Adults Clinical Examinations

Respiratory examination
Edited by Jane Watson, Lead for Continuing Professional Practice, Addenbrookes Hospital, Cambridge

©2021 Clinical Skills Limited. All rights reserved

This procedure describes how to carry out a respiratory examination. Before fraction of inspired oxygen (FiO2). (See the relevant clinicalskills.net
carrying out a physical clinical examination, ensure you have introduced procedures in the Observations category for more guidance.)
yourself, verified the patient’s full name and date of birth and gained their
verbal consent for the consultation. It is also important to undertake a Ask the patient if they need any assistance getting onto the couch. Follow local
detailed holistic history beforehand. policy on moving and handling. Once the patient is on the couch, adjust it to a
suitable height: it should be at a level between your waist and hips. Ensure
The purpose of the physical examination is to identify one or more possible adequate exposure while preserving the patient’s dignity as much as possible.
diagnoses—often called differential diagnoses—that are derived from both Ask the patient to point to any area of pain before beginning the examination.
the patient's history and physical symptoms.
Following best practice, you should examine all of the anterior thorax
Your preliminary global assessment of the patient is an important clinical followed by all of the posterior thorax, or vice versa, remembering the four
feature that needs to be recognised and documented. What is the patient’s key stages of respiratory examination: inspection, palpation, percussion and
overall skin colour? How about their position: are they sitting comfortably or auscultation. It is best to carry out the posterior examination with the patient
leaning forward? Are they mobilising freely? Are they able to complete full seated (or standing, if they are able), and the anterior examination with the
sentences or are they needing to catch their breath within sentences? This patient supine (Bickley, 2020).
allows you to make a prompt clinical assessment: if the patient is breathless
at rest, you are likely to need to address that before proceeding. Patient You may need to consider further investigations such as peak flow,
safety always has to be your priority. spirometry, sputum culture, blood gas analysis and chest X-ray.

Record the patient’s vital signs: temperature, blood pressure, pulse, Ensure you use appropriate PPE throughout, adhering to the latest national
respiratory rate, capillary refill time and oxygen saturation. Remember, if the guidance; see the clinicalskills.net procedures, “Putting on and taking off
patient is receiving oxygen, you must document this too, and include the PPE for COVID-19” and “Use of PPE for COVID-19 in a community setting”.

Explain the procedure to the patient General observations

!
13826

L/Min
60

100

150

250

300

400

500
200

350

450

550

650

800
600

700

EU
EN

Peak flow meter

m
ckha
Be
yal
e Ro ia
Th Victor
d st
an Tru
S S
NH Nate
ce rse NH
ma cti
Em r Pra nt Nu
Senio opme
vel
De

STERILE UNIVERSAL CONTAINER

80
Name MARK MCDONALD
W06088732 Ward D8
60
No.

Spec SPUTUM D.O.B. 5/9/54

Date 340
/1/2021 Time 08:30 Short-acting
IN VITR
O USE ONLY SINGLE USE ONLY beta2-agonist
inhaler

Select your PPE according to local policy and your risk assessment Sputum sample

Explain the procedure and gain consent. Ask the patient if they would like a Start the examination with some general observations of the patient at rest,
chaperone present before you begin the examination. Ensure privacy by building on your initial global assessment. Has the patient been using an
closing the door and/or drawing curtains. Decontaminate your hands by inhaler or nebuliser? Has the patient provided a sputum sample or do they
washing with soap and water and drying thoroughly or by using have a tissue with sputum in? Examine these if you can, taking note of volume,
alcohol-based hand sanitiser. colour, blood, odour, etc. (See procedure, “Assessment of respiration”.)
Do not undertake or attempt any procedure unless you are, or have supervision from, a properly trained, experienced and competent person.
Always first explain the procedure to the patient and obtain their consent, in line with the policies of your employer or educational institution.
Page 1 of 9
Adults Clinical Examinations

Respiratory examination Page 2

Examine the patient’s hands: (a) (b) Assess palmar creases for pallor

Examine the dorsum of each hand; check for temperature, signs of peripheral Assess pallor of the palmar creases by asking the patient to hyperextend their
cyanosis (see inset) and for nicotine staining. fingers and then stretch the skin on either side of the creases. Palmar pallor may
indicate low haemoglobin levels which may cause breathlessness (although the
test’s sensitivity is reduced in patients with darkened skin pigmentation).
(c) Nail abnormalities and finger clubbing (d) Check for asterixis

Look at the nails and note any nicotine staining and/or abnormalities, such as Ask the patient to lift their arms up horizontally straight ahead of them and
koilonychia (sometimes referred to as spoon nail because of the nail’s cock their wrists back. Observe for asterixis: flapping of the hands suggestive
concave appearance; see left inset). Koilonychia indicates iron deficiency. of carbon dioxide retention.
Look for signs of finger clubbing (right inset), which may indicate chronic
cardiovascular disease, lung cancer or hepatic cirrhosis.
(e) Hand tremor (f) Check the patient’s pulse

Hand tremor at rest may be due to excessive use of inhaled beta2-agonists Check the pulse for tachycardia as part of an overall assessment of the
such as salbutamol. patient’s condition (see introduction). (See also the clinicalskills.net
procedure on “Assessing the pulse”.)
Do not undertake or attempt any procedure unless you are, or have supervision from, a properly trained, experienced and competent person.
Always first explain the procedure to the patient and obtain their consent, in line with the policies of your employer or educational institution.
Page 2 of 9
Adults Clinical Examinations

Respiratory examination Page 3

Examine the face and mouth: (a) (b)

Look for central cyanosis: this is best assessed by looking at the inside of the Inspect the tongue and mouth for general hydration and health, and look for
patient’s lips and underneath the tongue. evidence of oral thrush (common in those using steroid inhalers, indicating
poor inhaler technique and/or high inhaled steroid use; see inset).
(c) Accessory muscles

Pale conjunctiva
(loss of
demarcation)

Gently pull down the patient’s lower eyelid to assess for pallor in anaemia. Inspect the neck. Are the accessory muscles working hard to support lung
ventilation? It is better to check the trachea and jugular venous pressure
when the patient is supine at the start of the anterior examination
(see page 7).

Look at the shape of the chest: (a) (b) The anteroposterior:transverse ratio
Anteroposterior diameter

Spine

Transverse diameter

Instruct the patient to remove their clothing to the waist. Note if there are any In the normal adult, the thorax will be wider than it is deep, i.e. the transverse
scars from previous surgery or chest drains. Observe for any signs of weight (lateral) diameter will be larger than the anteroposterior diameter (Guinan et
loss (cachexia; see page 4). Stand in a midline position behind the patient. al., 2020). The ratio of the anteroposterior diameter to the transverse
Look at the general shape of the chest. diameter is usually 1:2 (as shown in the illustration above).
Do not undertake or attempt any procedure unless you are, or have supervision from, a properly trained, experienced and competent person.
Always first explain the procedure to the patient and obtain their consent, in line with the policies of your employer or educational institution.
Page 3 of 9
Adults Clinical Examinations

Respiratory examination Page 4

Look at the shape of the chest: (c) Conditions that affect the shape of the chest

1 2 3 4

Barrel chest, in which the anteroposterior:transverse ratio may exceed 0.9 (1); kyphosis (2); scoliosis (3); and cachetic appearance in the tripod position (4).

Reassess the respiratory rate Palpate the chest from the back: (a)

am
Beckh
Royal
The toria
Vic
and Trust
S
NH e
Nat e S
NH
Emma Practic Nurse
ior
Sen pment
elo
Dev

While the patient’s chest is exposed you may wish to reassess their Ask the patient (if they are able) to cross their arms across the anterior of
respiratory rate, observing chest movement and counting the number of their chest and place their hands on opposite shoulders; this moves the
respirations; note the rate and rhythm. (See clinicalskills.net procedure on scapulae out of the way. Using both hands, gently palpate the thorax from the
“Assessment of respiration” for more guidance.) back, checking for areas of tenderness (Guinan et al., 2020). Start at the top
and work your way down the rib cage.

(b) Palpate the rib cage from the sides Posterior chest expansion

Palpate the lower rib cage from the sides. Place each hand on either side of the rib cage, making a fold of skin at the
centre. Ask the patient to inhale. As the patient inhales, note symmetry as
both lungs fill (right). Asymmetry may indicate a pneumothorax, consolidation
or fluid (see page 6).
Do not undertake or attempt any procedure unless you are, or have supervision from, a properly trained, experienced and competent person.
Always first explain the procedure to the patient and obtain their consent, in line with the policies of your employer or educational institution.
Page 4 of 9
Adults Clinical Examinations

Respiratory examination Page 5

Palpation for tactile fremitus: (a) Move your hands down the patient’s back

Ask the patient to slowly repeat the words, “Ninety-nine”. Using the sides of your hands to palpate as shown, feel for vibrations through the chest wall. Stronger
vibrations are felt over the larger airways, decreasing to softer vibrations at the base of the lungs. An increase in vibrations at the base of the lungs may
indicate a pneumothorax, consolidation or fluid. Move your hands down as the patient repeats the phrase.

(b) Move your hands to the patient’s sides Percussion technique

Move your hands to the patient’s sides as they repeat the phrase. To carry out percussion, place one finger of your non-dominant hand on the
surface of the skin and use one or two fingers of the dominant hand to
percuss the finger placed over the skin.

Percuss the posterior thorax: (a) (b) Percuss the sides

Percuss the posterior thorax at the sites marked with a red dot in the picture. Continue by percussing the posterior thorax at the sides, finishing at the level
Start at the top of the scapula on the patient’s left, then percuss the right side. of the lower lobe of the lung. Note any abnormalities. Abnormal percussion
Compare the sound obtained on the left and right sides. sounds such as dullness or hyper-resonance may indicate fluid, consolidation
or pneumothorax (see page 6).
Do not undertake or attempt any procedure unless you are, or have supervision from, a properly trained, experienced and competent person.
Always first explain the procedure to the patient and obtain their consent, in line with the policies of your employer or educational institution.
Page 5 of 9
Adults Clinical Examinations

Respiratory examination Page 6

Difference in sound could indicate pnuemothorax, consolidation or fluid

1 2 3

A difference in sound may indicate a thoracic abnormality, such as (1) a pneumothorax (air in the pleural space), (2) consolidation (airway filled with dense
material, such as infection) or (3) fluid.

Auscultate the lungs from the back (a) (b) Auscultate the lungs from the sides

Place your hand on the patients’ shoulder if they are standing. Ask the patient Listen to the lungs at the sites percussed on both sides of the thorax, as the
to inhale and exhale deeply through an open mouth, as you listen to the lungs patient continues to inhale and exhale deeply through an open mouth. This
from the back, using the diaphragm of the stethoscope. Listen to the lungs at concludes auscultation of the posterior thorax.
the sites that you percussed on the posterior thorax. Listen to one complete
respiratory cycle (inspiration and expiration) at each position. Make sure to
observe your patient when doing this and allow them to take rests as needed.
Note any added breath sounds, such as wheeze or crackles.

Palpate the neck Patient position for the anterior examination

Sternocotomy Pacemaker
scar scar

Cervical
nodes

Posterolateral Anterolateral
Supraclavicular
thoracotomy thoracotomy
nodes
scar scar

Standing behind the patient, feel for any raised cervical lymph nodes. Palpate If possible, the patient should adopt a supine position with their arms
also the supraclavicular nodes, in the angle between the clavicle and the abducted for the anterior examination, with the bed or couch at a 45° angle.
sternomastoid. Raised or tender lymph nodes may indicate infection or However, if the patient is sitting or standing, ask them to put their hand on
malignancy. their hips, if they are able. Inspect the patient’s chest for shape, respiratory
effort and scars.

Do not undertake or attempt any procedure unless you are, or have supervision from, a properly trained, experienced and competent person.
Always first explain the procedure to the patient and obtain their consent, in line with the policies of your employer or educational institution.
Page 6 of 9
Adults Clinical Examinations

Respiratory examination Page 7

Is the trachea midline? Assess jugular venous pressure

Sternocleidomastoid muscle
Internal jugular vein

Sternal
notch

Internal
carotid
artery

Clavicle

While the patient is supine, explain that you need to feel their “windpipe”. Ensure the patient is at a 45° angle, and ask the patient to turn their head
Check that there is no deviation of the trachea which could be pulled to one away from you. A raised jugular venous pressure may indicate tension
side by a collapsed lung or pushed away by a tension pneumothorax or a pneumothorax, a large pulmonary embolism, or right-sided heart failure.
large pleural effusion. Unless the jugular vein is raised, it is often impossible to see.

Palpate the anterior thorax: (a) (b) Palpate the left and right sides

Using both hands, gently palpate the thorax for areas of tenderness, starting Moving down, palpate the thorax on both sides simultaneously.
above the clavicular line (Guinan et al., 2020).
(c) Palpate the lower rib cage (d) Palpate the lower ribs at the sides

Continue to move down, palpating the lower rib cage. Palpate the lower rib cage at the sides.

Do not undertake or attempt any procedure unless you are, or have supervision from, a properly trained, experienced and competent person.
Always first explain the procedure to the patient and obtain their consent, in line with the policies of your employer or educational institution.
Page 7 of 9
Adults Clinical Examinations

Respiratory examination Page 8

Palpate for chest expansion: (a) (b) Patient inhales

Place your hands on either side of the rib cage, making a fold of skin at the As the patient inhales, note symmetry as both lungs fill. Asymmetry may
centre. Ask the patient to inhale. indicate a pneumothorax, consolidation or fluid.

Palpation for tactile fremitus: (a) (b) Feel for a change in vibration at the base of the lung

“Ninety-nine” “Ninety-nine”

2 3

2
3

Ask the patient to slowly repeats the words, “Ninety-nine”. Using the sides of A change in vibration at the base of the lungs may indicate a pneumothorax
your hands to palpate as shown, feel for vibrations through the chest wall. (vibration decreases in a simple pneumothorax but increases in a tension
Stronger vibrations are felt over the larger airways, decreasing to soft pneumothorax), consolidation (increased vibration), or fluid (decreased
vibrations at the base of the lungs. Move your hands down, as indicated by vibration).
the numbers 1, 2 and 3, as the patient repeats the phrase.

Percuss the anterior thorax: (a) (b)

Percuss the anterior thorax. Start above the clavicle on the patient’s left... ...then percuss the right side. Compare the sound obtained on the two sides,
noting any abnormalities such as dullness or hyper-resonance.
Do not undertake or attempt any procedure unless you are, or have supervision from, a properly trained, experienced and competent person.
Always first explain the procedure to the patient and obtain their consent, in line with the policies of your employer or educational institution.
Page 8 of 9
Adults Clinical Examinations

Respiratory examination Page 9

Percuss the anterior thorax: (d) (e)

Continue to percuss, moving down the front of the chest, on either side of the Percuss each side of the chest at the level of the lower lobe of the lung.
sternum.

Auscultate the lungs: (a) (b)

m
ckha
Be
yal
e Ro ia
Th Victor t
d
an Trus
S S
NH Nate e NH
ma actic rse
Em or Pr ent Nu
Seni lopm
ve
De

Place your hand on the patient’s shoulder if they are standing. Ask the patient Listen to the lungs at the sites percussed on both sides of the thorax, as the
to inhale and exhale deeply through an open mouth, as you listen to the patient continues to inhale and exhale deeply through an open mouth.
lungs, using the diaphragm of the stethoscope. Listen to the lungs at the sites
that you percussed on the anterior thorax. Listen to one complete respiratory
cycle (inspiration and expiration) at each position. Make sure to observe your
patient when doing this and allow them to take rests as needed. Note any
added breath sounds, such as wheeze or crackles.
Patient Notes ? X
Palpate the legs Documentation
General Notes Allergy Notes

03/01/2021 10:00
Mr McDonald presented today with a 3-day history of shortness of breath,
worsening on exertion, particularly when walking upstairs. History taken and
documented in medical notes.
Physical examination undertaken with Mr McDonald's consent. Chaperone
offered but declined by Mr McDonald.
Patient appeared rested and walked independently into the consultation room.
He was able to talk in full sentences. Appeared orientated and well hydrated. Nil
peripheral or central cyanosis evident, not using accessory muscles. Some
nicotine scarring on finger tips, other nil else of note.
Chest examination - pacemaker scar evident - healed, nil else of note. Chest
expansion equal, auscultation and percussion undertaken - nil additional sounds,
no tenderness on palpation noted. Tactile fremitus no abnormalities detected and
JVP not raised, nil oedema present.
Clinical observations: HR 94 bpm regular, SpO2 95% (on room air), BP 130/75,
RR 23, Temp 37.0.

Palpate the legs for any peripheral oedema, starting at the feet and moving Make the patient comfortable. Decontaminate your hands. Advise the patient
up each leg until there is no palpable fluid in the tissues. Check for calf of all the clinical findings and discuss the next steps. This will be dependent
sensitivity or skin colour/temperature changes. on the individual patient, so it is important to use your clinical
OK judgement. If
Cancel
ever you are not sure, you must speak to another healthcare professional.
Advise the patient where to seek further help if their symptoms worsen, such
as by calling 111.
Do not undertake or attempt any procedure unless you are, or have supervision from, a properly trained, experienced and competent person.
Always first explain the procedure to the patient and obtain their consent, in line with the policies of your employer or educational institution.
Page 9 of 9