🩺 Respiratory Examination

A respiratory examination is a systematic assessment of the lungs and the patient's overall respiratory status. It follows the standard medical framework of Inspection, Palpation, Percussion, and Auscultation (IPPA). The goal is to identify clinical signs of airway obstruction, lung parenchymal disease, or pleural pathology. When combined with a focused history and observations (SpO2, RR), it allows for a rapid differential diagnosis of common conditions like pneumonia, heart failure, and obstructive lung diseases.

A respiratory examination is indicated for any patient presenting with cough, shortness of breath (dyspnoea), wheezing, chest pain, or haemoptysis. It is a core component of the assessment for chronic conditions like COPD, Asthma, Bronchiectasis, and Cystic Fibrosis. It is also required for acute presentations such as suspected pneumonia, pulmonary embolism, or pleural effusion, and as part of a general preoperative or systemic review.

There are no absolute contraindications, but the examination should be modified for patients in significant respiratory distress. For instance, a patient with a suspected tension pneumothorax or acute severe asthma should not be subjected to a prolonged examination before life-saving interventions are initiated. Avoid repeated percussion or heavy palpation in patients with known rib fractures or severe pleuritic pain. Ensure patient dignity and warmth during exposure.

The equipment required is minimal: a clean stethoscope (with both diaphragm and bell), a pulse oximeter for oxygen saturation monitoring, and a peak flow meter if indicated. The environment should be private, well-lit, and the patient should ideally be sitting in a chair or on the edge of the bed to allow access to the posterior chest. Alcohol gel for hand hygiene is essential before and after patient contact.

Perform a general inspection (respiratory rate, cyanosis, accessory muscle use). Check the hands (clubbing, staining, tremor, asterixis), pulse, and face (conjunctival pallor, central cyanosis). Palpate the trachea for deviation and assess chest expansion. Percuss all lung fields anteriorly and posteriorly, comparing sides. Auscultate over all lobes, asking the patient to take deep breaths through an open mouth. Assess vocal resonance if abnormalities are found. Complete the exam by checking for pedal oedema and examining the lymph nodes if malignancy is suspected.

Findings must be synthesised: bronchial breathing and increased vocal resonance suggest consolidation (pneumonia). A stony dull percussion note with absent breath sounds indicates a pleural effusion. Hyper-resonance and reduced breath sounds suggest a pneumothorax or severe emphysema. Polyphonic wheeze is characteristic of asthma/COPD, while fine 'velcro' crepitations at the bases suggest pulmonary fibrosis. Dullness at the bases with coarse crackles often points toward pulmonary oedema in the context of heart failure.

Failure to adequately expose the chest or fully examine the posterior lung fields is a common mistake. Many students neglect to check for signs of CO2 retention (asterixis) or fine tremors from beta-agonist use. Assessing chest expansion often involves too much pressure on the ribcage, which restricts movement and provides a false result. Auscultation errors include asking the patient to breathe through their nose rather than their mouth, which creates upper airway noise that mimics adventitious sounds.

Start at the 'end of the bed' by observing the respiratory rate and use of accessory muscles. Always compare the left and right sides 'ladder-style' during percussion and auscultation. Don't forget to examine the posterior chest; this is where most clinical signs are found. When checking for vocal resonance, ask the patient to say '99' and listen for increased clarity (consolidation). Always finish by stating you would check the oxygen saturations, peak flow, and review any available imaging like a chest X-ray.

Relates to MLA 'Pneumonia', 'Asthma', 'COPD', and 'Lung Cancer'. Students should be able to distinguish between type 1 and type 2 respiratory failure based on ABG results and clinical signs (e.g., flap). Recognition of 'red flags' such as cachexia and clubbing in the context of lung malignancy or chronic infection is vital. Understanding the anatomy of the lobes is necessary to accurately describe the location of findings for clinical handover.