Respiratory Assessment Guide

Systematic Respiratory Assessment

Use the Look — Listen — Feel framework: Inspection → Palpation → Percussion → Auscultation.

1. Inspection

Respiratory Rate & Rhythm

Parameter	Normal	Abnormal / Notes
Rate (adult)	12–20 breaths/min	<12 = bradypnoea; >20 = tachypnoea; >30 = severe respiratory distress
Rhythm	Regular	See patterns below
Depth	Normal tidal volume ~500 mL	Shallow = pain, splinting; Deep = metabolic acidosis

Breathing Patterns

Cheyne-Stokes: Cyclical crescendo-decrescendo with apnoeic episodes — heart failure, CNS disorders, altitude
Biot's (ataxic): Completely irregular depth and rhythm with periods of apnoea — severe brainstem damage, meningitis
Kussmaul: Deep, rapid, laboured — metabolic acidosis (DKA, uraemia). The body attempts to blow off CO₂
Apnoeustic: Prolonged inspiratory hold, short expiration — pontine lesion

Respiratory Effort (Work of Breathing)

Accessory muscles: Sternocleidomastoid and scalenes recruited in moderate-to-severe distress; visible neck muscle use indicates significant effort
Intercostal/subcostal recession: Inward movement of soft tissues between or below ribs during inspiration — increased negative intrapleural pressure
Nasal flaring: Widening of nostrils — increased airflow demand, common in children and adults in distress
Tracheal tug: Downward movement of trachea during inspiration — severe obstruction or airflow limitation
Pursed-lip breathing: Self-applied PEEP to prevent small airway collapse — COPD patients, reduces air-trapping

Chest Shape

Barrel chest: AP:lateral diameter ratio >1:1 (normally ~1:2). Seen in COPD/emphysema due to chronic hyperinflation, downward displacement of diaphragm, horizontal ribs
Pectus excavatum (funnel chest): Posterior depression of lower sternum — can compress heart/lungs in severe cases
Pectus carinatum (pigeon chest): Anterior protrusion of sternum — asthma in childhood, Marfan syndrome
Kyphoscoliosis: Spinal curvature causing restrictive lung disease; severe cases require respiratory support

Clinical Pearl

Paradoxical breathing (inward chest movement during inspiration) indicates either flail chest or diaphragmatic fatigue — a pre-terminal sign requiring urgent intervention.

Cyanosis

Peripheral cyanosis — blue discolouration of fingertips/nail beds. Causes: cold, vasoconstriction, Raynaud's, reduced cardiac output. Not necessarily hypoxic.

Central cyanosis — blue discolouration of tongue, lips, mucous membranes. Indicates significant hypoxia (deoxyhaemoglobin >5 g/dL, SpO₂ typically <85%). Always clinically significant.

Digital Clubbing

Loss of normal angle between nail and nail bed. Schamroth's test: diamond window lost with clubbing.

Respiratory causes: Bronchiectasis, lung abscess, mesothelioma, lung cancer, cystic fibrosis, fibrosing alveolitis, empyema
Cardiac causes: Cyanotic congenital heart disease, subacute bacterial endocarditis
GI causes: Crohn's, UC, cirrhosis, coeliac
COPD alone does NOT cause clubbing — its presence should prompt investigation for malignancy

2. Palpation

Tracheal Position

Place index finger gently in suprasternal notch. Trachea should be central.

Direction	Causes
Deviation AWAY from affected side	Pleural effusion (large), tension pneumothorax — space-occupying
Deviation TOWARDS affected side	Lung collapse/atelectasis, pulmonary fibrosis — volume loss

Emergency

Tracheal deviation + haemodynamic instability + absent breath sounds = TENSION PNEUMOTHORAX until proven otherwise. Do NOT wait for CXR — needle decompression immediately.

Chest Expansion

Place both hands flat on the posterior chest (lower zones) with thumbs meeting at the midline. Ask patient to take a deep breath. Both thumbs should move equally (4–5 cm). Unilateral reduction indicates ipsilateral pathology.

Tactile (Vocal) Fremitus

Place ulnar border of hand on chest wall. Ask patient to say "99" or "one-one-one".

Finding	Interpretation
Increased fremitus	Consolidation (sound conducts well through solid tissue), fibrosis
Decreased/absent fremitus	Pleural effusion (fluid dampens), pneumothorax (air dampens), obesity, emphysema

3. Percussion

Place non-dominant middle finger firmly on chest wall. Strike with the tip of dominant middle finger. Compare symmetrically, apex to base.

Note	Quality	Clinical Meaning
Resonant	Hollow, low-pitched	Normal air-filled lung
Hyper-resonant	Very hollow, drum-like	Pneumothorax, emphysema (over-inflation)
Dull	Thud, higher-pitched	Consolidation (pneumonia), lung collapse, tumour
Stony dull	Extremely flat, like hitting a solid	Pleural effusion (liquid between lung and wall)
Tympanic	Drum-like over gastric bubble	Hollow viscus; pneumothorax in some cases

Liver dullness: Normally percuss from resonant (right lung) to dull (liver) at the 6th rib MCL. Loss of liver dullness = gas under diaphragm (bowel perforation).

4. Auscultation

Use diaphragm of stethoscope. Auscultate at least 6 zones anteriorly and posteriorly, comparing left and right. Ask patient to breathe through mouth.

Auscultation Zones Map

Zone	Best hears
Anterior upper (2nd ICS MCL)	Upper lobe, apex
Anterior middle (4th ICS)	Right middle lobe (right), lingula (left)
Lateral (5th–6th ICS MAL)	Lower lobe lateral
Posterior upper (above spine of scapula)	Upper lobe
Posterior middle (between scapulae)	Middle/lower lobe
Posterior lower (below scapulae)	Lower lobes — most dependent, commonest pneumonia/effusion site

Vocal Resonance

Bronchophony: "99" sounds louder/clearer over consolidation than normal
Whispering pectoriloquy: Whispered "1-2-3" transmitted clearly — consolidation
Aegophony: "E" sounds like "A" over effusion (nasal quality)

Breath Sounds & Clinical Pattern Recognition

Breath Sound Reference

Sound	Character	Phase	Cause
Normal vesicular	Soft, low-pitched, rustling	Inspiration > expiration (3:1)	Air entering alveoli — normal
Bronchial	Loud, harsh, tubular	Expiration > inspiration; gap between phases	Consolidation, collapse with patent bronchus, fibrosis
Bronchovesicular	Intermediate	Equal inspiration/expiration	Normal over main bronchi (2nd ICS sternal), early consolidation
Reduced/absent	Quiet or silent	Both phases	Pneumothorax, pleural effusion, obesity, COPD (air-trapping)
Wheeze (rhonchi)	Musical, high or low-pitched	Mainly expiratory (asthma, COPD); inspiratory stridor = upper airway	Airway narrowing — bronchospasm, secretions, oedema
Fine crackles	Soft, high-pitched, Velcro-like	Late inspiratory	Pulmonary fibrosis, early pulmonary oedema, pneumonia (early)
Coarse crackles	Loud, low-pitched, bubbling	Early inspiratory (also expiratory)	Bronchiectasis, COPD, secretions — clear with cough
Pleural rub	Leathery, grating, creaking	Both phases (does not clear with cough)	Pleuritis, pulmonary embolism with pleuritis, pneumonia
Stridor	High-pitched, monophonic	Inspiratory (occasionally biphasic)	Upper airway obstruction — croup, epiglottitis, foreign body, tumour

Clinical Pattern Recognition

Condition	Percussion	Fremitus	Breath Sounds	Added Sounds	Other Signs
Consolidation	Dull	Increased	Bronchial breathing	Fine crackles	Aegophony, bronchophony, fever
Pleural effusion	Stony dull	Absent/reduced	Absent (± bronchial above)	Pleural rub (early)	Tracheal deviation away (large), aegophony at upper border
Pneumothorax	Hyper-resonant	Absent	Absent	None	Tracheal deviation away (tension), reduced expansion
COPD exacerbation	Hyper-resonant	Reduced	Reduced air entry	Wheeze, coarse crackles	Barrel chest, pursed lip, prolonged expiration
Pulmonary oedema	Dull (bases)	Reduced	Reduced (bases)	Bilateral fine crackles ± wheeze ("cardiac asthma")	Orthopnoea, PND, S3 gallop, elevated JVP
Pulmonary fibrosis	Dull (bases)	Increased	Bronchial ± reduced	Fine bilateral basal Velcro crackles	Clubbing, insidious onset dyspnoea
Asthma (acute)	Resonant	Normal	Prolonged expiration	Expiratory wheeze (may be absent in severe)	Pulsus paradoxus, accessory muscles
Lung collapse	Dull	Reduced/absent	Absent or reduced	None	Tracheal deviation towards, reduced expansion ipsilateral

Interactive Symptom-to-Pattern Matcher

Select 3 or more clinical signs to get a suggested diagnosis. This is a learning tool only.

Dull percussion Stony dull percussion Hyper-resonant Bronchial breathing Absent breath sounds Reduced breath sounds Wheeze Fine crackles Coarse crackles Pleural rub Stridor Increased fremitus Absent fremitus Tracheal deviation away Tracheal deviation towards Bilateral signs Clubbing

COPD & Asthma Nursing Management

COPD — Pathophysiology & Staging

Emphysema Component

Destruction of alveolar walls → loss of elastic recoil
Air-trapping, hyperinflation, barrel chest
Reduced gas exchange surface area
Type A "Pink Puffer" — dyspnoea dominant, thin, pursed-lip

Chronic Bronchitis Component

Productive cough ≥3 months/year for ≥2 consecutive years
Airway inflammation, goblet cell hyperplasia, mucus hypersecretion
Mucociliary dysfunction → recurrent infections
Type B "Blue Bloater" — hypercapnia, oedema, cyanosis, cough

GOLD Staging (post-bronchodilator spirometry)

Prerequisite: FEV₁/FVC <0.70 (fixed ratio confirming airflow obstruction)

GOLD Stage	FEV₁ % Predicted	Severity	Typical Symptoms
GOLD 1	≥80%	Mild	Chronic cough, may be asymptomatic
GOLD 2	50–79%	Moderate	Dyspnoea on exertion, exacerbations
GOLD 3	30–49%	Severe	Dyspnoea limiting daily activities
GOLD 4	<30%	Very Severe	Disabling dyspnoea, respiratory failure, cor pulmonale

COPD Acute Exacerbation Management

Oxygen Target: SpO₂ 88–92%

COPD patients may rely on hypoxic drive. High-flow O₂ can suppress ventilatory drive → hypercapnic respiratory failure. Use Venturi mask 24% or 28%. Titrate to SpO₂ 88–92%. If unsure, start at 28% and monitor ABGs at 30–60 min.

Controlled oxygen: Venturi 24–28%, target SpO₂ 88–92%. Monitor via pulse oximetry and ABG
Bronchodilators: Salbutamol 2.5–5 mg nebulised q20 min (back-to-back if severe) + Ipratropium 0.5 mg nebulised q6h. Drive nebuliser with AIR (not O₂) to avoid over-oxygenation — unless SpO₂ <88%
Corticosteroids: Prednisolone 30–40 mg oral once daily × 5 days (reduces exacerbation duration and treatment failure)
Antibiotics: Only if purulent sputum (green/yellow), increased volume, or CXR infiltrate. Amoxicillin, doxycycline, or clarithromycin as per local protocol
NIV (BiPAP): Consider if pH <7.35 and pCO₂ >6 kPa despite medical treatment. IPAP 10–20 cmH₂O, EPAP 4–5 cmH₂O. Reduces mortality and intubation rate
Monitor: ABG at 30–60 min after oxygen therapy change, 1 h after starting NIV. Repeat if clinical deterioration

Asthma — Severity Assessment & Management

Mild / Moderate

PEFR ≥50% best/predicted
SpO₂ ≥92%
RR <25/min
HR <110/min
Can speak in sentences

Acute Severe

PEFR 33–50% best/predicted
SpO₂ ≥92%
RR >25/min
HR >110/min
Cannot complete sentences

Life-Threatening

PEFR <33% best/predicted
SpO₂ <92%
Silent chest
Cyanosis
Exhaustion, confusion
Bradycardia or arrhythmia
Hypotension

Acute Asthma Management Steps

High-flow O₂: 15 L/min via non-rebreathe mask (target SpO₂ ≥94–98%)
Salbutamol 5 mg nebulised: Back-to-back every 15–20 min for severe/life-threatening. Driven by O₂
Ipratropium 0.5 mg nebulised: Add for severe/life-threatening q4–6h
Prednisolone 40–50 mg oral (or IV hydrocortisone 200 mg if cannot swallow)
Magnesium sulphate 2 g IV over 20 min for life-threatening asthma or not responding to above
IV aminophylline: Consider under senior guidance if no response. Loading dose 5 mg/kg over 20 min (omit if on oral theophylline), maintenance infusion 0.5 mg/kg/h
Heliox/ketamine/ICU: Discuss early with senior and anaesthesia for near-fatal asthma

Inhaler Technique — Pressurised MDI (6 Steps)

Shake inhaler well (10 times) and remove cap
Exhale completely away from inhaler
Place mouthpiece between teeth, seal lips (or attach spacer)
Begin slow, steady inhalation — press canister ONCE at beginning of breath
Continue inhaling slowly over 3–5 seconds until lungs full
Hold breath for 10 seconds, then exhale slowly. Wait 30–60 s before second dose

Spacer Use

A spacer device improves lower airway deposition by 2–4x. Essential for children, elderly, poor coordination. Activate inhaler once into spacer, then inhale slowly — avoid multiple actuations into spacer before inhaling.

Inhaled Medications by Class (GCC Context)

Class	Drug	Common GCC Brand Names	Device	Notes
SABA	Salbutamol	Ventolin, Asthalin	MDI, nebuliser	Reliever; PRN use; tachycardia, hypokalaemia at high doses
SAMA	Ipratropium	Atrovent	MDI, nebuliser	Reliever; used with SABA; dry mouth, urinary retention
LABA	Formoterol, Salmeterol	Foradil, Serevent	DPI, MDI	Never alone in asthma; always with ICS; 12-hour duration
LAMA	Tiotropium	Spiriva	HandiHaler, Respimat	COPD maintenance; once daily; significant benefit in exacerbation prevention
ICS	Beclometasone, Budesonide, Fluticasone	Becotide, Pulmicort, Flixotide	MDI, DPI	Rinse mouth after use (oral candidiasis). NOT for acute bronchodilation
ICS/LABA combo	Budesonide/Formoterol, Fluticasone/Salmeterol	Symbicort, Seretide	DPI, MDI	Maintenance and reliever therapy (Symbicort SMART in asthma)

Chest Physiotherapy & Sputum Clearance

Active Cycle of Breathing Technique (ACBT)

Evidence-based airway clearance technique — suitable for most patients with retained secretions.

Phase	Technique	Purpose
1. Breathing Control	Gentle, relaxed tidal breathing at own pace. Lower chest movement. 3–5 breaths.	Rest period; reduces bronchospasm
2. Thoracic Expansion Exercises (TEE)	Deep breath in — hold 3 s (autogenic PEEP effect) — passive exhalation. 3–5 repetitions.	Moves air behind secretions via collateral channels (pores of Kohn)
3. Forced Expiration Technique (FET / Huff)	1–2 huffs from mid-to-low lung volume (medium breath → forced open-glottis expiration). Return to breathing control.	Moves secretions from peripheral to central airways for expectoration

Huff vs Cough

Huffing (FET) is more effective than coughing for secretion clearance — it creates higher airflow with less dynamic airway collapse. Teach patients to say "ha" forcefully with an open mouth.

Postural Drainage Positions

Lung Segment	Position	Notes
Upper lobe — apical	Sitting upright, leaning back 30°	Percussion over clavicles/shoulders
Upper lobe — anterior	Flat on back	Percussion anterior chest, 2nd–3rd ICS
Upper lobe — posterior	Leaning forward 30°	Percussion upper back
Right middle lobe	Right side down, head tilted down 15°	Percussion right lateral chest, 4th–5th ICS
Lingula (left upper)	Left side down, head tilted down 15°	Percussion left lateral chest
Lower lobes — superior	Prone, pillow under abdomen	Percussion lower back midscapular
Lower lobes — basal	Prone/lateral, foot of bed elevated 20 cm (Trendelenburg)	Percussion lower lateral and posterior chest. Contraindicated post-op, GORD, ICP elevation

Postural Drainage Contraindications

Head-down positioning is contraindicated in: raised ICP, uncontrolled hypertension, severe GORD, haemodynamic instability, recent upper abdominal/thoracic surgery, severe dyspnoea in supine position.

Airway Clearance Devices

PEP Therapy (Positive Expiratory Pressure)

Flutter device: Steel ball creates oscillating PEP (6–20 Hz). Vibrations loosen secretions while PEP splints airways open
Aerobika (OPEP): Oscillating PEP with spacer option; compact and portable
Acapella: Magnetic valve, angle-independent (useful for patients unable to sit)
Technique: Breathe in to 3/4 of full capacity, exhale actively through device at moderate effort (not forced); 10–20 breaths per cycle

High-Frequency Chest Wall Oscillation (HFCWO)

Vest device (AffloVest, The Vest): Inflatable vest delivers rapid oscillations 5–25 Hz to chest wall — loosens secretions
Indications: Cystic fibrosis, bronchiectasis, neuromuscular disease with poor cough, spinal cord injury
Frequency: Typically 20–30 min, 2–4 × daily
Combine with bronchodilator nebulisation before therapy for maximum benefit

Suctioning Technique

Oropharyngeal / Nasopharyngeal Suctioning

Parameter	Adult	Paediatric
Catheter size (French)	12–16 Fr	6–10 Fr (neonates 5–6 Fr)
Suction pressure	<150 mmHg (100–120 mmHg preferred)	<100 mmHg
Duration per pass	<15 seconds	<10 seconds
Pre-oxygenation	100% O₂ × 30–60 s before and after	FiO₂ +10–20% above baseline
NP depth	Tip of nose to earlobe distance	Same anatomical measurement

Endotracheal Tube (ETT) Suctioning

Open circuit: Disconnect from ventilator, use single-use catheter. Requires brief disconnection — higher derecruitment risk
Closed circuit (in-line): Catheter within a sealed circuit — preferred for high FiO₂/PEEP-dependent patients, ARDS, COVID-19. Reduces exposure risk, maintains PEEP
Depth: Advance until resistance felt (carina contact), then withdraw 1 cm before applying suction
VAP bundle compliance: HOB 30–45°, oral chlorhexidine care, subglottic secretion drainage, cuff pressure 20–30 cmH₂O, daily sedation hold

Incentive Spirometry & Cough Effectiveness

Incentive Spirometry

Indication: Post-operative atelectasis prevention, rib fractures, neuromuscular weakness
Technique: Upright position. Exhale normally, seal lips around mouthpiece. Inhale slowly and deeply to raise the ball/disk indicator. Hold 5–10 seconds. Rest. Repeat 10 × per hour when awake
Volume targets: Adult predicted IC = ~2,500–3,500 mL. Aim for ≥70% predicted
Encourage early mobilisation alongside incentive spirometry for maximum effect

Cough Effectiveness

Peak Cough Flow (PCF): >160 L/min required for effective secretion clearance
<160 L/min = inadequate — high risk of secretion retention and pneumonia
<270 L/min = unable to manage respiratory illness independently (neuromuscular)
Cough Assist (MI-E): Mechanical insufflation-exsufflation device — applies positive pressure (insufflation) then rapidly switches to negative (exsufflation), simulating cough. Settings: +30 to +50 cmH₂O insufflation, −30 to −50 cmH₂O exsufflation
Manual assisted cough: Abdominal thrust (quad-assist cough) coordinated with patient's cough effort

Sound	Key Feature
Vesicular	Normal, soft, insp > exp
Bronchial	Harsh, exp > insp, gap — consolidation
Wheeze	Musical, mainly expiratory — obstruction
Fine crackles	Late insp, Velcro — fibrosis/oedema
Coarse crackles	Early insp, clears with cough — secretions
Pleural rub	Leathery, both phases, no change with cough
Stridor	Inspiratory, high-pitched — UPPER airway

Patient Group	O₂ Target SpO₂	Delivery Device
COPD known hypercapnia risk	88–92%	Venturi 24–28%
COPD — no hypercapnia	94–98%	Nasal cannula 2–4 L/min
Asthma	94–98%	High-flow NRB if severe; nasal cannula if stable
Pneumonia (no COPD)	94–98%	Nasal cannula / simple face mask
Critical illness / arrest	As high as possible	15 L/min NRB