Year 1 MBChB

Clinical Skills Session

Respiratory Examination

Written by: The Clinical Skills Lecturer Team

Reviewed & ratified by:

MBChB Lead Dr Eion Judge

January 2020

Respiratory Examination

Aims and Objectives

Aim: To be familiar with the elements of a respiratory examination.

Respiratory rate

Oxygen saturation

Percussion & auscultation of the lungs

Objective: To revise anatomy & physiology of the lungs

Objective: To understand the anatomy & physiology, applying it to

the practical skills.

Objective: To be able to percuss & auscultate the lung fields

Objective: To understand reasons for undertaking a respiratory

rate and oxygen saturation.

Objective: To be able to measure a respiratory rate and oxygen

saturation.

Theory and background

Underpinning a respiratory examination is the knowledge of anatomy &

physiology together with applying the basics of the examination,

knowing why you do and knowing how to do or obtain the following:

1. Respiratory rate

2. Oxygen saturation

3. Chest expansion

4. Palpating an apex beat

5. Percussion

6. Auscultation

Additionally a respiratory exam is usually combined with a

cardiovascular exam and called a cardiorespiratory exam.

Know your anatomy

In order, to ensure that you perform a comprehensive examination of

the chest, you need to know the surface anatomy of the lungs. The

following images demonstrate the borders of the lungs and the surface

markings of the individual lobes. However, it should be remembered

that the lungs are a moving structure and the following are the most

common approximations of the positions. This link will take you to an

anatomy video produced by Dr Alistair Bond HARC.

https://files.fm/u/guhjtmm3

Surface marking of the lungs

Anterior chest wall

Copyright © 2020 Elsevier Inc

Lateral chest wall

Copyright © 2020 Elsevier In

The inferior border of the lung

(at rest) extends down to the

6th rib

The oblique fissure is marked

anteriorly by the point at

which the midclavicular line

crosses the sixth rib

The horizontal fissure on the

right is marked by the position

of the 4th costal cartilage.

The horizontal fissure extends as far as the oblique fissure in the mid-axillary line The lower border of the lung extends to the 8th rib in the mid-axillary line

Posterior chest wall

Copyright © 2020 Elsevier Inc

Procedure

Patient safety

On first meeting a patient introduce yourself, confirm that you have the

correct patient with the name and date of birth, if available please

check this with the name band and written documentation and the

NHS/ hospital number/ first line of address.

Check the patient’s allergy status, being aware of the equipment you

will be using in your examination. Ensure the procedure is explained to

the patient in terms that they understand, gain informed consent and

ensure that you are supervised, with a chaperone available as

appropriate. Don personal protective equipment (PPE) as required,

The inferior border of

the lung is marked by

the 10th or 11th rib.

The oblique fissure

extends up to the 4th

thoracic vertebrae

especially if you are likely to come into contact with bodily fluids. For a

respiratory exam you would not normally need to wear PPEs.

As part of the consent process you will need to advise the patient that

they may need to lean forward for part of the examination.

Be aware of hand hygiene and preventing the spread of disease, WHO

(2018) http://www.who.int/infection-prevention/tools/hand-hygiene/en/

Prior to any clinical examination a detailed history should be taken

from the patient, this will enable you to tailor the examination to the

patients presenting complaint and additional symptoms the patient

may elude to when you elicit a full history. For guidance on history

taking please click MBCHB students – Year 1 – History taking.

General inspection

Look at your patient and note or measure their general demeanour,

noting any signs of breathlessness, are they sweating or showing

signs of pain or discomfort. Do they look cachexic (see glossary) and

are they a normal colour, or are they showing signs of cyanosis or

pallor.

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Have a look around the bed, are there any clues that the patient has

respiratory problems. There may be oxygen, inhalers and urine bottles

(due to reduced mobility) etc.

You will need to check their vital signs their respiratory rate and oxygen

saturations (SpO2), as well as their pulse, temperature and BP which

will be covered in other teaching sessions in year 1 and 2. Additionally

you will need to inspect the anterior, lateral and posterior aspects, so

the patient will need to lean forward (and may need assistance to do

so). It is better to inspect, palpate, percuss and auscultate all aspects

of the anterior and lateral chest, then lean the patient forward and do

the same on the posterior aspect.

Respiratory rate

The respiratory rate is measured by the number of respirations

observed occurring in 1 minute. This is the respiratory rate, (1

respiration = 1 breath IN + 1 breath OUT). It is best to do this covertly

as, if the patient is aware you are checking their respiratory rate, they

may alter their breathing (such as breathing more noticeably) to help

you.

The normal healthy adult range is 12 – 20 respirations per minute. As

well as working out the rate of the respirations, you can also describe

the depth, rhythm, if the chest is moving in symmetry and the sound of

patients breathing.

Surface percutaneous oxygen

saturation (SpO2)

SpO2, also known as ‘Sats’ is the

measurement of the amount of oxygen

in the blood. A probe measures the

haemoglobin binding sites occupied by

oxygen in the blood. The measurement

is expressed as a percentage and the normal parameters are 94 –

100% on air (i.e. the patient does not have supplementary oxygen).

The body maintains a very precise balance for organ function. The

device used to measure the SpO2 is called a Pulse Oximeter. There

are different types of probes used depending on the part of the body

they are attached to, i.e. finger or ear. There are also different probes

for adults and children. It is important to use the correct probe on the

correct part of the body or it can produce a reading 50% lower or 30%

higher than the real value.

Inspection of the chest

Having already done a general inspection you should now visually

inspect the chest, you will need to inspect the anterior, posterior and

lateral aspects of the chest. You should check for rashes, scars,

lesions, deformities, the shape of the chest, signs of trauma etc.

Observe the breathing pattern for the depth, regularity, symmetry and if

any accessory muscles are being used to aid respiration.

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Palpation

Following inspection you should palpate the chest. You would start with

a general palpation to check for signs of tenderness, trauma etc. You

should also palpate for an apex beat (see CVS examination study

guide https://liverpoolclinicalskills.com/home/mbchb-students-2/year-

1/cardiovascular-examination/cardiovascular-examination-study-guide/

Percussion

Percussion is tapping on an

area to try and determine what

is underneath. You should

ensure you cover all lung

lobes (make sure you know

the anatomy). Place your

middle finger firmly in the

intercostal spaces (lay finger

along intercostal space) and tap with the middle finger of the other

hand. When percussing the clavicles, tap your finger directly on to

bone. You should compare sides by alternating similar areas on right

and left. As with inspection you should remember to assess the

anterior, lateral and posterior chest.

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See “Basics of examination” study guide

(https://liverpoolclinicalskills.com/home/mbchb-students-2/year-

1/basics-of-examination/) for how to percussion.

Percussion notes

There will be different sounds heard on percussion. When percussing

over the clavicles (overlying lung apices) or over normal lung tissue,

there will be a resonant sound. When you percuss over the heart or

Liver you will hear a dull sound.

Auscultation

For auscultation ask the patient to breathe in deeply, in their own time,

with an open mouth, making it easier for the patient and easier to hear

the breath sounds. Using the diaphragm or the bell (may be helpful if

patient is hairy as the hair will rub on the diaphragm causing added

sounds) of the stethoscope you need to compare the right and left

sides as you move down the chest. Auscultate a large number of sites

to ensure all the lobes are examined (remembering the lung borders)

and, as always auscultate the anterior, lateral and posterior chest

walls. You should listen for breath sounds, defined as vesicular if they

are normal although you can hear bronchial sounds in health if you are

listening over the sternal edge of around the 2nd / 3rd intercostal space

on the anterior chest wall.

Vesicular breath sounds

Vesicular breeath sounds are normal finding over the peripheral lung

fields. They are quiet and low pitched with no gap between the phases

of inspiration and expiration. However the expiratory phase is shorter

than the inspiratory phase.

Most clinicians will examine all elements on the anterior chest wall

(inspection, palpation, percussion, auscultation) and then repeat the

examination for the posterior and lateral chest. This avoids the patient

moving back and forth multiple times which may be difficult, especially

if they are short of breath.

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Glossary

Cachexic – Patient looks physically unwell and as at risk of death.

Cyanosis – A bluish tinge due to poor circulation/ oxygenation

Pallor – Paleness or lack of colour

Vesicular – Normal breath sounds

References

Haynes JM. The ear as an alternative site for a pulse oximeter finger

clip sensor. Respiratory care. 2007 Jun 1; 52(6):727-9.

Mannheimer PD. The light–tissue interaction of pulse oximetry.

Anaesthesia & Analgesia. 2007 Dec 1;105(6):S10-7.

Walters TP. Pulse oximetry knowledge and its effects on clinical

practice. British journal of Nursing. 2007 Nov 22;16(21):1332-40.