Ao••••ment •

Begin your respiratory assess- DJ!t~ry a-ss~ssment landmarks

ment by first observing the These illustrations show the anterior and posterior landmarks of the respiratory system.
patient's general appearance. You can use these landmarks to help describe the locations of your assessment findings.
Then use inspection, palpation,
percussion, and auscultation to Anterior view
perfonn a physical examina-
Suprasternal notch - --=i:.=:::::;z;......:;;;;~~ ~ ..,,....,......
tion. Examine the back of the . -:-.1?"""1°".+;---+-
' First rib
Manubrium - -- -t---+~ ..,_-'-'+- -
chest first, comparing one side
with the other. Then examine Angle of Louis - - -+ ---'--l"'lt-s--:-----11--J
•.......,,....,.,..___ Left upper lobe
the front of the chest using the Right upper lobe - --+-~ ~a::- __2--"
same sequence.
Right middle lobe---+-+- -
-b'~ =t-'::;._r-++--Body of the sternum
lnspecting the chest Right lower lobe--t-tt-ll
Inspect for chest-wall symme- -..- Left lower lobe
try. Note masses or scars that Xiphoid process - -C::-1-1r11.....,..~ "'l--- +----'d

indicate trauma or surgery.

mark lines key

Axillary line Posterior view
Mid_
clavicular line re:::::,,,...,,---- - -- First rib
M1dsternal line Spinous process of C7 ___,,...,:::;:~ ~;..:::~~ --;c:::::~:--=::;;:
Scapular line ,,,..<f"---....:~___::,-£-,,_.:;:.-.i..:::,.,- Right upper lobe

I
\ Left upper lobe-~ --:,-- - i- ---v"'==--Jl
\ Verteb; i ::•"-I Scapula----+
'

I \
\ \>0,~
--~~,)
(
1-...,{
Left lower lobe - - ---1+---,,----t- ~ - •-
Right r iddle lobe

~~ d} _,._,~-r~r--- Right lower lobe

\ Jf ~~ ~ - jJ' nt,'
j
1il ~ •l~
!I t ~l~ ~Fl 1

\\
I!!wc~1' '!!-
fJ-: y-,)
l.2J
I Y✓ ,')

.J
- Me n
athle t. ~.
..11 -t',ants,
c::
~ ,1 gers
Respiratory rate and pattern us ua lly u:-; / ( 1:_;,y, [na l
Count the number of br ea ths d' h , or
for a full mi nu te. ia p ra g ma :.,,,. breathing .
Adults normally bre ath e at a Mo st wo men, however
rat e of 12 to 20
breaths/minute. An infant's bre us ua lly use ch es t, /
ath ing rat e ma y 0
reach 40 breaths/minute. Th e int er co sta l, breathing.
res pir ato ry pa t-
tern should be even, coordina
ted, an d regular,
with occasional sighs.

Accesso ry muscle use

Observe the diaphragm an d the
int erc os tal mu s-
cles with breathing. Fr eq ue nt
us e of ac ce sso ry
muscles may indicate a res pir
ato ry pro ble m,
particularly when the pa tie nt
pu rse s his lip s an d
flares his nostrils wh en bre ath While
ing.
ins pe cti ng the
c he st, look
for t hese
ch ara cte ris tic s
th at ma y put a
CRAMP in yo ur
patie nt' s
res pir ato ry
m em or y sy ste m.
board
Ch est -wa ll asy mm etr y
Respiratory rate and pat ter
n (ab nor -
mal)
Ac ces sor y mu scl e use
Ma sse s or sca rs
Paradoxical mo vem ent

Inspecting related structures

Ins pe ct the sk in, ton gu e,
mo uth , fin ge rs, and na i·1 bed s.
Pa tie nts wi th a blu ish tin
t to the ir sk in an d rnucouths
me mb ran es are co ns ide red . g of e
cy an oti c. Cl ub b lil
fin ge rs ma y sig na l lon g-t
erm hy po xia .
 iv.ssess me nt •

Palpating the chest dry. S: i-enUc- p~.l~J;.1ti'.; n sho uldn 't

The chest wall should feel. smo oth, wam1, and
cus tochondnt1s, nb or vert e-
cause the patient pain. Pam may be cau sed by
trac ted co ughing. Crepitus,
bral fractures, or sore mus cles as a resu lt of pro
er the skin, indi cate s tha t air
which feels like puffed-rice cere al crac klin g und
ate for tact ile frem itus , palp a-
is leaking from the airways or lungs. Also palp
thro ugh the bro nch opu l-
ble vibrations caused by the tran smi ssio n of air
met ry and exp ansi on.
monary system. Then evaluate chest-wall sym

best picture

,1 !\fl
~f' •
(~~,, r!1u
)..'v \
the
('I'
' " r' Use the pads of your fingers to palp ate
'\ 1' Place your palm (or palms) lightly over the your finge rs over the
bulging , and front and back of the thora x. Pass
thorax. Palpate for tenderness , alignment , ation s. Note
es. Assess ribs and any scars , lumps, lesions, or ulcer
retractions of the chest and intercostal spac Also note
age the skin temperature, turgo r, and mois ture.
the patient for crepitus, especially around drain eous crep itus. The mus cles
on the patie nt's back . tenderness or subc utan
sites. Repeat this proce dure
should feel firm and smo oth.
r

- Reeplratory ey5 tem

t,e5t picture
Evaluating chest-wall
Checking for
tactile fremitus symmetry and expan sion
Ask the patient to fold his arms across his chest. Place your hands on the front of the chest wall with
This movement shifts the scapulae out of the your thumbs touching each other at the second inter-
way. Lightly place your open palms on both sides costal space. As the patient inhales deeply, watch
of the patient's back, as shown, without touching your thumbs. They should separate simultaneously
his back with your fingers. Ask the patient to re- and equally to a distance several centimeters away
peat the phrase "ninety-nine" loud enough to from the sternum. Repeat the measurement at the
produce palpable vibrations. Then palpate the fifth intercostal space.
front of the chest using the same hand positions. The same measurement may be made on the back
of the chest near the tenth rib. The patient's chest
may expand asymmetrically if he has pleural effusion,
atelectasis, pneumonia, or pneumothorax.

What the results mean

Vibrations that feel .
the other indicate !'more intense on one side than
side. Les . issue consolidation on that
PhysemasP 1nntense vibrations may indicate em-
, eumothorax
Faint or no 'b . , or P1eural effusion
vi rations in th ·
thorax may indicate bro e.upper posterior
fluid-filled pleur I nch1al obstruction or a
a space.

l=- - -------ll
 Assessment fl
r~
Percussing the chest c},{
h t percussion reveals the boundaries of th e ltwgs best picture
-r\lt
C ~~elps to determine whether the lungs are filled
____--\1 ~
:th air or fluid or solid material. ■ Hyperextend the middle finger of your left f, f\
hand if you're right-handed or the middle fin- \ f )
ger of your right hand if you 're left-handed. \ I j
■ Place your hand firmly on the patient 's 1 J

chest.
■ Use the tip of the middle finger of your ~
l11
1

dominant hand to tap on the middle finger of 1

your other hand just below the distal joint (as

shown).

Percussion sounds
~-~~~und , Description Clinical
.! ~~~~

Flat Short, soft, high- Consolidation, as in

pitched, extremely atelectasis and
dull, as found over extensive pleural
the thigh effusion

Dull Medium in intensity Solid area, as in

and pitch, moderate lobar pneumonia
length, thudlike, as
found over the liver

Resonant Long, loud, low- Normal lung tissue;

pitched, hollow bronchitis
■ The movement should come from the wrist of your
Hyperresonant Very loud, lower- Hyperinflated lung, dominant hand, not your elbow or upper arm.
pitched, as found as in emphysema or ■ Follow the standard percussion sequence over the
over the stomach pneumothorax
front and back chest walls.
Tympanic Loud, high-pitched, Air collection, as in
moderate length, a large pneumo-
musical, drumlike, thorax
as found over a
puffed-out cheek
 • Reeplrato ry ayetem

Diaphragmatic excursion
Percussion is also used to assess diaphragm atic excursion (the distance
the diaphragm moves between inhalation and exhalatio n). Keep in mind
that the diaphragm doesn't move as far in obese patients or patients with
certain respirator y disorders.

1,est picture

Measu ring diaphr agm movem ent

■ Ask the patient to exhale. ■ Repeat on the opposite side of the back.
■ Percuss the back on one side to locate the upper ■ Use a ruler or tape measure to determine u11:.i t 1,. :
edge of the diaphragm, the point at which normal lung tance between the pen marks. The distance , 110 m i.,i1,.
resonance changes to dullness. 1 ¼" to 2" (3 to 5 cm), should be equal on both thu 11_', 111
■ Use a pen to mark the spot indicating the position of and left sides. "
the diaphragm at full expiration on that side of the back.
■ Ask the patient to inhale as deeply as possible.
■ Percuss the back when the patient has breathed in
fully until you locate the diaphragm. Use the pen to
mark this spot as well.
-= •
--
~
,,..,
-=-
-i
o') -
-= ·
-i
-i

,...-=. - -

-~---=
!:
► -
-

i -::
"-
"' -=-
,.
-

Dull
Auscultating the ch e
.-\5- arr mo, :es thro ugh the
t rond u. n crea t es sou nd
u.-an•s thar rraYel to the
ct.est wall . The sou nds pro-
d:.:ced by brea thmg cha ngP
a.'- .3.lr mo, es from larg er au-
" a:,::; lO sma ller airw ays.
Sou nds als o cha nge tf they
pa..~ ~hr ou~ fluid . muc u'-.
- -
, , :-~ ,,·e<I airw ay5-. .-\u.'-- '
c ••·.nr-n of rhes e sou nds 2 -.--~ :i-- -t~ ~- !
ht~.; , ~')IJ w dete mun e the
, 1:: n of the ah·e olJ and
l l::J ~
, .rr mdm g pleu ra. 3 ~Q,...._..__ __
t __ ~ 3

~
.a.~ 1fy each sou nd you
t: - ~.r a , rrlm ~ to its m1:en~i-
· :- .f)\ ,no n. p1· ch. dura tion
.ind char ac 1 c-ns uc '\m e
. ' ,
,,. h , 1t ,·r · he "-Ound O<'r urs
-., h t "1th • I-,ial lf'nt mha !P"" r~ o , -
-
::;. :::;. r ,
_,,_._,_, , ..,I
::;.
J

l xha, t -.. nr hoth .

Posterior, 1e"
-- lJ

~ 1~-~ ~~:~~~~ I
C ·
2~ ~~ ·~ 2 -.~ ~
~ l ~~ .... - l::._7 \
(
\
3 r
~ ...... -
~-= _,~ r ~....... "- 4
(J
I ' ,...... - ~
5 ~H- -r.-- l~ - 5 \
r .. ~ ~

~/~
..
'
.... 7

"' ~
e• ~
 Assessing roice sounds
'---~ , -~, iht' l''-'"i"""n t",r ":i.,:~tl tl."\'tnttn.,. -
"-)i"" :~ .:~md.::, n-~":ultin...~ fn:un ~-ht~t Yil'nl-
rn:~~ di": .. t"'-'t"iff ~ ' dlt' !"\.'lilt'lll ~P~'-l.k~
\ Nll~l'k'll u~n....;;.ini~tm t,f \'\'lt't' ~,tmd~
-., '\.·- ur tn~r t.'\.)~t.."-'lid~,h:''-°l m't'-l...' 11h'
~1..~-
m(~ t.'\.1llUllt"'1l ~t"ln-.mmtl n,i1..'t" ~,und~
~ M.li'tl'fu.~ )htU\Y, t>~'phrn \Y. ,md
,,~ 1-t'Ic>\.l i1't'\·t(Ullt1'\}U._Y-

-
1~-,-: -}
~ A5sessing vocal fremit us
~ =--zljil~
~~
, :,("';>:r'. ._ _/
/ ,' \
~~ ~ •C: ~~, ~:-2:<"
-\.A'.. ::-s=::-,'·s?-":
\ _,,.,.:-::--
•=:·-·-_:>-t.,e,-2: 11<." ~c-u he-:m.
\\-c.°'f i.t.,
-"'<-"-': \\hel-e l'el0\\ \\ h il~ ~\'' ll li$t<)l1.
i ,1t°'n0 nnn l~ k1-.-,1t8'i bn.,11 ...-/11.11

{! ::-~c.=::- ~...·-,-:$ :.:- ::--~'--, "0, 2!:>110nn ,1I \ 'Ok.'8 sounds.

\- \ r: tj Brorchophony Egophony Whispered pectoriloquy

~
\ r \ ■ ~, 7'2 pa:-'en: t0 sa~ .
~"760 - n.:., e. - ■
■ Ash the patient to say. "E...
Over nom1al lung t issue. the
■ Ash tha pnti.ant t,1 wl1i~p,01.

■ Over norrnal lung tissue. the sound is muffled. ■ Over nonnol lllll\_l ti~:-:l 1<'. tt1t'
, -.uros sound muffled. ■ Over consolidat ed lung tissue. it numbers will l k~ ,1hnc1-c:t imi i:-:ti11i1u1$/1
■ Over con..c::olidated areas. the will sound like the letter a. able.
words sound unusual!) loud. ■ Over consolidntet.i lunp t,~.::u,,.
the numbers will be 1L1uti ,ind d,\H.
 y .ijlo_ne of normal b1··t:~.-:~t.;·i ;_.;, ,-; .•
You 'll hear four types of breath sounds ovl?r· nc,; r _,1 . ' .·; '
you listen. These illustrations show the norn1a, lo,.'..,rr:,··· ,

Bronchial
Tr
..
·• ,•

Anterior thorax Posterior thorax

Vesicular Vesicular

Bronchovesicular

Qualities of normal breath sounds

Breath sound .- Quality Inspiration-expiration Location
, ·. -it, (l:E) ratio

~
Trachea/ Harsh, I= E Above supraclavicular
notch, over the trachea

A high-pitched

~
Bronchial Loud, I< E Just above clavicles on each

~
high-pitched side of the sternum, over the
manubrium

~~
Bronchovesicu/ar Medium in Next to sternum, between
I= E
scapulae
/\ loudness
and pitch

Vesicular

~~
Soft, I>E Remainder of lungs
~ low-pitched
 a ◄

Abnormal findings
, { __,_
l ~t,
Chest--wal I ', outside the norm
abnormalities
Chest-wall abnormalities may
Chest deformities
be congenital or acquired. As
you examine a patient for chest-
wall abnom1alities, keep in
mind that a patient with a defor-
mity of the chest wall might
have completely nonnal lungs
and that the lungs might b e
cramped within the chest. The
patient might have a smaller-
than-normal lung capacity and
limited exercise tolerance, and
he may more easily develop res-
piratory failure from a respira-
tory tract infection.
Increased anteroposterior diameter
Paradoxical movement Depressed lower sternum
Paradoxical (uneven) movement of
the chest wall is abnormal. It can
occur as a result of chest-wall in-
jury, such as multiple rib fractures
or blunt force trauma to the chest.
With spontaneous breathing, para-
doxical movement occurs on the
injured chest side, which collapses
during inspiration and expands
during exhalation.

Pigeon cheat ~1_

(pectus carinatum) ,

Anteriorly displaced sternum

Raised shoulder and scapula, thoracic
convexity, and flared interspaces
 Abnormal findings •

normal respiratory patter~ G

Common abnon nal respira tory patter ns include tachypnea, bradypnea, apnea,
hyperpnea,
Kussmaul's respira tions, Cheyne-Stok es respirations, and Biot's respirations.
1 Ii'(~
"\ outside the norm
~
Grading dyspnea
To assess dyspnea (shortness of
breath) as objectively as possible , ask
Tachypnea ~it .. ·. your patient to briefly describe how
various activities affect his breathing.
Shallow breathing with increased respi-
Then document his response using
ratory rate
this grading system:
Grade
6radypnea _,~t .,, .
Decreased rate but regular breathing

Grade
Ti
b

Absence of breathing; may be periodic

Walks more slowly on a

Hyperpnea · ~ , _ ._
.~ level path than people of
Deep, fast breathing the same age because of
breathlessness or has to
stop to breathe when
walking on a level path at
his own pace

Rapid, deep breathing without pauses; Grade

in adults, more than 20 breaths/minute; Stops to breathe after
breathing usually sounds labored with walking approximately
deep breaths that resemble sighs 100 yards (91 m) on a
level path

Grade
Breaths that gradually become faster
and deeper than normal, then slower,
and alternate with periods of apnea

Biot's respirationa -~,

Rapid, deep breathing with abrupt paus·
es between each breath; equal depth to
each breath
CD Respiratory eyetem

Abnormal breath sounds

If you hear a sound in an area other than where y~u would expect to h~ar it, consi der tfr :-ibnrmno.J
For example, if you hear bronchial or bronchoves1cular breath sounds m an area wh c~n : _-,- ,, ,,uJrJ nrm , ·
hear. vesicul ar breath
.
sounds, then the alveoli and small bronchioles 1
in that are a might b e: 1:.-:1 'Nith flu ~Jally
, . , I( fi/
exuciate, as occurs m pneumonia and atelectas1s.

outside the norm

Discontinuous and continuous adventitious breath sounds

The characteristics of some discontinuous and continuous adventitious breath sound,
are compared in the chart below. Note the timing of each sound during inspiration and
Adventitious sounds expiration on the corresponding graphs.

Other breath sounds, called adven-

ti ti ous sounds, are abnormal no
matter where you hear them in the
lungs. These sounds, which are
l Sound

~aJ1!IiIID
superimposed on normal breath
sounds, include fine and coarse Fine crackles
crackles, wheezes, rhonchi, stri-
dor, and pleural friction rub.
Stridor is a loud, high-pitched
crowing sound, usually heard
without a stethoscope during aus-
cultation. It's caused by upper air- Coarse crackles
way obstruction.
Pleural friction rub is a low-
pitched, grating, rubbing sound
heard on inspiration and expira-
tion, It's caused by pleural inflam-
mation.
Wheezes
Inspiration Expiration

I Rhonchi
 Abnormal find'
ings
A
-

ta ke note

Documenting
breath sound s

Characteristics

i
• Intermittent
• Nonmusical
• Soft
• High-pitched
• Short, crackin 9
• Heard during . ' p~pping sounds
inspiration

• lntermttt
· ent
• Nonmusical
• loud
• low-pitched
• Bubbr1ng gu r
• Heard du'. rg ing sounds
nng early inspiration and possibly
.
[ during expiration

• Musica.1
•• H·igh-pitched
Squeak .
• Pred Y, Whistling
d . ominantl h sounds
unng · Y eard d unng
. expiration b t
• Mu . inspiration u may also occur

s1ca1
• l OW-pit h
•S C ed
• Hnoring , moa .
P eard durin n1ng sounds
rominent du~nboth inspiration a
g expiration nd expiration but are more
 Ausc11lt 01Inn ll111llng•, lot ' 11111

" I Ill ,111 ,I !1111 I ti 1,1111 , I /I II ,tltt ,, I

A8/tt,til11t1/N I11111 I ,, II It/ I ,,,,,111
• 1111111 /1111 ,11111/ 1,1111 I 11,1 ,
11111 111 11111111, t1III/ 1,l /1111/11//1
111,11
• 1111,111111 r, 11 ,11111, , 1111
• I 1ll1 il11lt1l1w l l ,11 11 1111 111111111/11
AMtll/llH
• M11~1, ,t,I I I1l(JI I , 111 I ,1,,,,, 11// JI
11-11111 v1,111v1111111111, wl ,,1tl/'-l~
11 WIii , 1:1 lttl ll~ f.11'l ll1111tfll1 ,114,
11IIH I FIi ,, I 11111 '11, ,,,, 11111 , 11111/f/111
\, \')' Ill
11111111 111111111111 Wl lh/:J/t:fti, tl/1111(.J
1 11 ll,, \ 11 1\ I )1, ,
wl11, 1,,, 111111()1:irl 111111111, lur,
\' \ \ h 'II\ II I \\
11111 I p tillllll 111-:l lllln11f ul 1hl:lf If
' \ ' \ l ' \ \ ' 1,, 11\ \
I ~ijV~l /.:l
\\ I I I I ' '\ I 'I'\
'
. thl, 1 t'tll, ti • 111(.JII pll ul,nd, l111ll()W, 1111111
At@l@nltttfli'
h , '. ti h 1 11 11111, I IHr I 11 <11 ,nl ,1,11 I m,11111 Ho11r,rli,,,
(t,,t,',I l\ 1 1' , '. h 'l\ t II tWl~lt:m, WI 11111/tiH
~ , l\\ 1\1,'\\
1 1
1 • 1 IIIH, l1l(JII f1ll 11l111II, lttlti
1!11':i plrtt lnt y omnklHH
• nrn,IOI 1npl lOIIY, ij(jO(II ,ony,
flrHI WlllHpHrr-l<I p'1r,forlloq11y

, ·~ ~ • I. •
Dronolllootottlfl
WIIHl l tiUlll 11ppor lul1r1 lti
fl fl'tlOlfl<I

• flrofttt1n, low pll ,,tir,rl r.,rnr,I<

Inn 11nnrrf rh1rh10 mlcJlnor,lr11
\ ... , ' IIOll

r \
) '
~~""" ✓~

\t
 • Diminished, 1ow-prcc;i1eci
chronic breath sounds
obStructive • sonorous or sibilant
pulmonary wheezes
disease (COPD) ■ Inaudible bronchophony,
egophony, and whispered
pectori loq uy
■ Prolonged ex pirat io n
■ Fine inspiratory crackles

■ Absent or diminished low -

Pleural effusion pitched breath sounds
■ Occasionally loud bronchial
breath sounds
■ Normal breath sounds on
contralateral side
■ Bronchophony, egophony,
and whispered pectoriloquy
at upper border of pleural
effusion

• High-pitched, tubular
Pneumonia
bronchial breath sounds over
affected area during inspira-
tion and expiration
• Bronchophony, egophony,
and whispered pectoriloquy
• Late inspiratory crackles
not affected by coughing or
position changes

Pneumothorax • Absent or diminished low-

pitched breath sounds
• Inaudible bronchophony,
egophony, and whispered
pectoriloquy
• Normal breath sounds on
contralateral side
uPPerairway
-
• Stridor
obstruction • Decreased or absent breath
sounds
• Wheezing