Lungs and respiratory system examination

Attention

• When examining children
• Look before going near them with stethoscope or thermometer
• RR and work of breathing most important indicators of chest infections in children
• Listening to chest not a reliable way to diagnose chest infections — listening to the chest is only one part of assessment
• Crepitus — crackling sensation under skin caused by air leaking into tissues from airways or lungs
• Crackles (creps) sound like rubbing hair between fingers. Ask person to cough. May clear if caused by sputum in upper airways — won't clear if there is a lot of secretion
• Practise exam — know what normal chest looks, sounds, feels like
• If anything abnormal or worrying — medical consult

What you need

• Warm hands with short fingernails
• Warm stethoscope — warm between your hands
• Good ears. If you have hearing problem — use amplified stethoscope
• Pulse oximeter
• Other equipment as needed — peak flow meter, spirometer

What you do

• Respiratory system starts at tip of nose — examination needs to include ears, sinuses, nose, throat, nodes in neck and axillae (armpits), chest and hands

Ask about

• Nose — discharge, nostrils clear or blocked
• Cough — when it started, when it happens, any triggers
• Sputum — how much, colour (eg clear, yellow, green, bloody)
• Noisy breathing
• Breathing out (wheeze)
• Breathing in (stridor) — important, could be obstruction
• Shortness of breath — at rest, after activity, exercise
• Sore throat
• Chest pain or discomfort
• How they sleep — lying, sitting, how many pillows
• Snoring that wakes others, stops breathing while asleep — could be OSA — see Breathing related sleep disorders 
• Swollen legs (oedema)
• Pain in calves — with shortness of breath could be DVT, PE
• Smoking, exposure to cigarettes, e-cigarettes or domestic smoke
• Occupational  history, exposure to asbestos, organic dusts, chemicals

Check

• Examine hands and look for clubbing — Figure 9.1
• Increased curvature of nails
• Loss of angle between nail and nail bed
• Sponginess of nail bed and/or spreading (expansion) of end of fingers 
• Check mouth for foreign body or upper airway obstruction
• Feel for swollen lymph nodes in neck and armpits
• Skin, hands, feet — are they warm, cool, sweaty, clammy

Expose chest and look

• Shape of chest (eg pigeon, barrel, concave)
• Breathing — look for
• Distressed, agitated, short winded, panting, unable to lie down
• Rhythmical or uneven
• Chest moving the same on both sides (symmetry)
• Excessive use of accessory muscles (eg intercostal muscles), indrawing, jugular vein distension
• Talking in full sentences, single words, not at all. Number of words spoken a good indicator of shortness of breath
• Wounds, lumps, depressions on front/back of chest or neck

If small child or baby 

• Alert, drowsy, lethargic
• Look at respiratory effort
• How fast they are breathing, stopping breathing (apnoea)
• Do nostrils flare (widen) a lot as they breathe in
• Do ribs and sternum (breastbone) suck inward when they take a breath (indrawing), does abdomen move
• Able to feed or drink from breast or cup
• Dehydrated

Feel chest (palpate)

• Check position of windpipe (trachea). Put ring and index fingers on heads of clavicles, middle finger on windpipe — Figure 9.2
• Is it in centre or moved to one side
• Is there tracheal tug — notch at bottom of neck sucking in

• Using palms of hands, feel gently for any sore areas, swellings or retractions (dents) of chest wall and intercostal spaces (between ribs) — Figure 9.3
• Feel for crepitus, especially around puncture wounds, drain sites
• Using pads of fingers feel over whole front and back of chest for lumps, scars, skin temperature, tone — Figure 9.4

• Should be no pain
• If pain — consider broken ribs, muscle strain from coughing, collapsed lung

Measure chest expansion (symmetry)

Compare movement of both sides of chest wall (symmetry). If problem expanding (inflating) one or both lungs — may be fluid in pleural space, pneumonia, pneumothorax, etc.

• Put hands on person’s back with tips of fingers below scapula, thumbs touching over spine — Figure 9.5
• Ask person to take deep breath. Your thumbs and fingers should separate evenly, equally, at same time

• Note any difference in movement
• Look at clavicles (collar bones) from above, do they rise and fall equally

Percuss chest

• Use hands and hearing to find edges of lungs inside chest
• 2 main sounds — resonant and dull, Table 9.1
• Check if filled with air, fluid, solid matter

Left front chest sounds dull over heart — from sternum to mid-clavicular line, at third or fourth rib space. Normal resonance again at sixth rib space

Practise on yourself

• Put non-dominant hand on top front of your chest with middle finger lying straight and flat
• With tip of middle finger of dominant hand, tap briskly on non-dominant middle finger just below top joint — Figure 9.6
• Tapping movement must come from wrist
• Will hear resonant sound

• Repeat on top of head. You will hear dull sound

Percuss patient

• Put hand firmly on chest, with straightened middle finger between ribs (in rib space)
• Follow percussion sequence for front — Figure 9.7 and back — Figure 9.8
• When percussing normal lungs, you hear resonant sound over most of lung

Listen to breath sounds (auscultation)

Stethoscope can only hear (penetrate) the lung approximately 5cm below the skin. Abnormalities that lie deeper might not result in an abnormal sound (eg large pneumonia but normal breath sounds).

• First listen quietly without stethoscope
• Wheeze or whistle, wet or dry cough
• Speaking in sentences, short phrases, or single words
• Sounds made by air passing through larger and smaller airways tell you about condition of lungs and  pleural (chest) cavity
• If normal lungs — soft sound as person inspires (breaths in), nothing as they expire (breath out)
• If pleural effusion (fluid) or pneumothorax (air around lung)  — sounds usually decreased
• If fluid in lung (eg infection, heart failure) — crackles as person breaths in and sounds audible when breathing out. If person has lobar pneumonia, sounds increased, sound harsh — bronchial breathing
• If blockage in large airways — loud higher pitched sound when person breathes in (stridor)
• If blockage in smaller airways (eg asthma, bronchiolitis) — may hear higher pitched sound when person breathes out (wheeze)

If small child — always rely on what you can see

• Level of distress, breathing rate, effort, chest movements more reliable
• See Clinical assessment of children 

Put warm stethoscope diaphragm firmly onto skin. Do not listen through clothing — covers sounds and confuses findings

• Ask person to take regular, deep breaths through open mouth
• Follow same sequence as for percussion — Figure 9.7, Figure 9.8. Listen at each spot for one complete breath — in and out
• Listen to back, compare one side of chest to other, then to front
• See Table 9.2 for normal breath sounds
• If unusual breath sounds — note type, loudness, length, timing (breathing in or out)
• Ask person to keep saying ‘ninety nine’ (99), listen for changes
• Check under arm for pleural rub (creaky leather sound), means pleura (membranes around lungs) inflamed and rubbing together

• Type of abnormal sound depends on where air flow is blocked, what is causing blockage — Table 9.3

If breath sounds 

• Not there — air not reaching alveoli (air sacs). Lung may have collapsed
• Pneumothorax, bad infection, severe pulmonary oedema, severe asthma, COPD (usually the breath sounds are audible in asthma or COPD exacerbation, but patients can have a silent lung in severe obstruction)
• Less than normal — less air reaching alveoli (air sacs). Lung may contain fluid (pulmonary oedema)
• Unusual — check medical history for repeated chest infections and/or chronic chest disease, medical consult

Using peak flow meter

• Measures how well person breathes air out of lungs, how well their medicine is working
• Reduced peak flow can be due to lung disease or to person not understanding what they need to do
• Can tell you there is something wrong with lungs but not what it is
• If you know result when they are well — can help you decide if asthma or COPD worse than normal. Check file notes

Attention

• Teach person to blow from deep in lungs, not just from mouth
• Use the same device for the same person (results can differ with different brands)
• Ideal is to have a measurement of person at their best so any deterioration can be recorded

What you need

• Peak flow meter
• Disposable mouthpieces
• Person’s inhaler medicine

What you do

• Ask person to sit up straight
• Put clean mouthpiece on meter
• Hold meter level (horizontal) with indicator facing upward. Make sure marker is on '0' (zero) or ‘start’
• Ask person to
• Take big breath in, get lungs as full as they can
• Seal lips around mouthpiece, blow out as hard and as fast as they can
• Note result, put marker back to zero/start, do this twice more
• Record best (highest) result 
• Ask person to take normal dose of reliever medicine
• Do procedure again after 15 minutes, record result 
• Compare result with normal or ideal to decide if treatment working

Spirometry

• Measures lung function — how much air person can blow out, how fast lungs can be emptied
• If 6 years or over — necessary test for diagnosing COPD
• Can diagnose asthma when person is acutely unwell — in between attacks spirometry is normal
• Use with history and examination
• Need training to carry out procedure, experience to interpret

Attention

• Do not attempt spirometry if COVID suspected — may need to add extra viral filter to your handheld spirometer. Check your health service policy
• Do not attempt more than 6 blows
• Do not attempt if person had eye, chest, abdominal surgery, or pneumothorax in last 6 weeks
• Must do procedure with greatest effort possible, no pausing
• If person coughs, takes extra breath, blocks mouthpiece with tongue — will not be accurate — must be done again
• Effort may be reduced by chest pain, abdominal problems, fear of incontinence. Manage these risks to reassure patient
• Takes longer for people with airflow obstruction to fully breathe out
• First — demonstrate procedure to person. People usually get better with practice so later results may be more accurate

What you need

• Accurate calibrated spirometer
• Pre-calibrated single use mouthpieces may be preferred
• Use nose clips if available

What you do

• Person sits up straight with feet firmly on floor. Tell them to try not to lean forward during test
• Ask person to 
• Breathe in as deeply as they can
• Seal lips around mouthpiece
• Blow air out as fast and as hard as they can, keep blowing until lungs feel completely empty
• When measuring breathing out (forced expiratory manoeuvre)
• Adults and children over 10 years should blow out for 6 seconds or more
• Children 10 years and under should blow out for 3 seconds or more
• You will need at least 3 good tests
• If person too tired to do 3 good tests in a row — rest in between
• When 3 good tests — give 2 puffs of salbutamol (200 microgram) via spacer, wait 15 minutes, repeat spirometry and get another 3 good tests

Breathing function measurements

FVC (forced vital capacity)

• Maximum volume of air which can be forcefully exhaled (breathed out)
• Abnormal if less than 80% of predicted value based on age, height, gender
• FVC6 is forced expiratory volume in first 6 seconds. Can be used instead of FVC, especially if severe lung disease and takes a long time to exhale

FEV1 (forced expired volume in one second)

• Volume expired in first second of a forced expiratory manoeuvre
• Abnormal if less than 80% of predicted value based on age, height, gender

FEV1/FVC ratio

• Calculated by dividing FEV1 by FVC, usually expressed as percentage
• Reduced ratio (less than 0.7 or 70%) suggests airflow obstruction consistent with asthma, COPD, and sometimes bronchiectasis

Improvement in FEV1 following bronchodilator (eg salbutamol)

• If airflow obstruction — improvement in FEV1 of more than 12% AND at least 200mL after bronchodilator suggests
• If lung function returns to normal — asthma
• If obstruction remains — COPD or asthma/COPD overlap

'Good' spirometry test

To be classified as a 'good' test, spirometry needs to meet criteria for acceptability and reproducibility

Acceptability

• Based on individual forced expiratory manoeuvre
• Best assessed by looking at both flow-volume and volume-time curves, and patient
• Blow of acceptable quality — Table 9.4 — good effort
  
• Starts quickly — steep rise in flow-volume loop
• At least 3 seconds if 7–10 years or 6 seconds if over 10 years
• No cough (at least in first second)
• Smooth continuous expiration with only 1 breath

Reproducibility

• Based on how similar 3 acceptable forced expiratory manoeuvres are compared to one another — before and after bronchodilator
• 2 best FVC results should be within 0.15L of one another
• 2 best FEV1 results should be within 0.15L of one another
• Highest FEV1 and FVC values should be used

Supporting resources

• Strong wulyan (strong lungs) video
• Lung health for kids app