Respiratory exam

• Preparation

  • Wash hands

  • Position: sitting

  • Draping: exposed to waist; female pts - exposed intermittently

• Inspection

  • General

    • LOC

    • Chest: masses, scars, lesions

    • Bruising with tenderness (fracture rib)

    • Muscle: atrophy, hypertrophy

    • Fingers: clubbing

  • Respiratory difficulty

    • Accessory muscle use (muscles of the neck)

    • Positioning

      • COPD - lean forward, pursed lips

      • Tripod position

    • Intercostal indrawing

    • Listen for sounds of breathing difficulty

  • Cyanosis

    • Central: lips, buccal mucosa, under tongue

    • Peripheral: fingernails

      • Check cap refill

  • Chest abnormalities

    • Spine: kyphosis, scoliosis

    • Chest: pectus excavatum (funnel-chested) or pectus carinatum (pigeon chested)

      • Barrel chested (increase AP diameter)

  • Resp rate

• Palpation

  • General (anterior and posterior)

    • Tenderness

    • Chest wall abnormalities

  • Trachea

    • Ensure mobile and midline

  • Chest expansion

    • On back, place thumbs at 10th rib with fingers grasping lateral rib cage

    • Ask pt to inhale and exhale deeply

    • Note chest expands and contracts symmetrically

• Percussion

  • At all areas of chest

  • Classify as flat, dull, resonant, hyper-resonant or tympanic

  • Normal lung = resonant

• Auscultation

  • Position: arms hang loosely at sides

  • Anterior and posterior

  • Normal breath sounds

    • Vesicular sounds

      • Normal soft and low-pitched sounds

      • Heard through inspiration, fade away ⅓ through expiration

      • Heard over most lung surface

    • Bronchial sounds

      • Loud, high-pitched

      • Last longer during expiration than inspiration

      • Heard bst in upper manubrium and 1st and 2nd interspaces between scapulae

      • From turbulent airflow through main-stem bronchi

    • Bronchvesicular sounds

      • Intermediate intensity and pitch

      • Equal in inspiratory and expiratory duration

      • Best heard in 1st and 2nd intercostal spaces over manubrium and between scapulae

      • Sounds are mixture of bronchial and vesicular sounds

  • Adventitious sounds

    • Crackles

      • High pitched, discontinuous, intermittent, nonmusical sounds

      • Abnormal lung tissue (pneumonia, fibrosis) or abnormal airways (bronchitis)

    • Wheezes

      • Continuous, high-pitched, shrill, musical sounds

      • Throughout inspiration, or more commonly, expiration

    • Rhonchi

      • Continuous, low-pitched “snoring or gurgling” sounds

      • Result from narrowing of larger airways often due to secretions

    • Pleural rubs

      • Loud coarse sounds with “raspy or leathery” quality

      • Inflammation or thickening of pleura (infection, trauma, neoplasm)

• Post encounter questions:

  • What findings might you elicit from atelectasis / pleural effusion / consolidation / pneumothorax?

• Legacy Exams

  • Palpation - Tactile fremitus

    • Place ulnar side of hand on patient’s chest and ask them to repeat “99”

    • Repeat on all parts of chest

    • Establish symmetry

    • Identify areas of increased, decreased or absent fremitus

    • On posterior exam, ask pt to cross arms at chest

  • Percussion - Diaphragmatic excursion

    • On back, determine level of diaphragm during quiet respiration

    • Ask pt to breathe in as deep as possible

    • Quickly mark level of diaphragm

    • Ask pt to expire as much as possible

    • Mark level of diaphragm on expiration

    • Normal is 3-5.5 cm

  • Auscultation - Transmitted voice sounds

    • Whispered pectoriloquy

      • Ask pt to whisper “99”

      • Normal = faint indistinct sound

      • Abnormal = sound is louder and clearer over suspected area

    • Egophony

      • Ask pt to vocalize a long “E” sound

      • Normal = muffled “E” sound

      • Abnormal “A” is heard

    • Positive tests = increased transmission of voice sounds due to consolidation (pneumonia)

Rational Clinical exam

• Clubbing (2001)

• Pleural effusion (2009)

• Pneumonia (1997)