ASSESSMENT OF

RESPIRATORY
SYSTEM

SUBMITTED BY
PANKAJ SINGH RANA
NURSE PRACTITIONER IN
CRITICAL CARE, SRHU
Functions of the Respiratory
System

 Air Distributor
 Gas exchanger
 Filters, warms, and
humidifies air
 Influences speech
 Allows for sense of smell
 Divisions of the Respiratory
System
 Upper respiratory tract
(outside thorax)
 Nose
 Nasal Cavity
 Sinuses
 Pharynx
 Larynx
 Divisions of the Respiratory
System
 Lower respiratory
tract (within thorax)

 Trachea
 Bronchial Tree
 Lungs
 Structures of the Upper
Respiratory Tract
 Nose - warms and moistens air
 Palantine bone separates nasal
cavity from mouth.
▪ Cleft palate - Palantine
bone does not form
correctly, difficulty in
swallowing and speaking.
 Septum - separates right and
left nostrils
▪ rich blood supply = nose
bleeds.
 Sinuses - 4 air containing
spaces – open or drain into
nose - (lowers weight of skull).
 Structures of the Upper
Respiratory Tract

▪ Pharynx - (throat)
▪ Base of skull to
esophagus
▪ 3 divisions
– Nasopharynx - behind nose
to soft palate.
▪ Adenoids swell and
block.
– Oropharynx - behind
mouth, soft palate to hyoid
bone.
▪ tonsils
– Laryngopharynx - hyoid
bone to esophagus.
 Structures of the Lower
Respiratory Tract
▪ Larynx - voice box
– Root of tongue to
upper end of trachea.
– Made of cartilage
– 2 pairs of folds
▪ Vestibular - false
vocal cords
▪ True vocal cords
 Structures of the Lower
Respiratory Tract larynx cont…

▪ Thyroid cartilage - adam’s

apple - larger in males due
to testosterone.
▪ Epiglottis - flap of skin
(hatch) on trachea, moves
when swallowing and
speaking.
– closes off trachea when
swallowing food
 Structures of the Lower
Respiratory Tract
▪ Trachea (windpipe)
– Larynx to bronchi
– Consists of smooth
cartilage and C
shaped rings of
cartilage.
– Tracheostomy -
cutting of an opening
in trachea to allow
breathing.
 Structures of the Lower
Respiratory Tract
▪ Bronchi
– Tubes that branch off
trachea and enter into
lungs
– Ciliated
– Branches: Primary bronchi
—secondary bronchi—
tertiary bronchi—
bronchioles
– Bronchioles branch into
microscopic alveolar ducts.
Terminate into alveolar
sacs
– Gas exchange with blood
occurs in sacs.
Structures of the Lower
Respiratory Tract
 Structures of the Lower
Respiratory Tract
▪ Lungs
– Extend from
diaphragm to
clavicles
– Divided into lobes
by fissures.
– Visceral pleura
adheres to the
lungs.
▪ Pleurisy =
inflammation of the
pleural lining
(Plural – Bronchioles
bronchi)
 Respiratory Physiology

▪ Pulmonary Ventilation =
breathing
– Mechanism
▪ Movement of gases
through a pressure
gradient - hi to low.
▪ When atmospheric
pressure (760 mmHg)
is greater than lung
pressure ---- air flows
in = inspiration.
▪ When lung pressure is
greater than
atmospheric pressure
---- air flows out =
expiration.
 Respiratory Physiology

▪ Pressure gradients are established by changes in

thoracic cavity.
– increase size in thorax = a decrease in pressure --- air
moves in.
– Decrease size in thorax = increase in pressure --- air
moves out.
http://people.eku.edu/ritchisong/301notes6.htm
 Inspiration

-contraction of diaphragm and

intercostal muscles
 Expiration
▪ relaxation of diaphragm and intercostal muscles
 Volumes of Air
Exchange
▪ Tidal volume - amount of air exhaled normally
after a typical inspiration. Normal - about 500 ml
▪ Expiratory Reserve volume - additional amount of
air forcibly expired after tidal expiration (1000 -
1200 ml).
▪ Inspiratory Reserve volume - (deep breath)
amount of air that can be forcibly inhaled over and
above normal.
▪ Residual volume - amount of air that stays
trapped in the alveoli (about 1.2 liters).
 Volumes of Air
Exchange
▪ Vital capacity - the largest volume of air an
individual can move in and out of the lungs.
▪ Vital capacity = sum of IRV+TV+ERV
▪ Depends of many factors
▪ size of thoracic cavity
▪ posture
▪ volume of blood in lungs  congestive heart failure,
emphysema, disease, etc…
 Volumes of Air Exchange

▪ Eupnea - normal quiet breathing, 12-17 breaths

per minute.
▪ Hyperpnea - increase in breathing to meet an
increased demand by body for oxygen.
▪ Hyperventilation - increase in pulmonary
ventilation in excess of the need for oxygen.
▪ Hypoventilation - decrease in pulmonary
ventilation.
▪ Apnea - temporary cessation of breathing at the
end of normal expiration.
 ASSESSMENT OF RESPIRATORY
SYSTEM

INTRODUCTION
 Respiratory medicine comprises a large part of everyday clinical
practice for two reasons:
▪ Respiratory conditions are common – accounting for more than 13
per cent of all emergency admissions and more than 20 per cent of
general practitioner consultations
▪ Respiratory symptoms and signs as elicited by respiratory history and
examination are often present in non-respiratory conditions as well
as respiratory conditions.
 CLINICAL HISTORY

The six key symptoms of respiratory disease are:

▪chest pain (that may be extended to chest
sensations)
▪dyspnoea
▪cough
▪wheeze
▪sputum production
▪haemoptysis
 CHEST PAIN
 

Ask the onset, character, severity, duration, radiation, and any

previous history of chest pain.
Pleuritic chest pain is pain that is made worse by breathing and is
often sharp and stabbing in nature when taking breath in.
A history of chronic pleuritic chest pain going back several months
or years could indicate an inflammatory disorder resulting in
pleurisy.
Chest pain that is dull and persistent in one area, and especially if it
is keeping the patient awake at night, could indicate a malignant
process within the chest that is affecting the chest wall
 DYSPNOEA
▪ analysis is done by chest pain, severity, duration, onset,
precipitating factors, and previous history
▪ Shortness of breath that has appeared out with no apparent
precipitating factor risk factors for thromboembolic disease and
suggest appropriate tests.
▪ A slow onset of gradually increasing shortness of breath
over many months may indicate as chronic obstructive
pulmonary disease (COPD) or interstitial lung disease.
▪ Conditions that have exacerbations of breathlessness such
as COPD, asthma or bronchiectasis.
 WHEEZE
Ask about the onset, duration and periodicity of wheeze.

Wheeze that occurs more at night and first thing in the morning,
and that may be exacerbated by exercise, is suggestive of asthma
and COPD.
A pronounced variation in the severity of wheeze (worse at night
and in the morning compared to daytime) is more suggestive of
asthma, but by no means excludes COPD.
enquire the relationship between other respiratory symptoms and
precipitating factors, specifically asking about exercise and cold or
foggy weather.
 WHEEZE
    Example A: History of crushing central chest pain radiating to the
arm and associated with nausea and vomiting and a feeling of
dread.
Conclusion: Myocardial ischaemic pain.

Example B: Progressive dyspnoea and fatigue over several

months. Pallor but no other symptoms or signs; haemoglobin 6.0
g/dL.
Conclusion: Anaemia.
 COUGH
Cough is the commonest symptom that is associated with pure
respiratory disease that includes both foreign elements and
substances generated by the host. Thus cough is a prominent
feature of upper respiratory infections, inhalation of irritants
such as dusts and chemicals, as a result of lower respiratory
infections. In addition to this, cough receptors within the lung
can be stimulated as happens in interstitial lung disease or in
endobronchial sarcoidosis.
Characteristic Likely diagnosis

Acute onset,sputum
purulent sputum, clearing Acute bronchitis
after 1–3 weeks Pneumonia

Regular sputum production, more than a Bronchiectasis

half egg-cupful, Occasionally chronic bronchitis
varying in purulence
‘Chronic productive cough for more than Medical Research Council criteria for definition of
3 months in each of 2 consecutive years.’ chronic
bronchitis
Clear or slightly opaque sticky sputum, white Asthma
yellow or green

of purulent sputum and organism Lime green -Haemophilus influenza

‘Rusty’ – Streptococcus pneumoniae
Dark green – Pseudomonas aeruginosa
Pinkish frothy- pulmonary edema
Foul smell and taste Chronic pulmonary sepsis with cavities in the lung
Infection from rotting teeth and associated gum disease
 FAMILY HISTORY
▪ In the family history, it is again important
to enquire about tuberculosis any of the
family members have had tuberculosis and
any contact with them, whether they had a
Bacille Calmette Guérin (BCG) vaccination or
not.
▪ If there is cystic fibrosis in the family,. A
strong family history of lung cancer in an
elderly patient is important not only
because the risk of lung cancer in the
individual is increased slightly.
 SOCIAL HISTORY
▪ Record an accurate smoking history.
▪ Enquire about passive smoking as this is known to at least
double the risk of lung cancer and ischaemic heart disease.
▪ In the social history, enquire about any relevant exposures.
The most important is exposure to asbestos, which overlaps
with the occupational history, and also enquire about anything
that may cause hypersensitivity pneumonia (extrinsic allergic
alveolitis). This includes a variety of moulds (mouldy hay,
certain moulds growing on hard woods, and occasionally even
in the house).
 SOCIAL HISTORY
▪ Enquire about exposure to birds and whether any symptoms
are related to cleaning the cage. Hypersensitivity pneumonia
results in a type III immune response with symptoms
appearing about 6 hours after exposure and continuing for 3
days. Symptoms include shortness of breath and flu-like
symptoms.
 OCCUPATIONAL HISTORY
▪ In the occupational history, record occupations
that are known to relate to respiratory disease.
Thus electricians, plumbers, power station
workers, etc., will have some risk of being exposed
to asbestos. These occupations have a markedly
raised standardized mortality ratio for
mesothelioma and asbestosis.
▪ There are many agents that have been identified
as sensitizers and which may induce asthma, and
those present in glues and paints are most
prevalent.
 PHYSICAL EXAMINATION
GENERAL OBSERVATIONS

TEMPERATURE
Cold fingers indicate peripheral vasoconstriction or heart
failure.
Warm hands with dilated veins are seen in CO 2 retention.
FINGERS
▪ Fingers stained with tar appear yellow/brown where the
cigarette is held (nicotine is colorless and does not stain). This
indicates smoking but is not an accurate indicator of the
number of cigarettes smoked.
 CYANOSIS
▪ This is a bluish tinge to the skin, mucous membranes, and nails,
evident when >2.5g/dL of reduced hemoglobin is present
▪ (O 2 Saturation about 85%). It is easier to see in good, natural
light.
▪ Central cyanosis is seen in the tongue and oral membranes
(severe lung disease, e.g., pneumonia, PE, COPD). Peripheral
cyanosis is seen only in the fingers and toes and is caused by
peripheral vascular disease and vasoconstriction.
 FINGER CLUBBING
▪ There is increased curvature of the nails. Early clubbing is seen
as a softening of the nail bed (nail can be rocked from side to
side), but this is very difficult to detect.

▪ When checking for clubbing, ask the patient to hold the distal
phalanx of one finger ‘back to back’ against the distal phalanx
of the same finger on the opposite hand, such that the two
fingernails are touching. Normally there is a small ‘window’
separating the two nail beds – loss of this ‘window’ indicates
clubbing. This is known as Schamroth’s test.
Finger clubbing
Respiratory causes of finger clubbing

▪ Bronchial carcinoma (non-small cell)

▪ Intrathoracic suppuration
▪ Bronchiectasis
▪ Empyema
▪ Cystic fibrosis
▪ Pulmonary abscess
▪ Fibrosing alveolitis (usual interstitial pneumonia).
▪ Rare causes include tuberculosis, sarcoidosis, pleural
mesothelioma, pleural fibroma, lipoid pneumonia.
PULSE
▪ Check rate, rhythm, and character. A tachycardic bounding
pulse = CO2 retention.
 
TREMOR
• Fine tremor: caused by use of B-agonist drugs (e.g., albuterol)
• Flapping tremor (asterixis): flapping when holding hands
dorsiflexed with fingers abducted. This is identical to the flap
of hepatic failure and is a late sign of CO 2 retention.
BLOOD PRESSURE
▪ Pulsus paradoxus is caused by pericardial effusion
and severe asthma.

JVP
▪ JVP is raised in pulmonary vasoconstriction or
pulmonary hypertension and right heart failure. It is
markedly raised, without a pulsation, in SVC
obstruction, with distended upper chest wall veins
and facial and conjunctival edema (chemosis).
NOSE
▪ Examine inside and out, looking for polyps (asthma), deviated
septum, and lupus pernio (red/purple nasal swelling of sarcoid
granuloma).
EYES
• Conjunctiva: evidence of anemia?
• Horner’s syndrome: caused by compression of the sympathetic
chain in the chest cavity (tumor, sarcoidosis, fibrosis)
• Iritis: TB, sarcoidosis
• Conjunctivitis: TB, sarcoidosis
• Retina: Papilledema in CO 2 retention or cerebral metastases.
Retinal tubercles in TB. Choroiditis in TB or syphilis
LYMPH NODES
▪ Feel especially the anterior and posterior triangles, the
supraclavicular areas. Don’t forget that the axillae receive
lymph drainage from the chest wall and breasts.
HANDS
▪ The hands are abnormally blue but warm indicate that the
patient is centrally cyanosed and this can be confirmed by
looking centrally at the tongue.
▪ Hands that are cool and blue may either indicate that there is
peripheral cyanosis or combined central and peripheral
cyanosis. Warm, well-perfused hands along with a flapping
tremor indicate carbon dioxide retention.
The Five Cs Explanation

Cyanosis A blue tinge with desaturated haemoglobin

Cancer Apical lung cancer can cause small muscle wasting

Cigarette smoking Tar staining from holding cigarettes

Clubbing Check for bogginess, curvature and the nail angle

CO2 retention flap Asterixis may be present in severe carbon dioxide

retention
SURFACE MARKINGS
Inspection of the chest
Check the whole chest for scars and lesions.
▪ Scars may indicate previous surgery. Look especially in the mid-
axillary lines for evidence of past chest drains.
▪ Radiotherapy will often cause lasting local skin thickening and
erythema.
▪ Veins: Look for unusually prominent surface vasculature.
 SHAPE
• Barrel chest: a rounded thorax with increase anteroposterior (AP)
diameter. Hyperinflation is a marker of smoking-related lung
disease.
• Pectus carinatum : also called “pigeon chest.” Sternum and costal
cartilages are prominent and protrude from the chest. It is
caused by increase respiratory effort when the bones are still
malleable in childhood, from asthma or rickets.
• Pectus excavatum: also called “funnel chest.” Sternum and costal
cartilages appear depressed into the chest. This is a
developmental defect, usually a normal variant with no
significance to pathology.
 SHAPE
• Surgical (subcutaneous) emphysema: Air in the soft tissues will
appear as a diffuse swelling. It occurs especially in the neck; it
may feel crackly to the touch.
• Deformity: Is there any asymmetry of shape? Remember to
check the spine for scoliosis or kyphosis.
• Surgery : TB patients from the 1940s and 1950s may have had
operations resulting in lasting and gross deformity
(thoracoplasty).
Deformity What you see Clinical significance

Barrel shaped chest Increased anterior - Hyperinflation, as in

posterior diameter asthma and chronic
obstructive pulmonary
disease
Pectus excavatum Depression of the May have suffered
Pectus carinatum sternum childhood respiratory
Outward bowing of the illnesses or rickets. May
chest have reduced lung
capacity.
Kyphosis Increased AP curvature of Can cause a restrictive
the spine lung defect

Scoliosis liosis Lateral curvature of the Can cause a restrictive

spine lung defect
Breathing type Clinical significance

Fast, deep breaths anxiety states

Deep, sighing breaths are Kussmaul’s systemic acidosis

respiration

Cheyne–Stokes breathing has an Respiratory faliure

alternating pattern of deep, regular
breathing with very slow, shallow
breaths

• Prolonged expiratory phase marker of outflow limitation, a sign of

smoking-related lung disease if coupled
with pursed-lip breathing.
 MOVEMENT
▪ Observe chest wall movement during breathing at rest. Also,
ask the patient to take a couple of deep breaths in and out,
and watch closely.
▪ Look for asymmetry. Decreased Movement indicates lung
disease on that side.
▪ decrease Movement globally is seen in COPD, along with a
“pump handle” movement of the ribs (hinged posteriorly
only), compared with the normal “bucket handle” (hinged at
the front and back).
▪ Harrison’s sulcus is a depression of the lower ribs just above
the costal margins and indicates severe childhood asthma.
 TRACHEA
Palpation
▪ The trachea should lie in the midline just beneath the sternal
notch. The trachea will shift as the mediastinum is pulled or
pushed laterally. The two most popular methods are as follows:
• Use a single finger to feel for the trachea; the distance between it
and the sternomastoids on each side should be the same.
• Use two fingers and palpate the sulci on either side of the trachea
at the same time. They should feel identical in size.
 Palpation
APEX BEAT OR PMI (POINT OF MAXIMUM IMPULSE).

This is normally at the fifth intercostal space in the mid-

clavicular line. It will shift with the mediastinum. However,
it is very difficult to palpate in the presence of
hyperexpanded lungs and may be shifted to the left if the
heart is enlarged
Chest expansion
▪ This is an objective measure of chest movement, using your
hands as a guide.
• Put both hands on the patient’s posterior thorax, at a level just
below the nipples, anchoring your fingers laterally at the sides.
• Extend your thumbs so that they touch at the spinous
processes; don’t press them against the chest.
• Ask the patient to take a deep breath. As they do this, watch
your thumbs; they should move apart equally. Any difference
in movement on one side should be visible.
• It is easy to move your thumbs yourself in the expected
direction. Be aware of this and allow them to follow the
movement of the chest.
TACTILE VOCAL FREMITUS

▪ This is the vibration felt on the chest as the patient speaks.

Each part of the chest is tested, as for percussion.
▪ Place the medial edge of your hand horizontally against the
chest.
▪ Ask the patient to say “99” or “1, 1, 1.”
▪ You should feel the vibration against your hand.
▪ This test is rather crude and often neglected by clinicians. The
changes are identical to those for vocal resonance.
vibration Clinical significance

increased Vibration consolidation

decreased or Increased Pneumothorax, collapse,

COPD and pleural
effusion
 TECHNIQUE
Percussion
▪ This takes some practice to master fully, thus it can serve
as an excellent indicator of how much time a student has
spent performing the maneuver.
▪ The aim is to tap the chest by the standard method and
listen to and feel for the resultant sound. For a right-
handed provider:
▪ Place the left hand on the chest wall, fingers separated
and lying between the ribs.
▪ Press the middle finger firmly against the chest.
▪ Using the middle finger of the right hand, strike the
middle phalanx of the middle finger of the left hand.
• The striking finger should be moved away again quickly, as keeping it
Percussion
pressed on the left hand may muffle the noise.

• The right middle finger should be kept in the flexed position, the
striking movement coming from the wrist (much like playing the
piano).

• In clinical practice, one should percuss each area of the lung, each
time comparing right then left.

▪ If an area of dullness is heard (or felt), this should be percussed in

more detail so as to map out the borders of the abnormality.
 Lung sound Clinical manifestation

Resonant Normal lung sounds

Dullness increase density (consolidation, collapse,

alveolar fluid, pleural thickening, peripheral
abscess, neoplasm)
Stony dullness unique extreme dullness heard over a pleural
effusion

Hyperresonant areas of decrease density (emphysematous

bullae or
pneumothorax) COPD
area of dullness over the heart that may be diminished in hyperexpansion
states (e.g., COPD or severe asthma).

area of dullness below the level of the sixth hyperinflated lungs, liver presence.
rib anteriorly on the right
AUSCULTATION

Technique
▪ The diaphragm should be used, except where better
surface contact is needed in very thin or hairy patients.
▪ Ask the patient to take deep breaths in and out through
the mouth.
▪ Listen to both inspiration and expiration.
▪ Listen over the same areas percussed, comparing left to
right.
▪ If an abnormality is found, examine more carefully and
define borders
 AUSCULTATION
TECHNIQUE
▪ The diaphragm should be used, except where better surface contact
is needed in very thin or hairy patients.
▪ Ask the patient to take deep breaths in and out through the mouth.
▪ Listen to both inspiration and expiration.
▪ Listen over the same areas percussed, comparing left to right.
▪ If an abnormality is found, examine more carefully and define
borders
Vocal resonance
▪ Auscultatory equivalent of vocal fremitus
▪ Low-pitched sounds transmit well and create a vocal
booming quality.
▪ •Ask the patient to say “99” or 1, 1, 1” and listen over the
same areas as before.
▪ The changes are the same as those for vocal fremitus.
▪ A marked increased resonance, such that a whisper can be
clearly heard, is termed whispered pectoriloquy .
Breath sounds Cilinical significance

Normal Often described as rustling. This is heard

especially well in inspiration and early
expiration.

Reduced sound local = effusion, tumor, pneumothorax,

pneumonia, or lung collapse
global = COPD or asthma (The “silent chest” is
a sign of a life-threatening asthma attack.)

Bronchial breathing Bronchial breathing is heard over

consolidation, lung abscess at the chest wall,
pleural effusion.
It is also heard at the upper border of a pleural
effusion.
Wheeze (rhonchi) musical whistling sounds caused by
narrowed airways. It is heard easier in
expiration.

Different-caliber airways different-pitch note; thus asthma and COPD

can cause a chorus of notes termed
polyphonic wheeze.

Monophonic wheeze a single airway is narrowed, usually by a

foreign body or carcinoma.

• Crackles (crepitations, rales) caused by air entering collapsed airways and

alveoli producing an opening snap. They are
heard in inspiration.

Coarse crackles larger airways opening and sound like the

snap and pop of a certain breakfast cereal.
Causes include fluid or infection.
 can also be reproduced by rolling hair at
the temples between the thumb and
Fine crackles occur later in inspiration forefinger. Causes include fluid, infection,
or fibrosis (particularly at lung bases)

creaking sound likened to the bending of

new leather or the creak of a footstep in
fresh snow. This is heard at the height of
Rub inspiration and is caused by inflamed
pleural surfaces rubbing against each other.
CONSOLIDATION
Important presenting patterns
• decreased Air entry locally, secondary to infection
• decreased Chest wall movement locally
• Dullness to percussion
• Bronchial breathing or increased breath sounds
• Coarse or fine crackles, localized
• increased Vocal resonance
COLLAPSE
• Blockage of a major airway and collapse of the distal lung segment
• Mediastinal shift towards the abnormality
• decreased Chest wall movement locally
• Dullness to percussion restricted to affected lobe
• decreased Breath sounds
• decreased Vocal resonance
PLEURAL EFFUSION

• Collection of fluid between the two pleural layers, creating a sound

barrier between the examiner and the patient’s lung
• Mediastinal shift away from the lesion (with a large effusion)
• decreased Chest wall movement locally
• Stony dull to percussion
• decreased Breath sounds with bronchial breathing at the upper
border
• decreased Vocal resonance
• Sometimes a pleural rub just above
Pneumothorax

• Air in the pleural space

• Mediastinal shift away from the lesion (with a tension
pneumothorax)
• decreased Chest wall movement locally
• Hyper resonant to percussion
• decreased Breath sounds
• decreased Vocal resonance
INTERSTITIAL FIBROSIS
• No mediastinal shift. The trachea may move toward the fibrosis in
▪ upper-lobe disease.
• increased or d chest wall movement
• increased percussion note
• increased breath sounds
• increased vocal resonance
• Fine crackles present
BIBLIOGAPHY

▪ Elizabeth A. Burns, Kenneth Korn, James Whyte IV,

Handbook of Clinical Examination and Practical
Skills, 2011, Oxford American Handbooks, page
181-200.
▪ Michael Glynn, William Drake, Hutchisons Clinical
Methods, 23 edition, Elsevier, page 148-164.
▪ www. Global. Oup. com