Lesson 5.3: Respiratory Examination
Patient position: sitting forward at 45 degrees or on the edge of the bed. Full anterior and posterior chest exposed. The examination must be bilateral and comparative.
Technique Checklist
- General inspection — RR, accessory muscles, pursed-lip breathing, barrel chest
- Hands — clubbing, peripheral cyanosis, nicotine staining, CO2 flap (asterixis)
- Face — central cyanosis (tongue), Horner syndrome, conjunctival pallor
- Neck — tracheal position (midline vs deviated), cervical lymphadenopathy
- Chest shape — barrel, kyphosis, scoliosis, asymmetry of expansion
- Chest expansion — both hands simultaneously, compare sides
- Percussion — anterior and posterior, compare upper/mid/lower zones each side
- Auscultation — anterior, posterior, and axillae; compare both sides
- Vocal resonance — say '99', compare sides
- Peak flow if asthma station; inhaler technique assessment if relevant
- Bedside: oxygen saturation (say this aloud)
Interpreting Respiratory Findings You Are Given
This table helps you interpret findings when the examiner hands them to you. You are not expected to detect these signs yourself.
| Finding | What It Means | What to Say to the Examiner |
|---|---|---|
| Dull percussion + bronchial breathing + crackles + increased VR one side | Consolidation — likely pneumonia | 'Findings suggest consolidation on the [right/left]. Likely pneumonia. I'd like a chest X-ray and sputum culture.' |
| Stony dull percussion + absent breath sounds + reduced VR one side | Pleural effusion | 'Findings suggest a pleural effusion on the [right/left]. I would like a chest X-ray and USS-guided aspiration.' |
| Hyper-resonant one side + absent breath sounds + tracheal deviation | Pneumothorax (tension if trachea deviates) | 'This suggests a [tension] pneumothorax. I would treat this as an emergency / arrange chest X-ray.' |
| Hyper-resonant bilateral + reduced breath sounds + wheeze | COPD / emphysema | 'Findings are consistent with COPD. I'd like spirometry and a chest X-ray.' |
| Bibasal fine inspiratory crackles bilateral | Pulmonary fibrosis or pulmonary oedema | 'Bilateral fine crackles — consistent with [fibrosis/oedema]. Clinical context will distinguish these.' |
Teaching MDI Inhaler Technique
- Remove the cap and shake the inhaler well for 5 seconds.
- Breathe out fully and gently — empty the lungs.
- Place the mouthpiece firmly between the lips, creating a seal.
- Start to breathe in slowly and deeply, then press the canister once.
- Continue breathing in slowly for 3–5 seconds — do not stop when pressing.
- Remove the inhaler. Hold your breath for 10 seconds.
- Breathe out slowly. Wait 1 minute before a second dose if needed.
- Replace the cap. Rinse mouth if a corticosteroid inhaler.
Common errors to correct when assessing a patient's technique: not shaking, breathing in too fast, firing before inhalation begins, not holding breath, tilting the head down.