Chapter 2: Admissions and assessment
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Respiratory examination
Anatomy
The respiratory system consists of an upper and lower airway (Figure 2.5). The upper airway starts with the nasopharynx and the oropharynx, then continues to the laryngopharynx and the larynx (Rushforth [74]). The lower airway starts at the trachea, which divides into two bronchi; these then divide into lobar bronchi, then secondary bronchi, tertiary bronchi, terminal bronchioles, respiratory bronchioles and alveolar ducts (Rushforth [74]).
Figure 2.5 Structures of the respiratory system. Source: Reproduced from Peate et al. ([61]) with permission of John Wiley & Sons, Ltd.
The right lung is made up of three lobes: upper, middle and lower. The left lung only has two lobes: upper and lower (Figure 2.6). The lungs are not stationary but expand and contract during inhalation and exhalation (Bickley and Szilagyi [9]). In order for this to happen smoothly, they are covered in two serous membranes: the visceral pleura and the parietal pleura (Bickley and Szilagyi [9]). The space between these two membranes can occasionally become filled with substances such as air, blood and fluid (Rushforth [74]).
Figure 2.6 Lung, fissures and lobes. RUL, right upper lobe; RML, right middle lobe, RLL, right lower lobe; LUL, left upper lobe; LLL, left lower lobe.
The lungs are within the thorax and are protected by the ribcage, which surrounds them; when examining the lungs, it can be helpful to use the thorax as a point of reference when describing the location of findings (Figure 2.7).
Figure 2.7 Structures of the chest and thorax.
Physiology
The respiratory system has two main functions: delivery of oxygen to cells and removal of carbon dioxide, which accumulates as a result of cellular metabolism (Moore [51]). The control of ventilation is either voluntary or involuntary. The former involves regulation of the respiratory muscles (intercostal muscles and diaphragm) via the central nervous system. Involuntary control of the respiratory muscles occurs via the respiratory centre (medulla oblongata and pons) in the brain (Moore [51]). Stimulation of the respiratory centre occurs when carbon dioxide levels in arterial blood become elevated. Detection of raised carbon dioxide levels results in an increase in the rate and depth of breathing to aid carbon dioxide removal. Hence, in normal pathology, the trigger for breathing is carbon dioxide (hypercapnia) and not oxygen levels. It is important to note that in a patient with chronic obstructive pulmonary disease (COPD), the trigger for respiration is hypoxia (low oxygen levels). This is due to chronically elevated carbon dioxide levels. Consequently, patients with COPD are at risk of respiratory arrest if over‐oxygenated (Moore [51]).
Related theory
The purpose of the respiratory assessment is to further refine the differential diagnoses identified from the patient history. The respiratory assessment will also assess the adequacy of gas exchange, the delivery of oxygen to the tissues and the removal of carbon dioxide (Moore [51]).
The order of examination for the respiratory system is:
- inspection
- palpation
- percussion
- auscultation.
Both the anterior (front) and the posterior (back) chest must be examined and the same techniques are used for both sides.
Inspection
Respiratory rate
When inspecting the respiratory rate, consider the rate, rhythm and effort. Signs to look out for include:
- Rate: tachypnoea (more than 18 breaths per minute) can be indicative of respiratory distress (acute asthma attack, pain, anxiety). Bradypnoea (less than 10 breaths per minute) can indicate a reduced level of consciousness, opioid overdose or depression of the respiratory centre.
- Rhythm: examples of abnormal rhythms include Kussmaul respirations (rapid deep breathing, as seen in states of acidosis such as diabetic ketoacidosis) and Cheyne–Stokes respirations (apnoeic episodes often seen towards the end of life).
- Effort: use of accessory muscles (shoulders and sternocleidomastoid muscles), nasal flaring and pursed lip breathing.
Skin colour
When inspecting skin colour, signs to look out for include:
- Peripheral cyanosis: this is usually evident in the skin and nail beds and is indicative of poor circulation.
- Central cyanosis: this is usually evident in a bluish tinge of the tongue and lips, and is indicative of circulatory or ventilator problems.
Sputum
If the patient has a productive cough, inspection of the sputum can help to ascertain possible causes (Fisher and Potter [28]). The following can be indicative:
- Purulent, yellow or green: infection.
- Mucoid, clear, grey or white: COPD or asthma.
- Serous, clear, pink or frothy: pulmonary oedema.
- Blood: malignancy, pulmonary embolus, clotting disorders or infection.
Chest deformities
Some examples of chest deformities are barrel chest, pigeon chest, funnel chest and flail chest (Table 2.4). Also check for the presence of any scars that could be indicative of previous lung surgery, radiotherapy tattoos or previous chest drains (Moore [51]).
Table 2.4 Examples of chest deformities
|
Normal adult
The thorax in the normal adult is wider than it is deep. Its lateral diameter is larger than its anteroposterior diameter. | |
|
Funnel chest (pectus excavation)
Possible cause: Marfan syndrome
Note the depression in the lower portion of the sternum. Compression of the heart and great vessels may cause murmurs. | |
|
Barrel chest
Possible cause: asthma or chronic obstructive pulmonary disease (COPD)
Note the increased anteroposterior diameter. This shape is normal during infancy and often accompanies ageing and COPD. | |
|
Pigeon chest (pectus carinatum)
Possible cause: severe childhood asthma
Note that the sternum is displaced anteriorly, increasing the anteroposterior diameter. The costal cartilages adjacent to the protruding sternum are depressed. | |
|
Thoracic kyphoscoliosis
Note that the abnormal spinal curvatures and vertebral rotation deform the chest. Distortion of the underlying lungs may make interpretation of lung findings very difficult. | |
|
Traumatic flail chest
Multiple rib fractures may result in paradoxical movements of the thorax. As descent of the diaphragm decreases intrathoracic pressure, on inspiration (breathing in) the injured area caves inward; on expiration (breathing out), it moves outward. |
Legs
Inspect the legs for any evidence of pulmonary oedema, calf swelling (indicative of a deep vein thrombosis) or erythema nodosum (which can be seen in tuberculosis, sarcoidosis or streptococcal throat infections) (Fisher and Potter [28]).
Palpation
Lymph nodes
Part of palpation when examining the respiratory system is to examine the lymph nodes in the neck. Patients often present with a lump or enlarged lymph nodes (lymphadenopathy), which can be an important sign of infection or malignancy (Dover et al. [23]). To do this, stand behind the patient and examine both sides of the neck at the same time. Use your middle and index fingers to softly palpate in circular movements the lymph nodes in the positions illustrated in Figure 2.8.
Figure 2.8 The lymph nodes of the head and neck.
Chest expansion
To assess for chest expansion and symmetry, adopt the position shown in Figure 2.9 and ask the patient to take a deep breath in. You should be able to see your thumbs move an equal distance apart. Reduced expansion may be indicative of fibrosis, consolidation, effusion or pneumothorax (Fisher and Potter [28]).
Figure 2.9 Position of hands to assess for chest expansion.
Tactile fremitus
Fremitus is the palpable vibration of the patient's voice through the chest wall (Bickley and Szilagyi [9]). See Figures 2.10 and 2.11 for the appropriate locations to feel for fremitus. Compare the two sides of the chest, using the ball or ulnar surface of your hand (Bickley and Szilagyi [9]). The vibrations felt should be symmetrical and will decrease as you work down the chest wall. Fremitus is usually decreased or absent over the precordium. Asymmetry could indicate:
- consolidation
- emphysema
- pneumothorax
- plural effusion (Rushforth [74]).
Figure 2.10 Locations for feeling fremitus: back.
Figure 2.11 Locations for feeling fremitus: front.
Faint or absent fremitus in the upper thorax could indicate:
- obstruction of the bronchial tree
- fluid
- obesity (Rushforth [74]).
Percussion
When percussing and auscultating, each side of the chest should be compared. To do this, percuss and auscultate in a ladder‐like pattern in the positions shown in Figure 2.12.
Figure 2.12 Ladder pattern for percussion and auscultation of the chest.
Resonance is heard over normal aerated lung tissue. There are two main types of percussion notes, which are associated with different lung pathologies. The two notes are dullness and hyper‐resonance (Fisher and Potter [28]):
- Dullness: heard over solid organ or fluid; can be indicative of a pleural effusion, consolidation or pleural thickening.
- Hyper‐resonance: heard over hyper‐inflated lung tissue or where there is air in the pleural space; can be indicative of a pneumothorax or COPD.
Auscultation
Auscultation should be performed using the bell of the stethoscope (see Figure 2.4) on both the anterior and the posterior chest.
Breath sounds
Normal breath sounds are also known as ‘vesicular breath sounds’; they are soft and are louder and longer on breathing in (inspiration) compared with breathing out (expiration) (Talley and O'Connor [82]). Bronchial breaths sound different; they have a hollow quality and are audible throughout expiration (Talley and O'Connor [82]). There is often a short, silent gap between inspiration and expiration (Bickley and Szilagyi [9]).
Adventitious sounds are added sounds on top of breath sounds. See Table 2.5 for examples of adventitious sounds.
Table 2.5 Examples of adventitious sounds
| Breath sound | Description | Potential cause |
|---|---|---|
| Wheeze | High‐pitched, hissing sound | Airway narrowing (bronchospasm or airway swelling), e.g. acute asthma attack |
| Stridor | High‐pitched sound, usually on inspiration | Life threatening: due to laryngeal or tracheal obstruction, e.g. choking or anaphylaxis |
| Coarse crackles | Low‐pitched, bubbling, gurgling sound | Pneumonia, bronchiectasis or fluid overload |
| Fine crackles | High‐pitched, popping sound | Restrictive and obstructive diseases, e.g. pulmonary fibrosis |
| Rhonchi | Continuous, low‐pitched, snoring sound | Problems causing obstruction of the trachea or bronchi, e.g. bronchitis |
Vocal resonance can also be assessed as this will give an indication of the lungs’ ability to transmit sound. The method of doing this is to ask the patient to say ‘99’ while auscultating over the chest. The patient's voice will become clearer in an area of consolidation while their voice will become muffled if there is a pleural effusion (Fisher and Potter [28]). This can be repeated while asking the patient to whisper ‘99’ (whispering pectoriloquy); increased transmission of sound will be heard over areas of consolidation.
Evidence‐based approaches
Rationale
Information obtained from the patient's history, the differential diagnoses identified, and the nurse's knowledge of anatomy and physiology will help to inform when it is appropriate to do a respiratory physical examination. Some examples of presentations that would lead to a respiratory examination are:
- dyspnoea
- cough
- chest pain
- wheezing.
Procedure guideline 2.1
