Guide to Respiratory Assessment Techniques

Respiratory function is the foundation of patient stability. Respiratory Assessment requires more than counting breaths; it involves detailed inspection, palpation, percussion, and auscultation to detect pathology early. Distinguishing between wheezes, crackles, and stridor is a critical safety skill for nursing students. This guide outlines the systematic techniques for evaluating the pulmonary system.

Anatomical Landmarks

Precise documentation requires referencing landmarks.

• Anterior: Suprasternal notch, Angle of Louis (Manubriosternal angle), Mid-clavicular line.
• Posterior: Vertebra prominens (C7), Spinous processes, Scapular lines.
• Lung Lobes:
  • Right Lung: 3 lobes (Upper, Middle, Lower). Right Middle Lobe is accessible only anteriorly/laterally (4th-6th rib).
  • Left Lung: 2 lobes (Upper, Lower).

1. Inspection Protocols

Observe mechanics before physical contact.

Breathing Patterns

• Eupnea: Normal rate (12-20 bpm) and rhythm.
• Tachypnea: >20 bpm. Shallow. (Fever, anxiety, exercise).
• Bradypnea: <12 bpm. Regular. (Drug overdose, ICP).
• Cheyne-Stokes: Periodic breathing. Cycles of increasing depth/rate followed by apnea. (Heart failure, dying).
• Kussmaul: Deep, rapid, labored. (Diabetic Ketoacidosis).
• Biot’s: Irregular pattern with apnea. (Brain damage).

Chest Configuration

• AP Diameter: Normal Anterior-Posterior ratio is 1:2. A 1:1 ratio indicates Barrel Chest (COPD hyperinflation).
• Pectus Excavatum: Funnel chest (depression of sternum).
• Pectus Carinatum: Pigeon chest (protrusion of sternum).

Signs of Distress

Tripod position (leaning forward), Retractions (suprasternal/intercostal), and Nasal Flaring indicate severe compromise. Check lips/tongue for central cyanosis.

2. Palpation Protocols

Confirm inspection findings through touch.

Tracheal Alignment

Palpate the suprasternal notch. Trachea should be midline. Deviation indicates tension pneumothorax (deviates away from lesion) or atelectasis (deviates toward lesion).

Thoracic Expansion

Place hands at T9/T10 posteriorly. Pinch a skin fold. Ask patient to inhale. Thumbs should move apart symmetrically. Asymmetry suggests pneumothorax, rib fracture, or severe pneumonia.

Tactile Fremitus

Palpate with ulnar surface of hands as patient says “99”.

• Increased Fremitus: Increased density/consolidation (Pneumonia). Sound travels better through solid/fluid.
• Decreased Fremitus: Barrier to vibration (Pneumothorax, Pleural Effusion, Emphysema).

Crepitus

Subcutaneous emphysema. Palpable “crackling” or bubble-wrap sensation under skin. Indicates air leak from lung into subcutaneous tissue.

3. Percussion Protocols

Tap intercostal spaces to assess underlying tissue density.

• Resonance: Low-pitched, hollow. Normal lung tissue.
• Hyperresonance: Louder, booming. Trapped air (Emphysema, Pneumothorax).
• Dullness: Thud-like. Fluid or solid replacement (Pneumonia, Pleural Effusion, Tumor).
• Flatness: Very dull. Bone or heavy muscle.
• Tympany: Drum-like. Gastric air bubble.

Diaphragmatic Excursion

Percuss posterior chest to map diaphragm movement during inspiration vs. expiration. Normal excursion is 3-5 cm. Reduced excursion suggests COPD or neuromuscular paralysis.

4. Auscultation Protocols

Use the diaphragm. Listen directly on skin. Instruct patient to breathe deeply through open mouth.

Normal Breath Sounds

• Bronchial: High pitch, loud. (Trachea). Exp > Insp.
• Bronchovesicular: Moderate pitch. (Main bronchi/sternal borders). Insp = Exp.
• Vesicular: Low pitch, soft. (Peripheral lung fields). Insp > Exp.

Adventitious Sounds

• Fine Crackles (Rales): Discontinuous, high-pitched popping (hair rubbing). Late inspiratory. Cause: Atelectasis, Fibrosis, early Heart Failure.
• Coarse Crackles: Low-pitched, bubbling/gurgling (Velcro). Early inspiratory. Cause: Pulmonary Edema, Pneumonia.
• Wheezes (Sibilant): Continuous, high-pitched musical. Expiratory. Cause: Asthma, COPD.
• Rhonchi (Sonorous): Low-pitched snoring/moaning. Cause: Bronchitis, secretions. May clear with cough.
• Stridor: High-pitched inspiratory crowing. Cause: Upper airway obstruction (Croup, Anaphylaxis). Emergency.
• Pleural Friction Rub: Grating/leather sound. Cause: Pleuritis.

Voice Resonance Tests

Perform if consolidation is suspected.

• Bronchophony: Patient says “99”. Normal: Muffled. Abnormal: Clear/Loud (Consolidation).
• Egophony: Patient says “E”. Normal: Hears “E”. Abnormal: Hears “A” (Consolidation).
• Whispered Pectoriloquy: Patient whispers “1-2-3”. Normal: Faint/Inaudible. Abnormal: Clear (Consolidation).

Documentation Example

Subjective: Patient reports dyspnea with exertion. No cough.
Objective:
Inspection: RR 24, regular, shallow. AP:Transverse 1:2. No accessory muscle use.
Palpation: Trachea midline. Expansion symmetric. Tactile fremitus normal.
Percussion: Resonant throughout.
Auscultation: Vesicular sounds in all peripheral fields. Fine inspiratory crackles noted at right lung base posteriorly. No wheezes.

FAQs on Respiratory Assessment

Conclusion

Respiratory assessment is a high-priority nursing skill. Systematic inspection, palpation, percussion, and auscultation identify life-threatening compromises. Accurate interpretation of breath sounds ensures effective intervention.