What are the four techniques to performing a respiratory physical assessment?
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Respiratory examination frequently appears in OSCEs and you’ll be expected to pick up the relevant clinical signs using your examination skills. This respiratory examination OSCE guide provides a clear step-by-step approach to examining the respiratory system, with an included video demonstration. Download the respiratory examination PDF OSCE checklist, or use our interactive OSCE checklist. You may also be interested in our paediatric respiratory examination guide. IntroductionWash your hands and don PPE if appropriate. Introduce yourself to the patient including your name and role. Confirm the patient’s name and date of birth. Briefly explain what the examination will involve using patient-friendly language. Gain consent to proceed with the examination. Adjust the head of the bed to a 45° angle. Adequately expose the patient’s chest for the examination (offer a blanket to allow exposure only when required and if appropriate, inform patients they do not need to remove their bra). Exposure of the patient’s lower legs is also helpful to assess for peripheral oedema. Ask the patient if they have any pain before proceeding with the clinical examination. You might also be interested in our OSCE Flashcard Collection which contains over 2000 flashcards that cover clinical examination, procedures, communication skills and data interpretation. General inspectionClinical signsInspect the patient from the end of the bed whilst at rest, looking for clinical signs suggestive of underlying pathology:
Objects and equipmentLook for objects or equipment on or around the patient that may provide useful insights into their medical history and current clinical status:
HandsThe hands can provide lots of clinically relevant information and therefore a focused, structured assessment is essential. InspectionGeneral observationsObserve the hands and note your findings:
Finger clubbingFinger clubbing involves uniform soft tissue swelling of the terminal phalanx of a digit with subsequent loss of the normal angle between the nail and the nail bed. Finger clubbing is associated with several underlying disease processes, but those most likely to appear in a respiratory OSCE station include lung cancer, interstitial lung disease, cystic fibrosis and bronchiectasis. To assess for finger clubbing:
Fine tremorAssess for the presence of a fine tremor:
Asterixis (flapping tremor)Asterixis (also known as ‘flapping tremor’) is a type of negative myoclonus characterised by irregular lapses of posture causing a flapping motion of the hands. In the context of a respiratory examination, the most likely underlying cause is CO2 retention in conditions that result in type 2 respiratory failure (e.g. COPD). Other causes of asterixis include uraemia and hepatic encephalopathy.
PalpationTemperaturePlace the dorsal aspect of your hand onto the patient’s to assess temperature:
Heart rateAssessing heart rate:
Calculating heart rate:
Pulse abnormalities
Respiratory rateAssessing respiratory rate:
Calculating respiratory rate:
Respiratory rate abnormalities
Jugular venous pressure (JVP)Jugular venous pressure (JVP) provides an indirect measure of central venous pressure. This is possible because the internal jugular vein (IJV) connects to the right atrium without any intervening valves, resulting in a continuous column of blood. The presence of this continuous column of blood means that changes in right atrial pressure are reflected in the IJV (e.g. raised right atrial pressure results in distension of the IJV). The IJV runs between the medial end of the clavicle and the ear lobe, under the medial aspect of the sternocleidomastoid, making it difficult to visualise (its double waveform pulsation is, however, sometimes visible due to transmission through the sternocleidomastoid muscle). Because of the inability to easily visualise the IJV, it’s tempting to use the external jugular vein (EJV) as a proxy for assessment of central venous pressure during clinical assessment. However, because the EJV typically branches at a right angle from the subclavian vein (unlike the IJV which sits in a straight line above the right atrium) it is a less reliable indicator of central venous pressure. See our guide to jugular venous pressure (JVP) for more details. Measure the JVP1. Position the patient in a semi-recumbent position (at 45°). 2. Ask the patient to turn their head slightly to the left. 3. Inspect for evidence of the IJV, running between the medial end of the clavicle and the ear lobe, under the medial aspect of the sternocleidomastoid (it may be visible between just above the clavicle between the sternal and clavicular heads of the sternocleidomastoid. The IJV has a double waveform pulsation, which helps to differentiate it from the pulsation of the external carotid artery. 4. Measure the JVP by assessing the vertical distance between the sternal angle and the top of the pulsation point of the IJV (in healthy individuals, this should be no greater than 3 cm). Respiratory causes of a raised JVPA raised JVP indicates the presence of venous hypertension. Respiratory causes of a raised JVP include:
Hepatojugular reflux testThe hepatojugular reflux test involves the application of pressure to the liver whilst observing for a sustained rise in JVP. See our cardiovascular examination guide for details on how to elicit hepatojugular reflux.
FaceGeneralInspect the face for any signs relevant to the respiratory system:
EyesInspect the eyes for signs relevant to the respiratory system:
MouthInspect the mouth for signs relevant to the respiratory system:
Inspection of the chestScarsClosely inspect the chest wall for scars and other abnormalities:
Chest wall deformitiesInspect for evidence of chest wall deformities:
Trachea and cricosternal distanceAssess tracheal positionGently assess the position of the trachea, which should be central in healthy individuals (this can be uncomfortable, so warn the patient in advance): 1. Ensure patient’s neck musculature is relaxed by asking them to position their chin slightly downwards. 2. Dip your index finger into the thorax beside the trachea. 3. Gently apply side pressure to locate the border of the trachea. 4. Compare this space to the other side of the trachea using the same process. 5. A difference in the amount of space between the sides suggests the presence of tracheal deviation. Causes of tracheal deviation
Assess cricosternal distanceCricosternal distance is the distance between the inferior border of the cricoid cartilage and the suprasternal notch: 1. Measure the distance between the suprasternal notch and cricoid cartilage using your fingers. 2. In healthy individuals, the distance should be 3-4 fingers. Cricosternal distance is actually based on the size of the patient’s fingers so if their fingers are significantly different in size from your own, it may be worth using their fingers for the assessment. Causes of abnormal cricosternal distanceA distance of fewer than 3 fingers suggests underlying lung hyperinflation (e.g. asthma, COPD).
Palpation of the chestPalpate the apex beat1. Palpate the apex beat with your fingers placed horizontally across the chest. 2. In healthy individuals, it is typically located in the 5th intercostal space in the midclavicular line. Causes of a displaced apex beatRespiratory causes of a displaced apex beat:
Assess chest expansion1. Place your hands on the patient’s chest, inferior to the nipples. 2. Wrap your fingers around either side of the chest. 3. Bring your thumbs together in the midline, so that they touch. 4. Ask the patient to take a deep breath in. 5. Observe the movement of your thumbs (in healthy individuals they should move symmetrically upwards/outwards during inspiration and symmetrically downwards/inwards during expiration ). 6. Reduced movement of one of your thumbs indicates reduced chest expansion on that side. Respiratory causes of reduced chest expansion
Percussion of the chestPercussion of the chest involves listening to the volume and pitch of percussion notes across the chest to identify underlying pathology. Correct technique is essential to generating effective percussion notes. Percussion technique1. Place your non-dominant hand on the patient’s chest wall. 2. Position your middle finger over the area you want to percuss, firmly pressed against the chest wall. 3. With your dominant hand’s middle finger, strike the middle phalanx of your non-dominant hand’s middle finger using a swinging movement of the wrist. 4. The striking finger should be removed quickly, otherwise, you may muffle the resulting percussion note. Areas to percussPercuss the following areas of the chest, comparing side to side as you progress (see image example below):
Types of percussion note
Tactile vocal fremitusAssessing tactile vocal fremitus involves palpating over different areas of the chest wall whilst the patient repeats a word or number consistently (e.g. “ninety-nine”). The presence of increased tissue density or fluid affects the strength at which the patient’s speech is transmitted as vibrations through the chest wall to the examiner’s hands. Technique1. Ask the patient to say “99” repeatedly at the same volume and in the same tone. 2. Palpate the chest wall on both sides, using the ulnar border of your hand. 3. Cover all major regions of the chest wall, comparing each side at each location. Abnormal tactile vocal fremitus
An alternative method of assessmentVocal resonance (see below) is an alternative method of assessing the conduction of sound through lung tissue and involves auscultating over different areas of the chest wall whilst the patient repeats a word or number consistently. The presence of increased tissue density or fluid affects the volume at which the patient’s speech is transmitted to the diaphragm of the stethoscope. Given both tests assess the same thing, there is no reason to perform both vocal resonance and tactile vocal fremitus in the same examination.
Auscultation of the chestWhen auscultating the chest, it is important that you have a systematic approach that allows you to compare each area on both the left and the right as you progress. Auscultate the chestTechnique1. Ask the patient to relax and breathe deeply in and out through their mouth (prolonged deep breathing should, however, be avoided). 2. Position the diaphragm of the stethoscope over each of the relevant locations on the chest wall to ensure all lung regions have been assessed and listen to the breathing sounds during inspiration and expiration. Assess the quality and volume of breath sounds and note any added sounds. 3. Auscultate each side of the chest at each location to allow for direct comparison and increased sensitivity at detecting local abnormalities. Quality of breath sounds
Volume of breath sounds
Added sounds
Assess vocal resonanceAssessing vocal resonance involves auscultating over different areas of the chest wall whilst the patient repeats a word or number consistently. The presence of increased tissue density or fluid affects the volume at which the patient’s speech is transmitted to the diaphragm of the stethoscope. Technique1. Ask the patient to say “99” repeatedly at the same volume and in the same tone. 2. Auscultate all major regions of the anterior chest wall, comparing each side at each location. Abnormal vocal resonance
An alternative method of assessmentTactile vocal fremitus is an alternative method of assessing the conduction of sound through lung tissue and involves feeling for sound vibrations on the chest wall with your hands as the patient speaks. Given both tests assess the same thing, there is no reason to perform both vocal resonance and tactile vocal fremitus in the same examination.
Lymph nodesPalpate the patient’s lymph nodes1. Position the patient sitting upright and examine from behind if possible. Ask the patient to tilt their chin slightly downwards to relax the muscles of the neck and aid palpation of lymph nodes. You should also ask them to relax their hands in their lap. 2. Inspect for any evidence of lymphadenopathy or irregularity of the neck. 3. Stand behind the patient and use both hands to start palpating the neck. 4. Use the pads of the second, third and fourth fingers to press and roll the lymph nodes over the surrounding tissue to assess the various characteristics of the lymph nodes. By using both hands (one for each side) you can note any asymmetry in size, consistency and mobility of lymph nodes. 5. Start in the submental area and progress through the various lymph node chains. Any order of examination can be used, but a systematic approach will ensure no areas are missed:
Take caution when examining the anterior cervical chain that you do not compromise cerebral blood flow (due to carotid artery compression). It may be best to examine one side at a time here. A common mistake is a “piano-playing” or “spider’s legs” technique with the fingertips over the skin rather than correctly using the pads of the second, third and fourth fingers to press and roll the lymph nodes over the surrounding tissue. Example of logical systematic examination of the lymph nodes1. Start under the chin (submental lymph nodes), then move posteriorly palpating beneath the mandible (submandibular), turn upwards at the angle of the mandible and feel anterior (preauricular lymph nodes) and posterior to the ears (posterior auricular lymph nodes). 2. Follow the anterior border of the sternocleidomastoid muscle (anterior cervical chain) down to the clavicle, then palpate up behind the posterior border of the sternocleidomastoid (posterior cervical chain) to the mastoid process. 3. Ask the patient to tilt their head (bring their ear towards their shoulder) each side in turn, and palpate behind the posterior border of the clavicle in the supraclavicular fossa (supraclavicular and infraclavicular lymph nodes). Respiratory causes of lymphadenopathy
Posterior chest assessmentWith the patient still sitting forwards, ask them to fold their arms across their chest so that their hands are touching the opposite shoulder. This results in rotation of the scapulae to better expose the underlying chest wall for assessment. Assess the posterior chest including inspection, chest expansion, percussion, tactile vocal fremitus (or vocal resonance) and auscultation. Allocate adequate time to assessing the posterior aspect of the chest as this is where you are most likely to identify clinical signs.
Final stepsAssess for evidence of pitting sacral and pedal oedema (e.g. congestive heart failure). Assess the calves for signs of deep vein thrombosis (e.g. swelling, increased temperature, erythema, visible superficial veins) as the patient may have shortness of breath secondary to pulmonary embolism. Inspect for evidence of erythema nodosum, which can be associated with sarcoidosis.
To complete the examination…Explain to the patient that the examination is now finished. Thank the patient for their time. Dispose of PPE appropriately and wash your hands. Summarise your findings. Example summary“Today I examined Mrs Smith, a 64-year-old female. On general inspection, the patient appeared comfortable at rest, with no evidence of shortness of breath. There were no objects or medical equipment around the bed of relevance.” “The hands had no peripheral stigmata of respiratory disease and were symmetrically warm. There was no evidence of a fine tremor or asterixis.” “The pulse was regular at 70 beats per minute and the respiratory rate was 16 breaths per minute.” “On inspection of the face, there were no stigmata of respiratory disease.” “Assessment of the JVP did not reveal any abnormalities. The trachea was centrally located and the cricosternal distance was within the normal range.” “Closer inspection of the chest did not reveal any scars or chest wall deformities. The apex beat was palpable in the 5th intercostal space, in the mid-clavicular line and chest expansion was equal.” “Percussion of the chest revealed normal resonance throughout all lung fields.” “Auscultation of the chest revealed normal vesicular breath sounds, with no added sounds. Vocal resonance was also normal.” What are the 4 steps in conducting a respiratory exam?The four steps of the respiratory exam are inspection, palpation, percussion, and auscultation of respiratory sounds, normally first carried out from the back of the chest.
What are the techniques used for respiratory assessment?A focused respiratory objective assessment includes interpretation of vital signs; inspection of the patient's breathing pattern, skin color, and respiratory status; palpation to identify abnormalities; and auscultation of lung sounds using a stethoscope.
What nursing assessment techniques are appropriate for the respiratory system?During a respiratory assessment, a nursing student will use skills of inspection, palpation, percussion, and auscultation.
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