Assessment and Observation of the Respiratory System

Learning objectives for this chapter

By the end of this chapter, we would like you:

-To describe the basic anatomy and physiology of the respiratory system.

-To explain how to collect a focused health history related to the respiratory system.

-To describe how to assess dyspnoea.

-To identify smoking as a key cause of respiratory disease in the United Kingdom (UK), and to explain how nurses should respond to a patient who smokes.

-To explain how to undertake a physical examination of the respiratory system.

-To discuss the age-related differences to be considered when assessing the respiratory system.

-To understand how to auscultate a patient’s anterior and posterior thorax in a systematic way.

-To list abnormalities which may be identified in a patient’s breathing pattern and breath sounds.

-To explain how to document respiratory system assessment findings.

-To recognise the common respiratory problems / conditions, and their typical clinical findings, to enable differential diagnosis

-To describe the variety of special assessment techniques which may be used in the physical examination of the respiratory system.

Fundamental anatomy and physiology of the respiratory system

The respiratory system consists of the lungs, airways and associated structures. It has two key roles: (1) to supply oxygen to the body’s cells, and (2) to remove carbon dioxide and other gaseous waste products from the body’s cells. It does this via processes including: (1) ventilation, and (2) diffusion.

The main organs of the respiratory system are the lungs. The right lung has three lobes, and the left lung has two lobes. It is important for nurses to bear in mind that the lungs are very large organs; indeed, each lung extends anteriorly about 4 centimetres above the top rib, and on deep inspiration they may expand down to about the twelfth thoracic vertebrae (T12).

The lungs are surrounded by tissue called pleura, which is well-lubricated to prevent friction during inspiration and expiration. The lungs sit within the thorax, a bony cage consisting of the 12 thoracic vertebrae, 12 pairs of ribs and the sternum. The thorax acts to protect the respiratory structures, and also helps to facilitate breathing.

Breathing is controlled by the diaphragm and the intercostal muscles. During inspiration, the diaphragm contracts downwards, while the intercostal muscles pull the chest wall outwards. This creates a negative pressure in the lungs, resulting in the lungs filling with air. During expiration, the diaphragm and intercostal muscles relax and air is expelled from the lungs.

During inspiration, air travels into the lungs via the airways. The upper airways include structures such as the mouth / nose, the pharynx, the larynx and the upper trachea, a flexible tube which, in adults, is approximately 10 centimetres long. These upper airway structures have three key roles: (1) to assist with the movement of air into the lower airways, (2) to protect the lower airway from foreign matter which may be inhaled, and (3) to warm, filter and humidify inspired air. The lower airways consist of structures including the lower trachea, the bronchi, the bronchioles and the alveoli. Essentially, the lower airways are branching tubes which become progressively smaller, until they terminate in the alveoli, a series of balloon-like structures. It is at the level of the alveoli that gas exchange – essentially, oxygen in and carbon dioxide out – occurs.

Respiratory system – focused health history

When assessing a patient’s respiratory system, the nurse must commence by collecting a health history. This involves collecting data about:

• Present health status
  • Chronic illnesses
  • Allergies
  • Shortness of breath
  • Medications
  • Tobacco smoking (past and current)
• Past medical history
  • Previous respiratory diseases
  • Injuries and / or surgeries to the chest
• Family history of respiratory conditions
• Environmental conditions
• Recent international travel

In some cases, a person will present with a specific problem related to their respiratory system.

Dyspnoea – or ‘shortness of breath’ – is a particularly common symptom associated with the respiratory symptom. It may be due to a variety of causes. For example:

• Obstructed ventilation.
• Restricted ventilation.
• Reduced perfusion.
• Interstitial disease.

During assessment, dyspnoea is measured by recording a person’s respiratory rate. Dyspnoea can also be assessed in other ways; for example, when taking the health history, a nurse may assess the number of words a person can say before needing to pause to take a breath.

When assessing a patient with dyspnoea, it is important for nurses to remember that this is a very distressing symptom, and one which may place the person’s life at immediate risk. If a nurse identifies that a patient is severely dyspnoeic, the assessment should cease while this symptom is addressed.

As you collect a general health history from a patient, it is important that you assess and identify risk factors for respiratory disease. As noted in a previous section of this chapter, tobacco smoking is a leading cause of respiratory disease in the UK.

Respiratory system – physical examination

A nurse may commence a physical examination of the patient’s respiratory system:

• Inspect the patient for general appearance, posture, breathing effort, etc.
• Observe the respirations for rate, quality, pattern and chest expansion.
• Inspect the patient’s nails, skin and lips for colour.
• Measure the oxygen saturation (SpO2).
• Inspect the anterior and posterior thorax for shape and symmetry.
• Auscultate the anterior and posterior thorax, and the lateral thorax.
• Palpate the anterior and posterior thorax for tenderness, bulges, symmetry, fremitus, etc.
• Percuss the anterior, posterior and lateral thorax for tone.
• Palpate the trachea for position.

When physically assessing a client’s respiratory system, it is important for a nurse to note that there are a number of important age-related differences. Consider these age-related differences specific to the assessment of the respiratory system:

• The respiratory assessment of an infant or a young child who is crying is very difficult, and is likely to produce inaccurate data. It is important that young children are calm before a respiratory assessment is commenced.
• When undertaking a respiratory assessment with an older adult, it is important for nurses to be aware that age-related structural problems may make the expansion of the thorax more difficult.

Assessing a patient’s respirations and respiratory effort is a key part of the physical examination of the respiratory system. When auscultating a patient’s chest, it is essential that a nurse uses a systematic process to ensure that all areas of the chest are heard.

When auscultating the chest, a nurse may identify a number of abnormalities in the patient’s breathing pattern or rhythm. Read the information in the following table:

Abnormality	Description
Bradypnoea	A respiratory rate of <10 breaths per minute; the respiratory rhythm and depth remain smooth and even.
Tachypnoea	A respiratory rate of >16 breaths per minute; the respiratory rhythm and depth remain smooth and even.
Hyperventilation	A very rapid respiratory rate; the respiratory rhythm and depth are increased. When hyperventilation occurs due to ketoacidosis, and is very deep and laborious, it is termed Kussmaul breathing.
Biot	Breathing characterised by intermittent periods of apnoea, with a disorganised pattern, rate and depth.
Cheyne stokes	Intervals of apnoea interspersed with deep, rapid breathing. This is seen in severely ill patients, often those who are nearing death.
Air trapping	Breathing characterised by rapid inspirations with prolonged, forced expirations where the air in the lungs is not fully exhaled. This is most often seen in patients with chronic obstructive pulmonary disease and similar conditions.

When auscultating the chest, a nurse may identify a number of abnormalities in the patient’s breath sounds. Read the information in the following table:

Abnormality	Description
Stridor	A harsh, high-pitched sound, often associated with inflammation or obstruction in the laryngeal or tracheal regions.
Fine crackles	A fine, high-pitched crackling / popping noise, usually heard at the end of inspiration. It cannot be cleared by coughing. It is often evident in mild pneumonia, heart failure, asthma and restrictive pulmonary disease.
Medium crackles	A moist, medium-pitched sound, usually heard midway through inspiration. It cannot be cleared by coughing. It is often evident in more severe pneumonia, heart failure, asthma and restrictive pulmonary disease.
Coarse crackles	A low-pitched bubbling / gurgling sound, usually heart at the beginning of inspiration. It cannot be cleared by coughing. It is often evident in very severe pneumonia, heart failure, asthma and restrictive pulmonary disease. It may also be heard in pulmonary oedema and pulmonary fibrosis.
Wheeze	A high-pitched, squeaking sound which may occur on inspiration and / or expiration. Often heard in diseases which result in narrowing of the airways, such as asthma.
Rhonchi	A low-pitched, coarse, loud ‘snoring’ or ‘moaning’ noise, which occurs primarily during inspiration. It may be cleared by coughing. Caused in disorders which result in obstruction of the trachea or bronchi, such as chronic bronchitis.
Pleural friction rub	A low-pitched, coarse rubbing or grating sound, heard continuously throughout inspiration and expiration. It cannot be cleared by coughing. It is heard in diseases which result in inflammation of the pleural surfaces.

Abnormal breath sounds are divided into two categories:

• Adventitious sounds.
• Diminished sounds.

It is important for nurses to remember that a number of errors in auscultation may result in adventitious sounds, including:

• The stethoscope is bumped or touched.
• The client is shivering because they are cold, feverish or afraid, etc.
• The stethoscope rubs against the client’s skin or hair.
• There are extraneous environmental noises.

If a nurse identifies a possible adventitious sound, they should check to confirm that none of these errors are occurring, ask the patient to cough, reposition the stethoscope and listen again. If the adventitious sound is heard again, the nurse can be confident that they are hearing it correctly.

Special assessment techniques for the respiratory system

There are a number of special assessment techniques particular to the respiratory system:

• Palpating the posterior chest wall for thoracic expansion. Palpation involves a nurse using their hands to feel the texture, size, shape, consistency and pulsations, etc., of different parts of a patient’s body. The nurse should stand behind the patient, and place their thumbs on either side of the client’s spine. The fingers of each hand should be extended outwards across the patient’s posterior chest wall. The patient should be instructed to take a number of deep breaths. The lateral movement of the thumbs as the client breathes in should be equal. Unequal movement is indicative of a number of problems with the respiratory system.
• Percussion, including of the posterior and lateral thorax. This involves a nurse striking a finger directly against the client’s chest wall, and listening to the sound that is created.
• Palpating the posterior thorax. When using palpation as a technique to assess the respiratory system at the level of the thorax, a nurse usually asks a patient to verbalise.

Differential diagnosis in the respiratory system

When assessing a patient’s respiratory system, there are a number of common problems and conditions a nurse may identify. Consider the conditions and their key clinical findings:

Respiratory Problem or Condition	Typical Clinical Findings
Acute bronchitis.	Cough; substernal chest pain; fever; malaise; tachypnoea; rhonchi; wheezing.
Pneumonia.	In viral pneumonia, a non-productive cough; in bacterial / fungal pneumonia, a productive cough; fever; malaise; pleuritic chest pain; pulmonary consolidation.
Tuberculosis.	The early stages of the disease may be asymptomatic. Progresses to frequent, productive cough; fatigue; anorexia; weight loss; night sweats; fever.
Pleural effusion.	The manifestation depends on the amount of fluid accumulated. In severe cases, there is dyspnoea; intercostal bulging; decreased chest wall movement.
Asthma.	Increased respiratory rate with prolonged expiration; severe dyspnoea; audible wheeze; tachycardia; anxiety; accessory muscle use; cough; diminished breath sounds.
Emphysema.	Unwell general appearance; dyspnoea on minimal exertion; pursed-lip breathing; tripod positioning; diminished breath sounds; wheezing and crackles.
Chronic bronchitis.	Productive cough; increased mucous production; dyspnoea; rhonchi; crackles.
Pneumothorax.	The manifestation depends on the extent of the lung collapse. Dyspnoea; anxiety; chest pain; tachypnoea; cyanosis; hyperresonant breath sounds; decreased chest wall movement; tracheal displacement, etc.
Haemothorax.	The manifestation depends on the extent of the lung collapse. Dyspnoea; anxiety; chest pain; tachypnoea; cyanosis; muffled breath sounds; decreased chest wall movement; tracheal displacement; dullness with percussion, etc.
Atelectasis.	Diminished or absent breath sounds; decreased oxygen saturation.
Lung cancer.	Persistent cough; weight loss; congestion; wheezing; haemoptysis; dyspnoea; diminished breath sounds; wheezes; dullness with percussion, etc.

Conclusion

As you have seen throughout this chapter, it is essential that nurses are able to accurately and comprehensively assess the respiratory system. This chapter has introduced the fundamental knowledge and skills nurses require to do so. It began with an overview of the fundamental anatomy and physiology of the respiratory system. The chapter then explained the processes involved in collecting a general health history for the respiratory system, and in performing a physical examination of the respiratory system. Finally, this chapter considered a number of special observation and assessment techniques which may be used in the physical examination of the respiratory system.