Respiratory system

How to use these guides

The articles in this series, which can be torn out for use in practice, are intended to support clinician development and to assist in the overall assessment of patient presentations. The information should be used to aid consideration of differential diagnoses in situations where life-threatening conditions have been ruled out.

The extent and explanation of each examination will not be to the depth of those provided in core literature texts, so further reading and consolidation are advised to support understanding supplemental to these articles. Key questions are included for reader consideration and to direct further study.

Most examinations are taught in a rigid format. However, in clinical practice, practitioners need to be flexible and adapt their approach depending on the presenting condition and circumstances. While there is no single set way to carry out each of these examinations, a good structure will reduce omissions and errors, and support the gathering of information to inform patient care.

Contemporary texts provide the underpinning reference sources throughout this series, as many of the examination processes and techniques are universally applied; however, differences will be highlighted. Readers will be signposted to these key texts for each clinical examination.

The series will cover the following systems:

Respiratory examination

This article summarises a structured approach to the assessment of the respiratory system. This examination enables clinicians to identify acute and chronic abnormalities (Lane and Rouse, 2016). Further study is required to understand the sensitivity and specificity of each assessment.

Of classifiable diagnoses, respiratory conditions are the second most common (Baker, 2017). The majority are benign and require no intervention, some are more serious but can be treated safely in the community and a few are life-threatening.

Clinicians must inform their management plan with well-structured, thorough history-taking and clinical examination. A full, in-depth examination is not necessary for time-critical emergencies.

Before starting, the clinician must introduce themselves, state their role and briefly explain what the assessment entails to obtain informed consent.

Equipment required

Patient positioning

The most convenient position is for the patient to sit, allowing the clinician full access to the thorax. This also allows for easier expansion of the lungs (Moore, 2017) and possibly assists with respiration in a symptomatic patient. The thorax should be exposed; dignity and comfort should be considered throughout and, where practical, a chaperone should be offered.

General observations

First, note any general observations:

Hands

Consider the appearance of then inspect the hands. Start with the nails, followed by the dorsum then the palms. You should be able to recognise and consider the significance of the following:

A radial pulse should be taken and SpO₂ recorded if not done already (Kirk, 2018a; Matthews, 2018)

Blood pressure should be measured if not taken during the primary survey (Thompson (2018):

Face

Chest

The inspection, palpation, percussion, auscultation (IPPA) approach is used here.

Palpation

Palpation of the anterior and posterior chest should include the examinations below. Although palpation, percussion and auscultation are non-invasive, informed consent should be gained for each, and patient comfort and dignity considered.

Chest expansion can be measured in several ways:

First, place hands ipsilaterally on the chest wall, below the nipple line and using the fingers to anchor at the sides (Figure 1)

Extend the thumbs so they touch at full expiration

The patient should be asked to take in a full breath, and movement observed. The thumbs should be drawn apart; clinicians should be cautious not to pre-empt any movement

Tactile fremitus can be tested, but vocal resonance during auscultation is usually assessed instead now (Rawles, 2015)

Ask the patient to repeat ‘111’ and feel the vibrations. The authors prefer to use the edge of the hand along the fifth metacarpal to do this

Trachea positioning can be determined by placing two fingers above the sternal notch then palpating (Thomas and Monagan, 2014)

Any tenderness and crepitus should be noted, and interventions provided. Patient comfort should be considered if either is discovered.

Percussion

The clinician should spread their fingers over the chest with the middle finger running along the intercostal space and pressure applied. The middle finger should then be struck quickly by the middle finger of the other hand so as not to muffle the tone. Percussion should be started above the clavicle at the lung apex, moving down the anterior of the chest at intervals of 3–4 cm (Figure 2), for comparing ipsilaterally before moving inferiorly in position (Lane and Rouse, 2016).

Percussion should be done in a quiet area; the sound produced once this skill is acquired should be audible without causing discomfort. It should be practised regularly on normal people so the clinician can recognise normal resonance and perfect the skill. The sound could be (Thomas and Monagan, 2014):

Normal resonance with a thud and some resonance in a patient with no concerns

Hyporesonance: where dullness can be heard over consolidation or collapse; and stony dullness over pleural effusion

Hyper-resonance with an extended resonance indicates a lower density than expected, such as in pneumothorax or emphysema.

Use of the stethoscope

Many stethoscopes have a bell and a diaphragm. The bell is primarily for lower frequency sounds; the diaphragm can limit lower-frequency sounds so higher frequency sounds are more obvious. The bell has therefore been said to be superfluous in respiratory assessments (Welsby et al, 2003).

The diaphragm should be used; both high- and low-frequency sounds can be heard in normal and abnormal presentations. With the author's stethoscope, resting the diaphragm on the chest allows for auscultation of low frequencies, and restricting its movement by using firm pressure means higher frequencies can be auscultated. Stethoscopes vary so clinicians should read the instructions to use them correctly and to their full potential.

EtCO₂ monitoring

EtCO₂ monitoring may be used in acute and serious cases, including obstructive issues such as COPD and asthma, pulmonary embolism and heart failure resulting in dyspnoea. The expired CO₂ and wave form can inform the extent and severity of conditions and the effectiveness of treatment. EtCO₂ monitoring can also be useful in monitoring patients experiencing trauma or shock (Aminiahidashti et al, 2018). Deighton (2018) describes EtCO₂ monitoring and its prehospital use.

Circulatory considerations

Respiratory presentations can result from a circulatory problem, especially pulmonary oedema and heart failure. Therefore, if the symptoms of respiratory distress appear to be idiopathic, a cardiovascular examination, such as that described by Dearnley-Lane (2020), should be completed.