Physical Assessment-Respiratory

Palpation

A thorough respiratory assessment includes palpation and percussion over the anterior and posterior chest. To palpate, press gently with your fingertips all over the chest wall in a systematic fashion. Start above the clavicles anteriorly, palpating from side to side and moving inferiorly to the costal angle and laterally to the midaxillary line. As you palpate, note muscle mass, plus any bony defects, nodules, or masses. Ask the patient about tenderness. Repeat on the posterior chest wall, starting above the scapulae and including the entire thorax to below the 12th rib and out to the midaxillary line. You should feel firm muscle tissue without nodules, bony abnormalities, or masses, and without tenderness.

Observe respiratory rate and rhythm.

Begin the respiratory assessment by counting your patient's respiratory rate and simply observing his breathing pattern. Don't tell the patient you are counting his respirations, as that may alter his breathing pattern. Is his rate of breathing normal, about 12 to 20 breaths per minute for an adult? Is the rhythm of his breathing regular? Are his breaths especially shallow or deep? Is your patient's breathing effortless, or does it take effort for him to breathe? Compare the inspiratory and expiratory phases of respiration. Are they equal? Patients with chronic obstructive pulmonary disease, or COPD, often have a prolonged expiratory phase of respiration, as they have difficulty moving air out of their lungs. Note his posture. Patients in respiratory distress may have to sit upright to breathe or lean forward in what is called a tripod position. As you assess your patient's respiration, consider other health issues that may affect his breathing. For example, trauma to the chest or abdomen, inflammation of abdominal organs, recent surgery, or increased abdominal pressure due to pregnancy or even obesity can all affect a patient's ability to breathe.

Auscultation

Finally, use the diaphragm of your stethoscope to auscultate over all lung fields. As you listen, think about which lobe of the lung you are listening to, because you might hear abnormal lung sounds in just one lobe. Remember, the right lung has three lobes, while the left has two. To make lung sounds easier to hear, reduce extraneous noise: Close the door, turn off the TV, and ask the patient and others to refrain from talking while you are listening to his lungs. Place your stethoscope directly on the patient's skin; trying to listen to lung sounds through clothing only makes your job more difficult. Don't allow clothing or bedding to rub against the stethoscope tubing, and be sure the stethoscope tips are seated snugly in your ears. Finally, ask the patient to take deep breaths, with his mouth open, each time you move your stethoscope. The more air your patient moves, the easier your job! Be sure to have patient stop and rest if he becomes lightheaded. Normal breath sounds vary according to the diameter of the airways. For example, anteriorly over the trachea, you should hear a loud, high-pitched, hollow sound called a bronchial breath sound. It is abnormal to hear this sound over peripheral lung tissue, that is, away from the trachea and the large bronchi. Over the mainstem bronchi, which are relatively large-diameter airways, you should hear medium-pitched and quieter sounds, called bronchovesicular breath sounds. Note that the areas over which bronchovesicular breath sounds are expected are small, but are present both anteriorly and posteriorly. Over most of the lung tissue, you should hear soft, fine, breezy, low-pitched sounds called vesicular breath sounds. They are normally heard over peripheral lung tissue, which is formed by groups of alveoli and is where air exchange occurs. It may be helpful for a beginner to practice respiratory auscultation with thin people or with children, as their breath sounds are more prominent. Auscultate over all areas of the anterior and posterior thorax, moving side to side and working your way inferiorly to the lung bases. When you listen to posterior lung sounds, ask the patient to cross his arms in front of his chest. This pulls the scapulae apart and exposes more lung tissue. Be sure to listen to each full cycle of inspiration and expiration before moving your stethoscope, as just one part of the respiratory cycle might generate abnormal sounds. You should hear breath sounds over all lung tissue, and the quality of the breath sounds should be similar as you listen from side to side. Diminished or hard-to-hear lung sounds are most common with thick chest walls (in either muscular or obese patients), or when the patient is not taking deep breaths. However, diminished breath sounds can also be associated with disease. Occasionally you might not hear any breath sounds at all over a particular part of the lung; this can result from airway obstruction, with collapse of lung tissue (such as pneumothorax), or when lung tissue has been surgically removed. Note the quality of the lung sounds and listen carefully for any abnormal sounds, such as crackles or wheezes. Crackles, which are sometimes called rales, are wet, popping sounds created by air moving through liquid or by collapsed alveoli snapping open on inspiration. They are most common at the end of inspiration. Wheezes are continuous sounds caused by air moving through constricted airways. Airways can be narrowed by a number of causes: the bronchial constriction that accompanies asthma, bronchial inflammation, mucus accumulation or mucous plugs, or tumors. Wheezes can be high-pitched, which is common with asthma, or low-pitched with almost a snoring quality. Low-pitched wheezes are sometimes called rhonchi. Mild wheezing is often limited to the expiratory phase of respiration, while more severe wheezing can be heard throughout the respiratory cycle. Both wheezing and crackles may clear with coughing, so ask the patient to take a deep breath and cough a couple of times, then listen again. Occasionally, you will hear other abnormal lung sounds. Stridor is a high-pitched sound typically generated when a larger airway is blocked by a foreign body, severe inflammation, or a mass. A friction rub may result when the pleural membranes covering the lungs and lining the thoracic cavity are inflamed. A friction rub is a scratching or squeaking sound that persists throughout the respiratory cycle and does not clear with coughing.

Check oxygen saturation.

If your patient is using oxygen, be sure to note the type of delivery device as well as the oxygen flow rate, measured in liters per minute. Then use an oximeter to measure his oxygen-saturation level. (For more information, see the skills module on vital signs.)

Components

Observe respiratory rate and rhythm. Check oxygen saturation. Inspect chest configuration and the work of breathing. Palpate and percuss anteriorly and posteriorly. Auscultate lung sounds, including listening for adventitious sounds.

Inspect chest configuration and the work of breathing.

Next, expose the patient's thorax and inspect it for symmetry and configuration. Normally, a chest is twice as wide as it is deep, but a patient with chronic respiratory disease and increased work of breathing may develop a barrel-shaped chest with an increased anterior-to-posterior diameter. Inspect for the use of accessory muscles of respiration (the use of neck and intercostal muscles with breathing) and for retraction of the soft tissue between the ribs. These are all signs of increased work of breathing. Don't forget to look at the posterior thorax, noting any bony deformities. Abnormal spinal curvature, such as kyphosis or scoliosis, can make breathing difficult.

Equipment

Pulse oximeter Stethoscope

Percussion

Use the same pattern to percuss over the lung tissue, taking care to percuss between the ribs and moving from side to side. The tone generated by lung percussion should be resonance, which is a low-pitched, hollow sound. Finally, check lung expansion, either anteriorly or posteriorly. Place your hands over the patient's ribs, with your thumbs close together at midline and your fingers spread. Ask the patient to take a deep breath. With normal expansion, you will feel the rib cage expand smoothly and symmetrically under your hands, as your thumbs move apart.