Comprehensive Respiratory Examination: Techniques and Pathology
The comprehensive respiratory examination is a systematic clinical assessment involving inspection, palpation, percussion, and auscultation to evaluate lung function and identify signs of disease. It begins with general observation and proceeds through specific techniques applied to the chest, head, neck, and extremities, allowing clinicians to correlate physical findings with underlying respiratory pathologies like COPD or pneumonia.
Key Takeaways
The respiratory exam follows a strict sequence: inspection, palpation, percussion, and auscultation.
Always ensure patient privacy, good lighting, and proper hand hygiene before starting the exam.
Inspection begins immediately, noting general environment, work of breathing, and chest shape.
Palpation assesses chest expansion, tactile fremitus, and checks for tracheal deviation.
Percussion differentiates between air-filled (resonant) and solid/fluid-filled (dull) lung tissue.
What are the essential general principles and sequence for a respiratory examination?
A respiratory examination requires adherence to strict general principles to ensure patient comfort, safety, and accurate findings. The process starts the moment you meet the patient, requiring you to introduce yourself and seek permission. Maintain a safe environment with good lighting, ensure privacy, and always wash your hands. The patient should be positioned at 45 degrees with the chest fully exposed. The physical assessment follows the classic sequence: inspection, palpation, percussion, and finally, auscultation.
- Start with greeting and seeking permission.
- Ensure privacy, good lighting, and strict hand hygiene.
- Position the patient at 45 degrees with full chest exposure.
- Sequence: Inspection, Palpation, Percussion, Auscultation.
How do you perform the initial inspection of the respiratory system and environment?
Initial inspection involves observing the patient's general environment and appearance from the end of the bed. Note any supportive equipment, such as oxygen therapy or nebulizers, which indicate acute or chronic distress. Observe the respiratory pattern, noting rate, rhythm, and depth. Look for signs of increased work of breathing, such as indrawing (recession) or the use of accessory muscles. Identify chest wall deformities and correlate findings like a "barrel-shaped" chest with hyperinflation seen in emphysema.
- Check for bedside O2 therapy or nebulizers.
- Assess recession and accessory muscle use.
- Note compensatory pursed-lip breathing.
- Identify chest wall deformities.
- Barrel chest suggests emphysema/hyperinflation.
What specific signs should be inspected in the head, neck, and extremities?
Inspection extends to the hands, face, and neck, revealing systemic manifestations of respiratory disease. In the hands, look for finger clubbing, cyanosis, tar stains, and muscle wasting, which may indicate chronic hypoxia or apical lung tumors. The face may show conjunctival pallor or signs of Horner's Syndrome (ptosis and miosis), often linked to Pancoast tumors. Neck examination focuses on JVD, tracheal position, and lymph node enlargement, providing crucial clues about cardiac involvement or mediastinal masses.
- Check for finger clubbing and central cyanosis.
- Assess for fine tremors or coarse flap (CO2 retention).
- Look for Horner's Syndrome (ptosis + miosis).
- Evaluate JVD and cricosternal distance.
- Note tracheal deviation (pushed away or pulled toward).
Why is detailed inspection of the thorax surface important in the respiratory assessment?
Detailed inspection of the thorax is essential to identify localized abnormalities affecting respiratory mechanics. Observe the symmetry of chest wall movement during respiration; asymmetrical expansion can point to unilateral lung pathology. A thorough check of the surface features reveals important historical information. Look for scars, which indicate previous surgeries like thoracotomy, and note any skin changes such as bruising, sinuses, or radiation marks, helping localize potential areas of disease before palpation.
- Assess symmetry of chest movement.
- Identify scars from previous surgery (Thoracotomy, VATS).
- Note skin changes (bruising, radiation marks).
How is palpation used to assess respiratory function and identify underlying pathology?
Palpation assesses cardiac involvement, chest wall integrity, and vibration transmission. Begin by locating the apex beat and checking for a right ventricular heave, suggesting pulmonary hypertension. Next, assess chest expansion symmetrically, noting any paradoxical movement (Hoover's Sign), indicative of severe hyperinflation. Palpate the chest wall for tenderness or surgical emphysema. Tactile fremitus helps distinguish consolidation (increased fremitus) from pneumothorax or effusion (decreased fremitus) by assessing sound transmission.
- Check apex beat and Right Ventricular Heave.
- Assess chest expansion and Hoover's Sign.
- Palpate for surgical emphysema/tenderness.
- Fremitus increased in consolidation.
- Fremitus decreased in pneumothorax/effusion.
What is the purpose of percussion, and how are the findings interpreted in the respiratory exam?
Percussion involves tapping the chest wall to generate sounds reflecting the density of the underlying lung tissue, primarily detecting asymmetry. The normal sound over an air-filled lung is resonant. Abnormal findings include hyperresonance, which suggests excess air, as seen in pneumothorax or emphysema. Conversely, a dull or muffled sound indicates solid tissue, such as consolidation or a mass. Stony dullness, the most severe finding, signifies a large pleural effusion, where fluid completely blocks sound transmission.
- Primary value is detecting asymmetry.
- Resonant = Normal lung.
- Hyperresonant = Excess air (Pneumothorax, Emphysema).
- Dull = Solid tissue (Consolidation, Mass).
- Stony Dull = Large Pleural Effusion (fluid).
How is auscultation performed, and what do different breath sounds indicate about lung pathology?
Auscultation listens to breath sounds, originating from turbulent airflow in the upper airways. Always compare sounds symmetrically. Normal vesicular breath sounds are soft and low-pitched. Pathologically, hearing bronchial breathing over the lung fields indicates consolidation. Adventitious sounds include wheezes (musical, expiratory), suggesting narrowed airways (asthma/COPD), and crackles (rales), indicating fluid or opening airways (pneumonia, edema). A pleural rub is a coarse, grating sound from inflamed pleural surfaces.
- Compare sounds symmetrically.
- Vesicular sounds are normal; bronchial sounds over lung fields are pathological.
- Absent/diminished sounds mean air/fluid blockage.
- Wheezes indicate narrowed small airways.
- Crackles (rales) suggest fluid or secretions.
- Increased vocal resonance suggests consolidation.
What are the typical physical examination findings for common respiratory pathologies?
Correlating physical findings with specific pathologies is crucial. COPD typically presents with hyperresonant percussion and wheezes due to air trapping. Pneumonia, characterized by consolidation, yields dull percussion and bronchial breath sounds. Conditions involving space-occupying elements, like a simple pneumothorax, result in hyperresonance and decreased breath sounds. Severe conditions like tension pneumothorax or large pleural effusions cause tracheal deviation away from the affected side, while atelectasis pulls the trachea toward the affected side.
- Pneumonia: Dull, Rales, Bronchial sounds.
- COPD: Hyperresonant, Wheezes.
- Simple Pneumothorax: Hyperresonant, Absent sounds.
- Tension Pneumothorax: Hyperresonant, Trachea Away.
- Pleural Effusion: Stony Dull, Trachea Away.
- Atelectasis: Dull, Trachea Toward.
Frequently Asked Questions
What is the significance of finding bronchial breath sounds over the lung fields?
Bronchial breath sounds heard away from the trachea are pathological. They indicate that air-filled lung tissue has been replaced by dense, solid tissue, most commonly seen in consolidation due as in pneumonia.
How does tracheal deviation help differentiate between lung pathologies?
Tracheal deviation indicates a shift in mediastinal pressure. It is pushed away by conditions that increase pressure (tension pneumothorax, effusion) and pulled toward conditions that cause volume loss (atelectasis, fibrosis).
What is the difference between a resonant and a hyperresonant percussion note?
Resonant is the normal, hollow sound of healthy, air-filled lung tissue. Hyperresonant is a louder, booming sound indicating excess air, typically found in emphysema or pneumothorax.
What does the presence of a coarse flap (Asterixis) suggest in a respiratory patient?
Asterixis, or a coarse flap, is often caused by hypercapnia (CO2 retention) in patients with severe obstructive disease like COPD exacerbation. High CO2 levels depress brainstem function.
What is the clinical meaning of Hoover's Sign during palpation?
Hoover's Sign is the paradoxical inward movement of the lower ribs during inspiration. This sign strongly indicates severe hyperinflation and diaphragmatic fatigue, commonly observed in advanced COPD.
