Respiratory Exam

Respiratory Exam

General

  • Wash your hands upon entering the room
  • Introduce yourself and the exam to the patient in a way that the patient will understand
  • Patient should be sitting
    • For patients who cannot sit, ex. bedridden patients, have the patient supine and rotate them as necessary to access the anterior and posterior chest
  • Drape the patient so the chest and back is exposed from the waist up
    • It may be helpful to examine the entire anterior chest before moving to the posterior chest
    • While examining the posterior chest, it may be helpful to ask the patient to cross their arms in front of their chest. This helps to move the scapulas out of the way
    • For female patients, keep the chest draped and only expose intermittently as necessary

Vital Signs

Vital signs should be measured on every patient. They include:

  • Blood pressure
  • Heart rate
  • Respiratory rate
  • Temperature
  • Oxygen saturation may also be included

Inspection

When inspecting the patient for respiratory anomalies, you should be looking for the following things:

  • General appearance
    • Obvious signs of respiratory distress, well/unwell etc.
  • Signs of respiratory distress
    • Level of consciousness - If the patient is not alert, it could suggest significant oxygen deprivation
    • Ability to speak - If the patient cannot sleep due to respiratory distress, it could suggest significant oxygen deprivation
    • Accessory muscle use - Examine for trapezius, sternocleidomastoid, scalene, and rectus abdominus use for breathing
    • Intercostal or subcostal indrawing
    • Paradoxical breathing - On inspiration, the abdomen distends, and the chest collapses, which is opposite to normal
    • Tripoding - Patients prop their arms against their legs to assist with breathing
    • Pursed lip breathing - Patients with COPD will often employ this breathing technique to keep their airways open
    • Audible breath sounds - Listen for obvious breath sounds such as wheezing, crackles, stridor and ronchi
  • Use of assistive breathing devices
  • Respiratory rate
    • As in vital signs, note the respiratory rate, but also note the depth and pattern
  • Cyanosis
    • Central cyanosis - Bluish mucous membranes
    • Peripheral cyanosis - Cool/bluish extremities
  • Clubbing
  • Chest wall abnormalities
    • Pectus excavatum (funnel chest) - Depression of the sternum
    • Pectus carinatum (pigeon chest) - Protrusion of the sternum
    • Barrel chest - Increased AP diameter of the chest relative to the transverse diameter
      • Normal - AP:Transverse diameter = 1:2
      • Barrel chest - AP:Transverse diameter = 1:1
  • Spinal abnormalities
    • Scoliosis - Abnormal lateral curvature or torsion of the spine
    • Kyphosis - Abnormal AP curvature of the spine

Palpation

It is important to approach palpation of the chest in a systematic way. When palpating the chest, the following things should be done:

  • Palpate the trachea
    • Palpate the trachea above the sternal notch to ensure it is midline
    • Displacement can suggest pneumothorax, atelectasis, pleural effusion, hemothorax or a non-pulmonary source such as a mass
  • General palpation (anterior and posterior chest)
    • Palpate lightly over the chest wall examining for areas of tenderness, masses, crepitus suggesting subcutaneous emphysema
    • Be sure to include the apices above the clavicles
  • Chest expansion (posterior chest)
    • Standing behind the patient, place your hands on either side of the patient's back at the level of the 10th ribs with your thumbs pointing toward the spine as shown in figure 1
    • Ask the patient to exhale completely, and then inhale deeply
    • Examine for equal, bilateral movement of your hands as the patient breathes
    • Asymmetric movement may suggest decreased air entry
  • Tactile fremitus (anterior and posterior chest)
    • Place the ulnar surface of both hands against the patient's chest and ask them to say "niney nine" repeatedly
    • Each time the patient says "niney nine", move your hands systematically down the patients chest, being careful to include the apices above the clavicles, and the right middle lobe and lingula in the axillae
    • You are palpating for transmission of vibration across the chest wall to your hand
    • Findings:
      • Increased vibrations - suggests consolidation
      • Decreased vibrations - suggests decreased air entry to that area

Percussion

There are two components to percussion of the chest:

  •  General percussion (anterior and posterior chest)
    • Percuss all areas of the lung, including the right middle lobe and lingula. It is important to percuss both the anterior and posterior chest
    • Normal is described as resonant, dullness clasically suggests a pleural effusion but may also suggest pneumonia, atelectasis etc. Hyperresonance suggests emphysema or a pneumothorax
  • Diaphragmatic excursion (posterior chest)
    • Ask the patient to fully exhale and hold their breath. Percuss down their back starting at the spine of the scapula, listening for the percussion note to change from resonant to dull. Mark this position
    • Ask the patient to fully inhale and hold their breath. Percuss down from your previous mark, listening for the percussion note to change from resonant to dull. Mark this position. Remember to tell the patient that they can release their breath.
    • The difference between the two markings is the diaphragmatic excursion
    • Normal is 4-5cm
    • It may be necessary to measure the diaphragmatic excursion on both sides if hemiparesis is suspected

Auscultation

When auscultating the chest, it is important to auscultate over all of the lung areas

  • General auscultation (anterior and posterior chest)
    • Ask the patient to take deep breaths through their mouth
    • Systematically auscultate the chest over the same areas as for percussion using the diaphragm of your stethoscope. It is important to compare sounds from side to side
    • Normal is equal air entry bilaterally
    • Abnormal sounds include crackles, wheezes, rhonchi, stridor and a pleural rub

Table 1: Adventitious sounds

Table 1: Adventitious sounds 

  • Egophony (over areas with abnormal breath sounds)
    • Ask the patient to say "EEEEE" as you listen over areas of suspected consolidation
    • Normal is the transmission of an "EEEEE" sound through your stethoscope
    • A positive test is the transmission of an "AYYYY" sound through your stethoscope
  • Whispered pectoriloquy (over areas with abnormal breath sounds)
    • Ask the patient to whisper "one two three" as you listen to areas of suspected consolidation
    • A positive test is the clear transmission of the whispered words through your stethoscope

Pulmonary Landmarks

The following are some useful pulmonary landmarks

Figure 5: Respiratory palpation, percussion and auscultation zones

Figure 1: Useful pulmonary landmarks

 References:

1:Courtesy Desherinka, Wikimedia Commons: http://upload.wikimedia.org/wikipedia/commons/c/cd/Acopaquia.jpg

2:Courtesy Ahellwig, Wikimedia Commons: http://upload.wikimedia.org/wikipedia/commons/8/83/Pectus1.jpg

3:Courtesy Jprealini, Wikimedia Commons: http://upload.wikimedia.org/wikipedia/commons/f/f4/Pectus_carinatum_mmf.JPG

4:Rolston D et al. Cleveland Clinical Journal of Medicine 2008;75:297-303