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Basic Respiratory Examination
WIPE
•
Wash hands
•
Introduce yourself
•
Permission
•
Position (Lying down at 45°, pillow behind head for comfort)
•
Exposure (ask patient to strip down to expose chest and back. If female they will usually
need to remove their bra, ensure a chaperone is present if appropriate and a blanket is
used to maintain patient dignity)
Identify Patient (confirm the following details before starting)
•
Name
•
Age
•
Date
Inspection
•
Start with general inspection
o Does the patient look in pain?
o Is he/she comfortable?
o Is he/she fully aware of what is happening?
o Does the patient appear of ‘normal’ colour
o Overall build (BMI)
o
•
Are there any indicative findings in the patient’s surroundings (e.g. oxygen,
nebulizer, sputum pot and sample, use of accessory muscles to breath or pursed
lips)?
Inspect the Hands
o
Nails (Clubbing)
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o Tar staining
o
Flapping Tremor (with respect to the respiratory system this is indicative of C0 2
retention)
o Temperature
•
Vitals
o BP
o Pulse
o

Comment on Rate & Rhythm from radial pulse

Comment on Volume and character from carotid pulse
Respiratory Rate (count this whilst taking the pulse to avoid the patient
consciously or unconsciously altering their breathing rate).
Moving on to the face:
•
Eyes
o Pale Conjunctiva (Anaemia),
o
Horner’s Sign Unilateral partial lid ptosis (may be coupled to unilateral miosis
and anhydrosis). Whilst several causes are possible for this sign, in the context of
the respiratory system consider Pancoast Tumour.
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•
Mouth
o Central Cyanosis
•
Face
o General Pallor
•
Neck
o (Carotid Pulse)
o Jugular Venous Pulse (JVP): Elevation of the pulsation (>3cm above sternal angle)
•
Inspection of the Chest
o Scars
o Chest Drains
o
Skeletal deformities (e.g. kyphosis)
o
Abnormalities in chest shape (e.g. pectus excavatum/pectus carinatum, barrel
chest).
o
Asymmetry in chest expansion
Palpation
o Tracheal Deviation (remember abnormalities may push or pull the trachea away
from the midline)
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o
Locate the apex beat then comment on:

Displacement (?)

Character
•
Normal
•
Pressure overloaded (sustained, heaving)
•
Volume overloaded (forceful, thrusting)
o Chest Expansion

Asymmetry (L vs R)
Percussion
o Percuss the lungs comparing left with right at each level. Remember that the
lungs extend above the clavicles and so percussion must also cover the apicies.
o Percuss the laterally in the axillae.
o
(Perform tactile vocal fremitus)
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Chest percussion sounds (over lung regions)
Resonant (over lungs)
Normal
Hyper-resonant
Pneumothorax
Dull
Collapse
Stony Dull
Pleural Effusion
Auscultation
o Ask the patient to breath normally and then deeply (do not continue this for too
long as your patient may become light headed)
o
Start above the clavicles, comparing left and right at each level and ending with
the axilla. Signs to identify include:

Crepitations

Reduced air entry (reduced breath sounds)

Pleural Rub
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Definitions
Wheeze: A continuous, course and high pitched abnormal breath sound which may
often be heard both in inspiration and expiration. Occurs due to narrowing of airways in
the lower respiratory tract. It is separated by the fact that it may often be heard without
use of a stethoscope.
Stridor: A loud and harsh breath sound most prominent in inspiration usually signifies
upper respiratory tract obstruction
Vesicular Breath Sounds: The ‘normal’ breath sounds that originate from turbulent
airflow through patent alveoli during inspiration and then expiration.
Bronchial Breathing: Occurs when there is severe small airway obstruction (e.g. from
severe consolidation or fibrosis). The sound heard is hence predominantly derived from
the larger airways (i.e. bronchi) and is often attributed a ‘harsh/blowing’ quality. There is
may be an ostensible gap between inspiration and expiration (due to reduced flow to
the alveoli).Bronchial breathing can be heard over the trachea in healthy patients,
however if found in the chest this should be considered abnormal. The best way to
appreciate this finding is with practice!
Palpate the Lymph nodes as shown. Whilst this can indeed be performed at any stage it makes
sense to perform this at this stage, as next you will need to sit the patient forward to examine
the back of the chest.
Now repeat the examination on the back of the chest as described above
o
Inspection (scars, asymmetry etc)
o
Palpation (chest expansion)
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o
Percussion (comparing left and right sides)
o
Auscultation (including vocal resonance)
Remember the lungs extend further inferiorly at the back than they do at the front.
Auscultation of the lower lobes is best appreciated from the back of the chest.
As Part of an overall COPD picture
Pink Puffer:
-
Emphysema
Blue Bloater:
-
Often thin and barrel
chested
Chronic Bronchitis
Often obese, may
have signs of cor
pulmonale
Cor Pulmonale
Right sided heart failure 2° prolonged pulmonary
hypertension (from lung pathology):
-
Right ventricular heave
↑ JVP
Peripheral oedema
To conclude your examination you should:
•
Consider examination of the cardiovascular system if appropriate
•
Offer further investigations (e.g. Bloods, ABG, Chest X-ray, Spirometry, Peak
Flow etc)
Example of how to present findings:
•
General introduction:
o “This is Zapp Roger a 80 year old man who presented with .... ... On examination
I found...”
•
Important Positive Findings
o List these off
•
Important Negative Findings
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o
•
However, there was no.... (these should be those relevant to ruling out
differentials)
Clinical Conclusions
o
“These findings are consistent with...”
o
Then be prepared to explain how you would like to proceed (investigations and
management etc)
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