RESPIRATORY ASSESSMENT

Mr. Nikhil D. Ketkar ( MSc Nursing )

INTRODUCTION
A comprehensive respiratory assessment includes physical examination and diagnostic
tests that provide information about respiratory function. Diagnostic tests can be used to
explore potential disease states. Common respiratory diagnostic tests include pulse oximetry,
blood gas analysis, chest x-ray, pulmonary function tests, and thoracic CT and MRI scans.
However, bedside clinical assessment provides vital information about respiratory function. It
is important for nurses in all practice settings to be able to perform a basic respiratory
assessment. This includes taking a patient history, and using the techniques of inspection,
palpation, percussion, and auscultation.

ANATOMIC LANDMARKS
It is important to review the anatomy of the chest wall and thoracic cavity, as anatomic
landmarks will use to document the location of respiratory assessment findings.
The thoracic cavity is made up of 12 pairs of ribs that connect in the posterior thorax to
the vertebral bodies of the spinal column. In the anterior thorax, the first 7 pairs of ribs are
attached to the sternum or breastbone by cartilage. The lower 5 ribs do not attach to the
sternum. The 8th, 9th, and 10th ribs are attached to each other by costal cartilage. The 11th and
12th ribs, known as “floating ribs,” are not attached in any way to the sternum; they move up
and down in the anterior chest, allowing for full chest expansion.

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 The following diagram shows the anterior chest again, with the lobes of the lungs
included. Various reference lines and angles are commonly used to identify respiratory
findings. For example:

 The angle of Louis (also called the sternal angle) is a useful place to start counting ribs,
which helps localize a respiratory finding horizontally. If you find the sternal notch,
walk your fingers down the manubrium a few centimeters until you feel a distinct bony
ridge. This is the sternal angle. The 2nd rib is continuous with the sternal angle; slide
your finger down to localize the 2nd intercostal space. The angle of Louis also marks
the site of bifurcation of the trachea into the right and left main bronchi and
corresponds with the upper border of the atria of the heart.
 Reference lines help pinpoint findings vertically. For example, the major division
("fissure") between lobes in the anterior chest crosses the 5th rib in midaxillary line
and terminates at the 6th rib in the midclavicular line

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Other terms used to document locations for chest physical assessment include:

 Supraclavicular - above the clavicles

 Infraclavicular - below the clavicles
 Interscapular - between the scapulae
 Infrascapular - below the scapulae
 Bases of the lungs - the lowermost portions
 Upper, middle, and lower lung fields

TAKING A RESPIRATORY HISTORY

Start your respiratory assessment by interviewing the patient and conducting a
respiratory history. Starting the assessment with an interview helps you establish rapport
with the patient and may lessen the patient's anxiety. During the history, you will be gathering
information about the patient's current and any previous respiratory problems. You may
interview the patient, and in some cases, family members or significant others. When doing
your assessment, keep in mind these six important respiratory symptoms:

 cough,
 sputum production,

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  dyspnea,
 hemoptysis,
 chest pain, and
 wheezing.

Procedure
 Explain to the patient what you are about to do – even if the patient is unconscious.
 Ensure the patient is comfortable.
 Make sure the patient is as relaxed as possible.
 Observe if the patient is distressed in any way.
 It is best to monitor and record the respirations immediately after taking the pulse –
this will aid in a more accurate recording, as the patient will not be aware that you are
observing respirations. Awareness that respirations are being recorded can make
people alter their breathing.
 Observe the rise and fall of the chest (inspiration and expiration) - this counts as one
breath.
 The respirations should be counted for a full minute in order to have an accurate
recording.
 Note the pattern of breathing and the depth of the breaths.
 Document your findings on the patient’s observation chart, note any changes and
report to the medical team.
 Before leaving ensure the patient is comfortable.

Time for the respiration record

The patient’s condition will dictate the frequency of recording. Respirations should
always be recorded when a patient is first admitted into hospital, to acquire a baseline record.

Safety
 Wash hands thoroughly between patients - to eliminate the risk of cross infection.
 Record respirations for a full minute to monitor the respiration pattern and to ensure
accuracy of the observation.
If a patient has been prescribed oxygen, ensure the oxygen mask or nasal cannulae is correctly
placed prior to recording respirations, and also check that the oxygen flow rate is set as
prescribed and recorded on the observation chart

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The following questions may be useful in taking a respiratory history:
 Are you having any trouble breathing?
 Do you have any chest pain with breathing? If so, what is the pain like, when does it
occur, and what relieves it?
 Do you have a cough? If yes, what does the cough sound like, when does it occur, do
you bring up any phlegm (sputum) when you cough, what does the phlegm look like?
Normal sputum is thin, clear to white in color, and tasteless and odorless. Yellow-green
colored sputum may indicate a bacterial infection and rust-colored sputum is
characteristic of pneumonia.
 Are you ever short of breath? If so, does your shortness of breath occur at rest or with
activity? Ask the patient specific questions about shortness of breath that impacts daily
living, such as being able to carry groceries from a car, or being able to clean floors or
do laundry.
 Do you have any problems breathing at night? If so, do you use pillows to help you get
in a position to breathe easier?
 Do you have any allergies? If yes, how does your allergy affect your breathing?
 Do you smoke now or have you ever smoked? If yes, how many years did you smoke
and how many packs of cigarettes did you smoke daily?
 What kind of work do you do/did you do? In your work are/were you exposed to
substances such as asbestos, chemicals, or cigarette smoke?
 Do you have a personal or family history of asthma, tuberculosis, lung cancer, cystic
fibrosis, bronchitis, emphysema, or any other lung disease?
Answers to these questions provide you with important information about the patient's
current problem and background data that could be contributing factors to respiratory
disease. Conduct the assessment in a comfortably warm room. Ask the patient to sit upright.
During all aspects of the assessment, observe for fatigue or discomfort. Allow the patient time
to rest if necessary.
If the patient is an older adult, ask the patient whether or not he or she has had an annual
flu immunization and pneumonia vaccine. Ask about any recent changes in exertional
capacity, fatigue, a change in the number of pillows needed to sleep at night, any significant
weight change, or a history of night sweats, or hand or leg swelling.
After the interview is completed, proceed in an orderly fashion by following the steps of
respiratory physical assessment:

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  inspection,
 palpation,
 percussion, and
 auscultation.

INSPECTION
Note the patient's age and it's impact on respiratory function. As people age, their
capacity for exercise decreases. The chest wall becomes stiffer and harder to move,
respiratory muscles may weaken, and the lungs lose some of their elastic recoil. The speed of
breathing out with maximal effort gradually decreases. Skeletal changes associated with aging
may accentuate the dorsal curve of the thoracic spine, producing kyphosis and increasing the
anterior-posterior diameter of the chest.
In any health care setting, you can use some practical ways of assessing concerns about
shortness of breath in a patient who can ambulate. One simple and useful assessment method
is to walk with the patient down a hallway or from one room to another or ask the patient to
perform an activity such as climbing stairs. By observing the patient doing these activities, you
can observe changes in the rate, effort, and sounds of the patient's respiratory pattern.
Assessing forced expiratory time is another practical means of observing respiratory function,
especially in a patient who may have COPD. Ask the patient to take a deep breath in and then
to breathe out as quickly and completely as possible, with the mouth open. While the patient
is doing a forced expiration, listen over the trachea and time the audible expiration. A forced
expiratory time of over 6 seconds suggests obstructive pulmonary disease.

Normal findings for chest inspection include:

 Side to side symmetric chest shape
 Distance from the front to the back of the chest (anterior-posterior diameter) less than
the size of the chest from side to side (transverse diameter)
 Normal chest shape, with no visible deformities, such as a barrel chest, kyphosis, or
scoliosis
 No muscle retractions when breathing
 Quiet, unlabored respirations with no use of accessory, neck, shoulder, or abdominal
muscles
 A regular respiratory rhythm, with expiration taking about twice as long as inspiration
 Skin color that matches the rest of the body's complexion

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  A respiratory rate of 12-20 in an adult.
Rapid, shallow breathing is called tachypnea. Tachypnea is seen in patients with
restrictive lung disease such as kyphosis, and in situations where pleuritic chest pain
prohibits full expansion of the chest wall. Restrictive lung disease refers to changes in the
chest structure that prohibit full chest expansion. Rapid deep breathing, known as hyperpnea
or hyperventilation, occurs as a result of physical exercise, anxiety, and metabolic acidosis.
Kussmal breathing, characterized by slow, deep breaths, occurs in patients with diabetic
acidosis and coma. Bradypnea, or a much slower than normal respiratory rate, is seen in
patients with drug-induced respiratory depression, and increased intracranial pressure.
Cheyne-Stokes breathing occurs when there are periods of deep breathing alternating with
periods of apnea. A Cheyne-Stokes breathing pattern may be seen in a patient with heart
failure, drug-induced respiratory depression, uremia, or brain damage. Ataxic breathing, also
known as Biot's breathing, is characterized by unpredictable irregularity. Biot's breathing
may be seen in patients with respiratory depression and brain damage at the level of the
medulla.

PALPATION
Palpation is an assessment technique in which the examiner uses the surface of the
fingers and hands to feel for abnormalities. Assessment data that can be obtained through
palpation includes identifying chest movement symmetry, chest skeletal abnormalities,
tenderness, skin temperature changes, swelling, and masses.
To assess the symmetry of chest expansion during breathing, stand behind the person,
and place your hands with fingers spread apart beneath his or her arms, on the sides of the
chest, about 2 inches below the axilla. Your fingers should be pointing toward the anterior
chest - this will let you feel the chest rising and falling on inspiration and expiration. Ask the
person to breathe out completely – observe your hands and thumbs to see that they have
moved equally on both sides.
After checking for symmetrical chest expansion, feel for tactile fremitus. Fremitus refers
to vibratory tremors that can be felt through the chest by palpation. To assess for tactile
fremitus, ask the patient to say “99” or “blue moon”. While the patient is speaking, palpate the
chest from one side to the other. Tactile fremitus is normally found over the mainstem
bronchi near the clavicles in the front or between the scapulae in the back. As you move your
hands downward and outward, fremitus should decrease. Decreased fremitus in areas where

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fremitus is normally expected indicates obstruction, pnemothorax, or emphysema. Increased
fremitus may indicate compression or consolidation of lung tissue, as occurs in pneumonia.

Normal findings on palpation include:

 normal chest size and shape,
 warm, dry skin,
 no tender spots,
 symmetrical chest expansion, and
 tactile fremitus over the mainstem bronchi in front and between the scapulae in the
back of the chest.

PERCUSSION
Percussion is an assessment technique which produces sounds by the examiner
tapping on the patient's chest wall. Just as lightly tapping on a container with your hands
produces various sounds, so tapping on the chest wall produces sounds based on the amount
of air in the lungs. Percussion sets the chest wall and underlying tissues into motion,
producing audible sounds and palpable vibrations. Percussion helps to determine whether the
underlying tissues are filled with air, fluid, or solid material.
Percussing the anterior chest is most easily done with the patient lying supine; the
patient should sit when percussing the posterior chest. Place the first part of the middle finger
of your nondominant hand firmly on the patient's skin. Then, strike the finger placed on the
patient's skin with the end of the middle finger of your dominant hand.
Work from the top part of the chest downward, comparing sounds heard on both the right
and left sides of the chest. Visualize the structures underneath as you proceed.

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 Resonant sounds are low pitched, hollow
sounds heard over normal lung tissue.

Flat or extremely dull sounds are

normally heard over solid areas such as
bones.

Dull or thudlike sounds are normally heard over dense areas such as the heart or
liver. Dullness replaces resonance when fluid or solid tissue replaces air-containing
lung tissues, such as occurs with pneumonia, pleural effusions, or tumors.

Hyperresonant sounds that are louder and lower pitched than resonant sounds are
normally heard when percussing the chests of children and very thin adults.
Hyperresonant sounds may also be heard when percussing lungs hyperinflated with
air, such as may occur in patients with COPD, or patients having an acute asthmatic
attack. An area of hyperresonance on one side of the chest may indicate a
pneumothorax.

Tympanic sounds are hollow, high, drumlike sounds. Tympany is normally heard
over the stomach, but is not a normal chest sound. Tympanic sounds heard over the
chest indicate excessive air in the chest, such as may occur with pneumothorax.
AUSCULTATION
Auscultation is the technique of listening to the sounds of the chest with a stethoscope.
The movement of air in and out of the respiratory system produces breath sounds. Breath
sounds are transmitted through the chest wall and may be heard through the diaphragm (flat

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piece) of a stethoscope placed firmly against the chest wall. Auscultation of the lungs is the
most important examining technique for assessing airflow through the tracheobronchial tree.
Ask the patient to sit with his arms folded across the chest with the hands resting, if
possible, on the opposite shoulders. This position moves the scapulae partly out of the way
and increases access to the lung fields. Instruct the patient to breathe deeply with his mouth
open. Listen carefully for at least one full breath in each location. Observe the patient for light-
headedness or fatigue and allow the patient to rest as often as necessary.

Look again at the auscultation patterns for the posterior chest

Start by listening to posterior chest, beginning with the areas above the scapulae. It is
useful to start here because the lung fields are closer to the wall of the posterior chest and
there's less interference from heart sounds than with the anterior chest. Move downward in a
stair-step fashion, comparing your findings from one side with those from the other side.
Chest auscultation involves:
 Listening for the sounds generated by normal breathing
 Listening for any adventitious or added sounds
 If abnormalities are detected, listening to the sounds of the patient's spoken or
whispered voice as they are transmitted through the chest wall

Normal Breath Sounds

Normal breath sounds are classified as tracheal, bronchial, bronchovesicular, and
vesicular sounds. The patterns of normal breath sounds are created by the effect of body
structures on air moving through airways. In addition to their location, breath sounds are
described by:
 duration (how long the sound lasts),
 intensity (how loud the sound is),
 pitch (how high or low the sound is), and
 timing (when the sound occurs in the respiratory cycle).
Tracheal breath sounds are heard over the trachea. These sounds are harsh and sound like
air is being blown through a pipe.
Bronchial sounds are present over the large airways in the anterior chest near the second
and third intercostal spaces; these sounds are more tubular and hollow-sounding than
vesicular sounds, but not as harsh as tracheal breath sounds. Bronchial sounds are loud and

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high in pitch with a short pause between inspiration and expiration; expiratory sounds last
longer than inspiratory sounds.
Bronchovesicular sounds are heard in the posterior chest between the scapulae and in the
center part of the anterior chest. Bronchovesicular sounds are softer than bronchial sounds,
but have a tubular quality. Bronchovesicular sounds are about equal during inspiration and
expiration; differences in pitch and intensity are often more easily detected during expiration.
Vesicular sounds are soft, blowing, or rustling sounds normally heard throughout most of the
lung fields. Vesicular sounds are normally heard throughout inspiration, continue without
pause through expiration, and then fade away about one third of the way through expiration.
In a normal air-filled lung, vesicular sounds are heard over most of the lung fields,
bronchovesicular sounds are heard between the 1st and 2nd interspaces on the anterior chest,
bronchial sounds are heard over the body of the sternum, and tracheal sounds are heard over
the trachea.

Normal findings on auscultation include:

 Loud, high-pitched bronchial breath sounds over the trachea
 Medium pitched bronchovesicular sounds over the mainstream bronchi, between the
scapulae, and below the clavicles
 Soft, breezy, low-pitched vesicular breath sounds over most of the peripheral lung
fields.

ABNORMAL BREATH SOUNDS

Abnormal breath sounds include:
 the absence of sound and/or
 the presence of "normal" sounds in areas where they are normally not heard.
o For example, bronchial (loud & tubular) breath sounds are abnormal in
peripheral areas where only vesicular (soft & rustling) sounds should be heard.
When bronchial sounds are heard in areas distant from where they normally
occur, the patient may have consolidation (as occurs with pneumonia) or
compression of the lung. These conditions cause the lung tissue to be dense. The
dense tissue transmits sound from the lung bronchi much more efficiently than
through the air-filled alveoli of the normal lung.
The term “adventitious” breath sounds refers to extra or additional sounds that are heard
over normal breath sounds. Sources differ as to the classification and nomenclature of these

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sounds, but most examiners commonly use the following terms to describe adventitious
breath sounds.
 crackles (or rales)
 wheezes (or rhonchi)
 pleural friction rubs
 stridor
Detection of adventitious sounds is an important part of the respiratory examination, often
leading to diagnosis of cardiac and pulmonary conditions.
Crackles (or rales) are caused by fluid in the small airways or atelectasis. Crackles are
referred to as discontinuous sounds; they are intermittent, nonmusical and brief. Crackles
may be heard on inspiration or expiration. The popping sounds produced are created when
air is forced through respiratory passages that are narrowed by fluid, mucus, or pus. Crackles
are often associated with inflammation or infection of the small bronchi, bronchioles, and
alveoli. Crackles that don't clear after a cough may indicate pulmonary edema or fluid in the
alveoli due to heart failure or adult respiratory distress syndrome (ARDS).
 Crackles are often described as fine, medium, and coarse.
 Fine crackles are soft, high-pitched, and very brief. You can simulate this sound by
rolling a strand of hair between your fingers near your ear, or by moistening your
thumb and index finger and separating them near your ear.
 Coarse crackles are somewhat louder, lower in pitch, and last longer than fine crackles.
They have been described as sounding like opening a Velcro fastener.
Wheezes are sounds that are heard continuously during inspiration or expiration, or during
both inspiration and expiration. They are caused by air moving through airways narrowed by
constriction or swelling of airway or partial airway obstruction.
 Wheezes that are relatively high pitched and have a shrill or squeaking quality may be
referred to as sibilant rhonchi. They are often heard continuously through both
inspiration and expiration and have a musical quality. These wheezes occur when
airways are narrowed, such as may occur during an acute asthmatic attack.
 Wheezes that are lower-pitched sounds with a snoring or moaning quality may be
referred to as sonorous rhonchi. Secretions in large airways, such as occurs with
bronchitis, may produce these sounds; they may clear somewhat with coughing.
Pleural friction rubs are low-pitched, grating, or creaking sounds that occur when inflamed
pleural surfaces rub together during respiration. More often heard on inspiration than
expiration, the pleural friction rub is easy to confuse with a pericardial friction rub. To

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determine whether the sound is a pleural friction rub or a pericardial friction rub, ask the
patient to hold his breath briefly. If the rubbing sound continues, its a pericardial friction rub
because the inflamed pericardial layers continue rubbing together with each heart beat - a
pleural rub stops when breathing stops.
Stridor refers to a high-pitched harsh sound heard during inspiration.. Stridor is caused by
obstruction of the upper airway, is a sign of respiratory distress and thus requires immediate
attention.

If adventitious sounds are heard, it is important to assess:

 their loudness,
 timing in the respiratory cycle,
 location on the chest wall,
 persistence of the pattern from breath to breath, and
 whether or not the sounds clear after a cough or a few deep breaths.
o secretions from bronchitis may cause wheezes, (or rhonchi), that clear with
coughing
o crackles may be heard when atelectatic alveoli pop open after a few deep
breaths

TRANSMITTED VOICE SOUNDS

If you hear adventitious sounds on auscultation, assess how these sounds change as the
patient speaks. Voice assessment can provide important clues about respiratory
abnormalities. Normal lungs are filled with air, and air does not transmit sound readily.
Normally, transmitted voice sounds are difficult to hear – spoken words are muffled and
indistinct and whispered words are usually not heard at all.
However, when substances such as fluid or solid masses replace air in the lungs, sounds are
transmitted more clearly. The sounds that can be assessed are:
 Whispered pectoriloquy: Ask the patient to whisper a sequence of words such as
“one-two-three”, and listen with a stethoscope. Normally, only faint sounds are heard.
However, over areas of tissue abnormality, the whispered sounds will be clear and
distinct.
 Bronchophony: Ask the patient to say "99" in a normal voice. Listen to the chest with
a stethoscope. The expected finding is that the words will be indistinct. Bronchophony
is present if sounds can be heard clearly.

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 Egophony: While listening to the chest with a stethoscope, ask the patient to say the
vowel “e”. Over normal lung tissues, the same “e” (as in "beet") will be heard. If the
lung tissue is consolidated, the “e” sound will change to a nasal “a” (as in "say").

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