1.

5
HOURS
Continuing Education

This article on respiratory system assessment is the

first of a four-part series. Future articles will include
instructions on focused examinations of the car-
diac, gastrointestinal, and neurological systems. A
systematic method of collecting both subjective and
objective data will guide the healthcare clinician
to make accurate clinical judgments and develop
interventions appropriate to the home healthcare
environment.

T
he health exam is an opportunity to ex-

Assessment
plore patients’ subjective symptoms and
objective signs, screen for diseases, and
identify risk for future medical problems. Al-
though technology for disease detection is con-
stantly improving, skilled physical assessment
may lead to fewer unnecessary diagnostic tests
and increased patient satisfaction (Verghese &
of the
Horwitz, 2009). In addition, many clinical signs
cannot be fully appreciated without a physical as-
sessment, which is necessary to recognize subtle
individual changes and ultimately improve patient
Respiratory
outcomes (Zambas, 2010). This article, the first in
a four-part series, focuses on examination of the
respiratory system.

Subjective Data
System
A focused assessment of the respiratory system
includes a review for common or concerning symp-
toms including: Cough—productive/nonproductive,
hoarse, or barking; Sputum characteristics—clear,
purulent, bloody (hemoptysis), rust colored, or
pink and frothy; Dyspnea (shortness of breath)
with or without activity, wheezing, or stridor;
Chest pain—on inspiration, expiration, or with
coughing and location of pain. Ask about associ-
ated symptoms such as cold symptoms, fever,
night sweats, and fatigue. For positive responses,
ask when symptoms started (duration), location,
severity, setting, time of day, alleviating factors
(what helps), and aggravating factors (what makes
it worse). In addition, ask about smoking history,
environmental exposure, past medical and family
history, and current medications (Bickley, 2012; Objective Data
Mansen & Gabiola, 2015). Inspection
Because older adults are at increased risk Visual inspection begins with observation of
for respiratory disease due to loss of elasticity facial expression, skin color, moisture, and
and decreased ventilation of the lower lobes, temperature. Skin should be warm and dry,
specifically inquire about fatigue, weight change, and skin color should be uniform and consis-
dyspnea on exertion, flu and pneumonia vaccine tent with ethnicity. Facial expression should
status, and change in number of pillows used at be relaxed, without signs of distress or ap-
night (Hogstel & Curry, 2005). prehension. Any indication that breathing is a

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 Deborah Fritz, PhD, FNP, ANP-BC

conscious effort may be a sign that something Particularly in the winter, be alert to signs of
is wrong. Observe nail beds, lips, mouth, ears, carbon monoxide poisoning, a significant home
and conjunctiva for oxygen saturation. A bluish health problem that occurs in poorly ventilated
color indicates cyanosis and hypoxia. Clubbing areas due to faulty furnaces, heaters, clothes
of the fingers may indicate chronic hypoxemia. dryers, stoves, and fireplaces. Early symptoms
Observe the neck for contraction of the ster- are headache, dizziness, confusion, diminished
nomastoid muscles; any use of neck muscles visual acuity, and nausea (McDonald et al., 2013).
to breathe signals difficult breathing (Bickley, With the patient properly draped and sitting
2012; Mansen & Gabiola, 2015). upright, observe the respiratory pattern for a

September 2015 Home Healthcare Now 415

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full minute. Ordinarily, control of ventilation is the anterior and posterior chest. It should be
involuntary and is mediated in the brain stem. free of tenderness, pain, or masses. A cracking
Respiratory centers in the brain integrate input sensation on palpation is crepitus, as minute
from neural and chemical receptors and provide air collections are displaced with fingertip pres-
neuronal drive to the respiratory muscles, which sure. This occurs when air from the lungs is
maintain upper airway patency and drive the tho- introduced into the subcutaneous space, usually
racic bellows to determine the level of ventilation. with a pneumothorax (Bickley, 2012; Mansen &
Normal adult respiratory rate is 14 to 20 with a Gabiola, 2015).
regular rate and frequency and should be quiet. Vocal fremitus is a vibration felt on the pos-
Breathing is considered abnormal if the rate is terior chest using the ulnar side of the hand.
irregular, too fast, too slow, or shallow (Table 1). Instruct the patient to say “baby” to create vibra-
Observe the shape of the thorax; it should be tions, each time the hands are moved from one
symmetrical with equal chest movement. Retrac- area to another. Solid areas of consolidation such
tion or bulging of the interspaces may indicate as with pneumonia or tumors will have increased
obstructed airways. Following a fall, ribs may be vibration; air-filled areas such as with chronic
fractured and the injured area may cave inward on obstructive pulmonary disease (COPD) or pneu-
inspiration, and outward with expiration (Bickley, mothorax will have less vibration. (Bickley, 2012;
2012). For the patient who cannot sit up, the Mansen & Gabiola, 2015).
respiratory assessment can be performed by roll-
ing to one side, then the other. Percussion
Percussion is performed by placing the middle
Palpation finger of the nondominant hand against the chest
Place your index finger in the suprasternal notch wall. The tip of the middle finger on the dominant
at the base of the trachea. The trachea should hand is used to strike the distal phalanx of the
be midline and slightly moveable. Pulling of the middle finger between the cuticle and the first
trachea to either side of the neck results from joint. Percussion is helpful to determine the den-
unequal intrathoracic pressure within the chest sity of the underlying lung tissue and identify the
cavity and may indicate partial to complete position of the diaphragm during inspiration and
pneumothorax, or other serious conditions. expiration. Percuss the posterior chest in each
Using the palmar surface of the fingers, palpate intercostal space, avoiding the ribs and scapula,

Table 1. Abnormal Breathing Rates and Patterns

Type Characteristics Associated Conditions

Tachypnea Regular respirations with a rate greater than Pneumonia, pulmonary edema, pulmonary effusion,
20 breaths per minute pain, fever, exercise, carbon monoxide poisoning,
COPD, heart failure

Bradypnea Regular respirations with a rate of less than CNS depression or stroke, oversedation, increased
12 per minute (age 12–50) and less than intracranial pressure (brain injury), hypothyroidism
13 per minute (age 50 and up)

Hyperventilation Overbreathing with respirations rapid and shallow Anxiety, exercise, metabolic disorders,
pneumothorax, asthma or COPD exacerbation,
hyperthyroidism, cardiac disorders

Hypoventilation Respirations very shallow Rib fracture, brainstem stroke, opiates

Kussmaul Deep and labored breathing that is regular and Anxiety, diabetic ketoacidosis, metabolic acidosis,
rapid poisoning, renal disease

Cheyne-Stokes Recurrent central apnea alternating with a Cardiopulmonary disease, neuromuscular disease,
crescendo–decrescendo pattern of tidal volume. sedation, acid-base balance disturbances
Deeper and faster, then shallow and slow with
apnea up to 60 seconds

Biots or ataxic Erratic rate and depth of breathing, alternating Medullary lesion, neurodegenerative disorders,
with interspersed episodes of apnea, deep gasps meningitis

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comparing one side with the other, using the side-
to-side ladder pattern, striking in each place twice
(Figure 1). Percussion sounds should be low-
pitched, hollow, and long in duration, or resonant. 1 1
In contrast, dullness occurs when fluid or solid
tissue replaces the normally air filled lung and are
2 2
thud-like with medium pitch and duration. Dull
tones may indicate pneumonia, pleural effusion,
or atelectasis. Very loud, lower pitch, and longer 3 3
percussion sounds, hyperresonance, when unilat-
eral may indicate emphysema or pneumothorax
6 4 4 6
(Bickley, 2012; Mansen & Gabiola, 2015).

Auscultation 7 5 5 7
Ask the patient to breathe slowly and deeply
through their open mouth. Using the diaphragm
of your stethoscope, listen in the ladder pattern
posterior (Figure 1) and anterior (Figure 2), noting
the breath sounds (Table 2). Listen in each area
for at least one full breath. In the person unable
to sit up without help—percuss the upper lung Figure 1. Percussion and auscultation pattern for posterior
and ascultate the dependent lung on each side. chest. From Bickley, Bates’ Guide to Physical Examination
Vesicular breath sounds are soft and generated by and History-Taking 11E. Reprinted with permission of Wolters
airflow of normal lungs. Bronchial breath sounds Kluwer Health.
are normally heard over the larger airways and
trachea. Bronchial breath sounds occurring over
lateral or posterior chest walls may indicate con-
1 1
solidation, as in pneumonia. Bronchovesicular
breath sounds normally heard between the scap-
ula are abnormal if heard over peripheral lung 2 2
fields and indicate lung tissue is dense, possibly
due to consolidation, infection, or compression.
3 3
Listen for any adventitious or added sounds
(Table 3). Crackles are caused by the small air- 5 4 4 5
ways reopening as the chest wall expands, forc-
6 6
ing air through passages narrowed by fluid, mu-
cous, or pus, and is heard most frequently in the
bases due to hypoventilation. The sound of hair
being rubbed between one’s fingers simulates
this sound. Rhonchi are coarse rattling respi-
ratory sounds somewhat like snoring, usually
Figure 2. Percussion and auscultation pattern for anterior
caused by secretions in bronchial airways. A chest. From Bickley, Bates’ Guide to Physical Examination
wheeze is a continuous, coarse whistling sound and History-Taking 11E. Reprinted with permission of Wolters
and suggests narrow airways (bronchospasm); Kluwer Health.
and common in asthma, COPD, and bronchitis.
If wheezing is heard on one side of the chest pleural linings rubbing together and can be de-
only, it may be the result of compression from scribed as the sound made by treading on fresh
a tumor or foreign body. Stridor is a medical snow. This occurs when the pleural layers are
emergency and is loud, rough, continuous, and inflamed and have lost their lubrication. Fric-
high pitched due to upper airway obstruction, tion rub sounds that continue while the patient
heard loudest over the trachea. Pleural friction is holding their breath are most likely cardiac
rub is the squeaking or grating sound of the related (Bickley, 2012; Mansen & Gabiola, 2015).

September 2015 Home Healthcare Now 417

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Table 2. Normal Breath Sounds
Type Location Heard Characteristics
Tracheal Over trachea and anterior neck Loud, high-pitched, hollow, and harsh;
inspiration = expiration
Bronchial Anterior over manubrium and posteriorly between Loud, high-pitched, and hollow;
C7-T3 vertebrae (between scapula) inspiration < expiration
Bronchovesicular Anterior over mainstem bronchi and upper two Softer than bronchial sounds with tubular
intercostal spaces and posteriorly left and right of quality; inspiration = expiration
the T3-T5 vertebrae
Vesicular Normal lung sounds all lobes except over scapula Soft, low-pitched, and breezy; inspiration is
2–3 times > expiration

Table 3. Adventitious or Added Breath Sounds brain is less sensitive to hypoxia (low oxygen) and
hypercapnea (higher than normal carbon dioxide)
Crackles (or Rales) Wheezes and Rhonchi
and higher residual volume. As a result of these
Discontinuous Continuous
changes, older persons are at increased risk for
Intermittent, nonmusical, ≥250 msec, musical, pneumonia and bronchitis (Minaker, 2011; Sharma
and brief prolonged (but not & Goodwin, 2006).
necessarily persisting
throughout the respiratory A great deal of information may be obtained
cycle) simply by use of our senses—hearing, vision, touch,
Like dots in time Like dashes in time and even smell and taste. Knowing what to ask, look
and listen for, and feel when you assess the lungs
Fine crackles: soft, Wheezes: relatively high-
high-pitched, very brief pitched (≥400 Hz) with and thorax will allow you to spot early signs of dis-
(5–10 msec) hissing or shrill quality tress and intervene in a timely manner.
Coarse crackles: somewhat Rhonchi: relatively low-
louder, lower in pitch, brief pitched (≤200 Hz) with Deborah Fritz, PhD, FNP, ANP-BC, is a Family Nurse Practitioner,
(20–30 msec) snoring quality St. Louis Veterans Administration Medical Center, St. Louis, Missouri.
The author and planners have disclosed no potential conflicts of
interest, financial or otherwise.
From Bickley, Bates’ Guide to Physical Examination and
Address for correspondence: Deborah Fritz, MSN, APRN, ANP-BC,
History-Taking 11E. Reprinted with permission of Wolters 915 North Grand Blvd., St. Louis, MO 63106 (deborah.fritz@va.gov).
Kluwer Health.
DOI:10.1097/NHH.0000000000000283

Physical Changes Associated With Aging REFERENCES

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Mansen, T., & Gabiola, J. (2015). Patient-Focused Assessment. Bos-
(barrel chest), and diminished chest expansion ton, MA: Pearson Education, Inc.
(Hogstel & Curry, 2005). Bones become thinner, McDonald, E. M., Gielen, A. C., Shields, W. C., Stepnitz, R., Parker,
more rigid, and change shape, and muscles may E., Ma, X., & Bishai, D. (2013). Residential carbon monoxide (CO)
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level with less carbon dioxide removed from the Minaker, K. L. (2011). Common clinical sequelae of aging. In L. Gold-
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body, and decreased ability to cough. Osteoporo- New York: NY: Elsevier Saunders.
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Aging also causes the alveoli to lose their shape system physiology and immunology. Clinical Interventions in
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cough reflex with decreased sensitivity, large nation. British Medical Journal, 339, b5448.
Zambas, S. I. (2010). Purpose of the systematic physical assess-
amounts of particles that are more difficult to ex- ment in everyday practice: Critique of a “sacred cow”. Journal of
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For more than 170 additional continuing nursing education activities on

home healthcare topics, go to nursingcenter.com/ce.

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