Respiratory Examination
General Inspection
Examine
General appearance and position of the
patient
Using 02, nebulisers or inhalers?
Rationale
May be sat forward if distressed or
acutely breathless
Clues to hypoxia, Asthma, COPD. Note
02% when obtaining ABG’s
Inspect sputum – may give clues to
infection and also note amount of sputum
Central / peripheral cyanosis?
Will identify severity of breathlessness
Sputum pot on locker?
Overall colour of patient
 RR? Using accessory muscles of
respiration? Pursed lip breathing?
Hands
Examine
Feel for temperature
Rationale
Gives an indication of perfusion – may
also be raised in C02 retention secondary
to peripheral vasodilation
As above (C02 retention)
May be peripherally cyanosed – the nail
beds should refill in 2 seconds or less
Thoracic causes of clubbing:
 Bronchial carcinoma
 Chronic lung suppression
- Empyema, abscess
- Bronchiectasis
- Cystic fibrosis
 Fibrosing alveolitis
 Mesothelioma
Are they a smoker?
Ask the patient to hold their hands out
with their palms facing out and hold this.
In C02 retention the patient may develop
a tremor and flap
The palmar creases should be gently
pulled apart – anaemia
Look at the veins of the hand
Look at the colour of the hand and check
for venous return in the nail beds
Look at the nails for clubbing
Tar staining
Test for C02 flap and tremor
Check palmar creases
Arms & Neck
Examine
Pulse Check
Rationale
Check rate and rhythm at the radial
artery.
A patient who has retained C02 may have
a bounding pulse
Blood Pressure
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Clinical Educators
Bradford Hospitals NHS Trust
Examine
Jugular Venous Pressure (JVP)
Rationale
Heart failure is the most common cause
of  JVP; Cor Pulmonale is right heart
failure due to chronic pulmonary
hypertension induced by chronic hypoxia
secondary to diseases of the lung. (e.g.
COPD, Asthma, Bronchietasis,
Pulmonary fibrosis)
Face
Examine
Look at the patients tongue
Rationale
Colour – are they centrally cyanosed?
Smell – infection often causes an
unpleasant breath
Anaemia
Check for pale conjunctivae of the eye
Chest Examination
Inspection
Have the patient expose their chest but maintain their dignity!
Action
Count the patients respiratory rate
Rationale
Good indicator of respiratory distress/
pain
Use of accessory muscles and intercostals
drawing are signs of significant
respiratory distress
Scars may indicate previous surgery
check also the patients back and axilla
May indicate lung pathology –
consolidation, carcinoma, pleural
effusion, pneumothorax
May have traumatic chest injury – flail
chest
May have deformity – pigeon chest
deformity, kyphoscoliosis, funnel chest
deformity
Look in more detail for the use of:
 Accessory muscles
 Intercostals drawing
 Scars
Is chest movement symmetrical?
Note the shape of the chest
Palpation
Action
Examine the lymph nodes
Rationale
Best done from behind the patient – all the lymph
nodes of the neck and head should be palpated
paying particular attention to the supra-clavicular
nodes
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Clinical Educators
Bradford Hospitals NHS Trust
Action
Feel the trachea
Feel for the apex beat
Palpate for chest expansion
Tactile Fremitus
Rationale
The trachea should be felt to be central above the
supra sternal notch – it may be deviated in
pneumothorax or lung pathology that produces
mediastinal shift.
In patients with chronic airway obstruction there
may be a downward movement of the trachea or tug
on inspiration.
Should be located at the 5th ICS in the mid-clavicular
line. May be displaced in lung pathology causing
mediastinal shift
Both upper and lower chest should be assessed.
Place your hands on the patients chest and ask the
patient to take a deep breath in and out – you should
be feeling for chest movement, compare sides and
upper and lower parts of the thorax
Place the lateral edge of the palm and little finger on
the chest wall and ask the patient to say “99” – use
both hands together to allow comparison between
each side and use the same areas that are used later
for palpation and auscultation.
Tactile fremitus will be increased with consolidation,
decreased if there is air between the lung and chest
wall and decreased or absent in the presence of fluid
or pleural thickening.
Percussion
Percuss the chest following a “j” shape down the chest wall. Percuss from side to side
with the percussed finger in contact with the thorax.
The hand should be horizontal to the chest in line with the ribs, purcussing in the inter
costal spaces. Make note of any changes in the percussion note (see below)
Type
Tympanitic
Hyper resonant
Resonant
Dull
Detected over
Hollow viscus
Pneumothorax
Normal lung
Pulmonary consolidation
Pulmonary collapse
Pulmonary fibrosis
Pleural effusion
Stony dull
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Clinical Educators
Bradford Hospitals NHS Trust
Auscultation
Use the diaphragm (In very thin patients you may need to use the bell) and listen from
side to side using the same “j” shape ending in the axillae.
Note any changes in lung sounds – you may hear:
Auscultatory Findings
Pitched bronchial breath
sounds
Pitched bronchial breath
sounds
Diminished or absent
breath sounds
Wheeze
Crackles (crepitations)
Vocal Resonance
Whispering Pectoriloquy
Disease Process
 Pneumonic consolidation.
 Collapsed lung or lobe when bronchi are patent.
 Lung compression by pleural effusion
(Occasionally)
 Tension pneumothorax (occasionally)
 Localised areas of pulmonary fibrosis, e.g. T.B,
chronic suppurative pneumonia
 Pleural effusion
 Marked pleural thickening
 Collapsed lung or lobe when large bronchi
occluded
 Pneumothorax
 Emphysema (symmetrical diminution over both
lungs)
 Asthma
 COPD
 Partially obstructed bronchus (tumour, foreign
body, secretions)
 Bronchiectasis (coarse crackles)
 COPD/ Chronic Bronchitis
 Pulmonary oedema
 TB
 Pneumonic consolidation
This is the auscultatory equivalent of vocal fremitus.
Whilst listening with the stethoscope over the same
areas of the chest ask the patient to say ‘99.’
Normally the sound produced is fuzzy. Sounds will
be increased with consolidation, decreased if there is
air between the lung and chest wall and decreased or
absent in the presence of fluid or pleural thickening.
As a refinement of vocal resonance you may ask the
patient to whisper “99”. Over areas of consolidation the
increased transmission of sound is so marked that the
sound is still heard clearly. This is known as whispering
pectriloquy.
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Clinical Educators
Bradford Hospitals NHS Trust
The Back
Now sit the patient forward and repeat palpation, percussion, and auscultation down
the back.
Completing the Examination
Finally analyse any sputum the patient may have and perform a peak flow reading
recording this information in the patient’s chart.
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Clinical Educators
Bradford Hospitals NHS Trust