How to Perform a Respiratory Examination

How to Perform a Respiratory Examination

Performing a systematic respiratory examination is essential for diagnosing conditions such as pneumonia, asthma, COPD, and lung malignancy.

This guide follows the standard OSCE format, focusing on clinical signs of respiratory distress and the physical assessment of the lungs.

Introduction: The WIPER Initial Steps

Before beginning the examination, ensure you have established a professional rapport:

• W – Wash: Clean your hands using the WHO 7-step technique.

• I – Introduce: State your name and role clearly.

• P – Permission & Pain: Obtain informed consent and ask if the patient is experiencing any chest pain or shortness of breath.

• E – Exposure: The patient should be exposed from the waist up. Ensure privacy and offer a clinical sheet to maintain dignity.

• R – (Re)position: The patient should ideally sit at a 45° angle for the initial inspection, but they will need to sit upright for the posterior chest examination.

Part 1: Peripheral Examination (General Inspection)

Signs of respiratory disease are often visible before you even touch the chest.

End of the Bed Inspection

Observe the patient’s general state:

• Respiratory Rate: Count the breaths per minute (normal is 12–20).

• Work of Breathing: Note any use of accessory muscles (sternocleidomastoid), pursed-lip breathing, or intercostal recession.

• Cyanosis: Look for a bluish tinge to the lips (central) or fingers (peripheral).

• Paraphernalia: Look for inhalers, nebulizers, oxygen masks, or sputum pots (inspect the color and consistency of any phlegm).

Hands & Arms

• Clubbing: Associated with lung cancer, bronchiectasis, and cystic fibrosis.

• Staining: Look for nicotine staining (tobacco use).

• Fine Tremor: May indicate excessive use of beta-2 agonists (e.g., Salbutamol).

• Asterixis (CO2 Retainers): Ask the patient to “stop traffic.” A flapping tremor indicates CO2 retention (hypercapnia), often seen in severe COPD.

• Pulse: Assess the radial pulse for rate and character.

Face & Neck

• Eyes: Look for Horner’s Syndrome (miosis, ptosis, anhidrosis), which may indicate a Pancoast tumor. Check for conjunctival pallor.

• Mouth: Inspect for Central Cyanosis under the tongue and oral candidiasis (associated with steroid inhaler use).

• Trachea: Gently palpate the trachea to check for deviation (suggesting tension pneumothorax or massive pleural effusion).

• Cricosternal Distance: Measure the gap between the cricoid cartilage and the suprasternal notch (reduced in hyperinflation/COPD).

Part 2: Respiratory Inspection

Inspect the chest wall for:

• Shape: Note any Barrel Chest (hyperinflation), Pectus Excavatum, or Kyphoscoliosis.

• Scars: Look for thoracotomy scars or chest drain sites.

• Expansion: Observe for symmetrical chest movement during deep inspiration.

Part 3: Palpation

• Chest Expansion: Place your hands around the chest with thumbs meeting in the midline. Ask the patient to take a deep breath; your thumbs should move apart symmetrically by at least 5cm.

• Tactile Vocal Fremitus: Use the bony ulnar border of your hand while the patient says “99.” Increased vibration suggests consolidation (pneumonia); decreased vibration suggests fluid (effusion) or air (pneumothorax).

Part 4: Percussion & Auscultation

You must compare the left and right sides at every level (the “ladder” pattern).

Percussion

Percuss the supraclavicular, infraclavicular, and chest wall zones.

• Dullness: Suggests consolidation, collapse, or fluid.

• Stony Dullness: Classic sign of Pleural Effusion.

• Hyper-resonance: Suggests pneumothorax or emphysema.

Auscultation

Use the diaphragm of your stethoscope. Ask the patient to take deep breaths through their open mouth.

• Breath Sounds: Identify if they are Vesicular (normal) or Bronchial (harsh, indicating consolidation).

• Added Sounds: Listen for Wheeze (asthma/COPD) or Crackles (pulmonary oedema, fibrosis, or infection).

• Vocal Resonance: Auscultate while the patient says “99.” Increased volume suggests consolidation.

Part 5: Completing the Examination

To finish your OSCE respiratory assessment, state you would:

1. Examine the Lymph Nodes: Specifically the supraclavicular and cervical chains.

2. Check for Pitting Oedema: To rule out Cor Pulmonale (right heart failure due to lung disease).

3. Peak Flow: State you would measure the patient’s Peak Expiratory Flow Rate (PEFR).

4. Sputum Sample: Inspect the sputum pot and send for culture if indicated.

5. Review the Chart: Check O2 saturations and temperature.

Summary of Common Lung Findings

Video Demonstrations

For a visual guide to respiratory assessment, refer to these resources:

• Respiratory Examination Technique – Dr. James Gill

• Clinical Skills: Lung Auscultation Explained