungs until the pressures are equal.
Expiration is a passive process where the intercostal muscles and
diaphragm relax. The lungs recoil to their resting size and position.
Positive alveolar pressure is created and the air moves out of the lungs.
Respiratory Examination
Systematic Examination
There are three aspects to consider when carrying out a systematic
examination:
LOOK: inspect
FEEL:
palpate and percuss
LISTEN: auscultate
Respiratory Examination
General Survey
First you need to take time to look at your patients overall appearance,
remembering the importance of basic assessment i.e. airway, breathing,
circulation, disability and exposure and move on only when there is no
immediate intervention in these areas. Also consider whether your
patient appears to be alert or confused or aggressive. You will need to
check their blood pressure in both arms, heart rate, respiratory rate and
pulse. Look at hands, check for signs of cyanosis and any nail
deformities.
Does you patient look pale, sweaty are there any signs of cyanosis, are
there signs of any shortness of breath? Examining the hands is very
important in patients with respiratory disease as there are many
abnormalities that can be found such as finger clubbing, peripheral
cyanosis, tobacco staining and CO2 retention.
Other signs and symptoms of a respiratory condition include, shortness
of breath, anxious or distressed, pallor, cough, wheezing, confusion,
stridor, cyanosis of lips and peripheral cyanosis, chest pain, tripod sitting
position, clubbing of finger nails, fine hand tremor when asked to place
hands out in front of them for 20-30 seconds.
Respiratory Examination
Inspection
•Check the patients rate, rhythm and depth/work of
breathing.
•Check position of trachea, is it midline?
•Look at the patients chest (anterior and posterior),
does the shape appear normal?
• Is there swelling, bruising or scarring on the chest
wall?
• Can you hear any abnormal noises (without
stethoscope) i.e. grunting, wheeze, stridor?
•Inspect Sputum.
Respiratory Examination
Sputum
There are four main types of sputum;
Serous- This is clear and watery although can be frothy and pink in
colour. It can indicate acute pulmonary oedema and can be a sign of
alveolar cell cancer.
Mucoid- This is clear grey or white in colour and is viscid in texture. It
can indicate the presence of chronic bronchitis, COPD or asthma.
Purulent- This is usually yellow or green in colour. The yellow purulent
sputum indicates acute bronchopulmonary infection and /or asthma.
Green purulent sputum indicates a long standing infection such as
pneumonia, bronchiectasis or cystic fibrosis or the presence of a lung
abscess
Rusty- This is as the name suggests rusty red in colour and indicates the
presence of pneumoccal pneumonia.
Respiratory Examination
Palpate the anterior and posterior
chest wall, check for tenderness.
Respiratory Examination
Chest Expansion
it is important when examining the chest to check for symmetry when the
patient is breathing.
To do this place your hands at the level of the 10th rib as shown in the
photograph.
Ask the patient to breath in deeply, watch your thumbs move apart, this
should be equal.
Also feel the rib cage expand and contract.
This can be done on the anterior of the chest or the posterior
Respiratory Examination
Tactile Fremitus
Fremitus refers to the palpable vibrations transmitted through the
bronchopulmonary tree to the chest wall when the patient speaks. To
detect tactile fremitus you need to place either the ball or bony aspect of
your hand or the ulna border of your hand in certain places on the chest
and ask the patient to say “99”. You will feel the vibrations through the
lungs as air is transmitted. You should perform this anteriorly and
posteriorly.
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Intense vibrations can indicate consolidation in tissue.
Faint or absent vibrations can indicate obstruction or fluid filled
pleural space.
Respiratory Examination
Hand positioning for tactile fremitus
Respiratory Examination
Percussion
Percussion is performed to establish whether the lungs are filled
with air, fluid or solid material and to establish lung boundaries.
Percuss in the rib spaces, place your middle finger flat in the
space and using your dominant hand tap the middle finger with
the tip of your finger. Use a systematic approach comparing sides
as shown in the picture.
Normal percussion sound is resonant, long and loud, low pitched
and hollow.
A solid area will sound dull and “thud-like”.
Hyperinflated lung as in pneumothorax will sound hyperresonant,
very loud and lower pitched.
Respiratory Examination
Auscultation
The sound heard through the stethoscope when you are listening
to the chest are different depending on where you are listening.
Vesicular sounds are heard over most of the lung fields, this is
soft and of a low pitch.
Bronchovesicular sounds are heard over the lower trachea and
left and right main bronchi, this sound is intermediate in intensity
and pitch.
Bronchial sounds are heard over the trachea in the neck and they
are loud and high pitch.
You should listen to the chest in the same pattern as when you
percussed the chest, ensuring you compare sides.There are
many breath sounds that can indicate abnormalities within the
lungs. Click on the link and then listen to both recordings of lung
sounds.
Respiratory Examination
Summary
You have now reached the end of this activity. Here is a summary
of the key points:
• It is important to know the anatomy of the thorax and lungs
prior to any examination of the respiratory system.
• When you examine the chest use a systematic approach i.e.
general survey, inspection, palpation and auscultation.
• It is important that you have an understanding of the normal
sounds when percussing the chest and the normal breath sounds
when ausultating, and normal vibrations when performing tactile
fremitus.
Respiratory Examination
References
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Douglas, G, Nicol, F and Robertson, C (2009) Macleod’s
Clinical Examination. Churchill Livingstone
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Hogan-Quigley, B, Louise Palm, M, Bickley, L (2012) Bates’
Nursing Guide to Physical Examination and History Taking.
First Edition. Lippincott, Williams and Wilkins.
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Rushforth, H (2009) Assessment made incredibly easy. First
UK Edition. Lippincott, Williams and Wilkins
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Tortora, G and Derrickson, B (2010) Essentials of anatomy
and physiology. Wiley Plus
Respiratory Examination
Guided learning (Duration: 2 hours)
1. Identify a patient in practice and under the supervision of an
Advanced Nurse Practitioner or doctor, watch a respiratory
examination and then perform a respiratory examination. Use
the templates provided as an aid memoir.
2. Discuss your findings with the ANP or doctor.
3. Research common respiratory conditions such as:
a. COPD
b. Asthma
The British Thoracic website will help your research.
1. Write a reflective piece of work about a patient you have
seen and the guidelines you have learnt.
2. You will also be able to attend a day long face to face skills
workshop to complement this learning activity.