Respiratory Assessment Techniques

Respiratory Assessment

Auscultation

• Use the diaphragm of the stethoscope to listen to lung sounds
• Patient should be sitting, leaning slightly forward, with arms resting across the lap
• Instruct patient to breathe slowly in through the mouth, deeper than usual
• Auscultate the posterior, lateral, and anterior areas in a sequential manner, comparing bilaterally throughout the lung fields
• Place the diaphragm of the stethoscope firmly on the chest wall over intercostal spaces
• Listen to an entire inspiration and expiration at each stethoscope position

Normal Breath Sounds

• Bronchial: high-pitched, loud, heard on inspiration and expiration over the trachea and larynx
• Bronchovesicular: medium-pitched, blowing sounds of medium intensity, heard on inspiration and expiration over the major bronchi
• Vesicular: low-pitched, soft sounds, heard on inspiration and expiration, best heard over peripheral lung fields

Adventitious Sounds

• Also known as abnormal sounds
• May be caused by various conditions, such as pneumonia, bronchitis, or pulmonary edema
• If an adventitious sound is heard, have the patient cough and listen again to determine if the sound has cleared with coughing

Landmarking the Lungs

• It is essential to know how to determine which lobe of the lung you are listening to
• Use landmarks to identify the different areas of the lung

Posterior, Lateral, and Anterior Breath Sounds

• Posterior: sounds heard on the back of the chest
• Lateral: sounds heard on the sides of the chest
• Anterior: sounds heard on the front of the chest

Respiratory Assessment

• Inspection: observe size, shape, and configuration of the chest, respiratory rate and effort, positioning, and skin color
• Palpation: note tenderness, temperature, moisture, texture, and superficial lumps or bumps
• Auscultation: listen to breath sounds, noting any adventitious sounds

Palpation - Confirming Symmetrical Chest Expansion

• Stand behind the patient and place warmed hands at T10/Tenth rib with thumbs pointed toward the spine
• Ask the patient to exhale and then inhale, noting movement between the thumbs
• Unequal expansion is indicative of pneumothorax, # ribs, pneumonia, or trauma

Palpation - Assessing Tactile Fremitus

• Tactile fremitus is a palpation vibration that can be felt using the palmar aspect of the hand
• Most prominent between the scapulae and around the sternum
• Decreased fremitus occurs when anything obstructs transmission of vibrations - effusions, pneumothorax, emphysema
• Increased fremitus occurs with compression or consolidation of lung tissue - pneumonia

Assessment of Respiratory Alterations

• Assess for signs and symptoms of respiratory alterations, such as cyanosis, restlessness, confusion, pain during inspiration, laboured/difficult breathing, orthopnea, use of accessory muscles, adventitious breath sounds, and thick frothy blood-tinged sputum/copious sputum
• Assess factors that influence characteristics of respirations, such as exercise, anxiety, acute pain, smoking, medications, positioning, and neuro injury
• Assess pertinent lab values, such as ABG's, SpO2, and CBC

Chest Landmarks

• Anterior thoracic landmarks: nipple line, angle of Louis, suprasternal notch, costal angle, midsternal line, midclavicular line, and anterior axillary line
• Lateral thoracic landmarks: midaxillary line
• Posterior thoracic landmarks: posterior axillary line, vertebral line, and scapular line

Respiratory Assessment

• Importance of assessing respiratory alterations, including cyanosis, restlessness, confusion, pain during inspiration, labored/difficult breathing, orthopnea, use of accessory muscles, adventitious breath sounds, and thick frothy blood-tinged sputum/copious sputum.

Factors Influencing Respiratory Characteristics

• Exercise, anxiety, acute pain, smoking, medications, and positioning as factors that influence respiratory characteristics.

Laboratory Values

• Importance of assessing pertinent laboratory values, including ABG's, SpO2, and CBC.

Landmarks of the Chest and Lungs

• Anterior thoracic landmarks:
  • Nipple line
  • Angle of Louis
  • Suprasternal notch
  • Costal angle
  • Midsternal line
  • Midclavicular line
  • Anterior axillary line
• Lateral thoracic landmarks:
  • Midaxillary line
• Posterior thoracic landmarks:
  • Posterior axillary line
  • Vertebral line
  • Scapular line

Respiratory History

• Importance of reviewing significant history, including:
  • Disease
  • Lifestyle choices (tobacco/marijuana use)
  • Cough (chronic/productive/non-productive)
  • Activity intolerance
  • Chest pain and SOB
  • Recurring attacks of bronchitis or pneumonia
  • Work environment containing pollutants
  • Chronic hoarseness
  • Hx of HIV or TB
  • Family history

Positioning the Patient

• Importance of positioning the patient correctly for assessment, including elevating the head of bed (HOB) 45-90 degrees, using supine and side-lying positions, and ensuring side-to-side comparison.

Inspection

• Importance of inspecting the chest, including:
  • Size, shape, and configuration
  • Respiratory rate and effort
  • Positioning (normal/tripod)
  • Use of pursed lip breathing/accessory muscles
  • Skin color (pink, ashen, gray, cyanotic)
  • Symmetrical expansion
  • AP diameter (1/3 to ½ of side-to-side diameter)

Palpation

• Importance of palpating the entire chest wall, including:
  • Tenderness
  • Temperature
  • Moisture
  • Texture
  • Superficial lumps or bumps
  • Masses or pulsations/unusual movement
  • Crepitus (a coarse crackling sensation)
• Confirming symmetrical chest expansion using palpation, including:
  • Posterior and anterolateral assessment
  • Pinching skin between thumbs to assess movement

Tactile Fremitus

• Importance of assessing tactile fremitus, including:
  • Palpation vibration using the palmar aspect of the hand
  • Decreased fremitus with effusions, pneumothorax, or emphysema
  • Increased fremitus with compression or consolidation of lung tissue

Breath Sounds

• Importance of assessing breath sounds, including:
  • Normal breath sounds (bronchial, bronchovesicular, and vesicular)
  • Decreased or absent breath sounds with obstruction or loss of lung elasticity
  • Increased breath sounds with consolidation or fluid

Auscultation

• Importance of auscultating the lungs, including:
  • Using the diaphragm of the stethoscope
  • Assessing lung sounds in a sequential manner (posterior, lateral, and anterior)
  • Comparing bilaterally throughout the lung fields
  • Ensuring the patient breathes slowly and deeply through the mouth
  • Avoiding background noise and confusion with lung sounds