Examination of the Chest for Respiratory Therapists

Pectus carinatum and excavatum
As a Respiratory Therapist you will be assessing, treating, and caring for patients with disorders of the lungs and thorax. It is understandable that a respiratory student might believe that the most important part of assessment is listening to the patient’s breath sounds, but, auscultation alone is not enough. 
 
A thorough understanding of chest assessment aside from auscultation will help to determine and diagnose specific problems.  This examination should be performed systematically starting with inspection (what you can see just using your eyes) followed by palpation and percussion (what you can feel when touching the patient).
To perform a complete examination of the chest it is best  if the room is well lit, and if possible the patient should be sitting upright with legs swung to the side of the bed so both the anterior and posterior chest can be observed.  Of course this is not always possible.  In this case, it will suffice to have the patient in bed in the high fowler’s position.
Inspection begins from the moment you enter a patient’s room to greet them, and continues throughout the entire visit.  The very first thing to look for is signs of an increased work of breathing or respiratory distress.  This might be noticeable in patient positioning if the patient is tripodding or hunching over in order to breathe easier.  You may notice retractions, where the spaces between the ribs and in the area of the neck seem to get sucked in as the patient is inhaling, or,  pursed lip breathing as the patient tries to control their breathing.  If the patient appears to be distressed it is best to resolve the acute issue before continuing an assessment.
RTs should inspect the chest for shape and appearance.  First taking note of the AP diameter.  An increase in AP diameter (the distance between the anterior chest and the posterior chest) will tell the RT that the patient likely  has COPD.  The loss of lung elasticity and chronic hyperinflation that are hallmarks of the diagnosis will lead to increased AP diameter or what we call “barrel chest”.  Also falling under shape and appearance would be deformities of the sternum such as Pectus Excavatum in which the chest looks “caved in” or Pectus Carinatum in which the chest looks “puffed out”. Are there any masses visible on the neck or chest?  Does the patient have a chest tube in place?  Is there an abnormal spinal curvature that is obvious? Any one of these findings can lead to breathing trouble. 
While interviewing the patient it is important to quietly observe the condition of his skin.  Cyanotic skin is a clue that the patient’s blood is deprived of adequate oxygen while pitting edema of the limbs may point in the direction of heart failure. Erythema, a rash on the skin that can be itchy and painful might be an alert that a patient has a viral or bacterial infection.  A patient’s skin can give us a lot of information about what is happening in the thorax. 

Chatting with the patient will also help the RT to assess the patient’s level of consciousness and respiratory pattern and rate.  Does the patient become short of breath just because they are answering questions?  Does the patient behave appropriately? Does it seem as though the patient is engaged in self care such as grooming?  Using only observation and inspection an RT can learn quite a bit before moving on.

Palpation is the next step in an advanced assessment of the chest.  Firstly palpating the trachea to ensure that its position is midline.  Any deviation from midline is suggestive of a disease process in the thorax. Abnormal pressures in the chest cavity from large pleural effusions or pneumothorax can cause a tracheal shift. Continuing with palpation an RT can feel for subcutaneous emphysema which happens when air gets trapped under the skin and feels a bit like “rice crispies” to the touch.  Subcutaneous emphysema is usually caused by some sort of tear in the lung tissue.

Palpation is an important skill in assessing the symmetry and volume of a patient’s breath.  Placing hands in a butterfly pattern on the posterior chest wall and moving near the base of the rib cage while asking the patient to take a deep and forceful breath will show the RT if the lung expansion is equal and bilateral.  Palpation is also performed to get a sense of the vibrations transmitted through the thorax while the patient is breathing and speaking.  Changes in vibrations felt beneath the palms of the examining RT, known as fremitus are noted as increased or decreased and can help determine the presence of consolidations or trapped air in the thorax.

After palpation is completed the next step is to percuss the patient.  Percussion produces audible sounds which can be interpreted to separate fluid, air, or solid material in the chest cavity.  It is performed by placing the distal portion of the middle finger firmly against the area of the chest being evaluated and then striking the fingernail with a finger from the other hand.  One side of the chest can then be compared to the other as the RT listens for areas of air (sounding like a drum), areas of fluid (producing a dull sound) and areas of more solid consolidation (producing a flat sound). 

A complete chest assessment would be finalized by listening to the patient’s breath sounds and comparing what you are hearing to what was found previously.  Armed with the findings an RT will be able to discern the patient’s progress and/or offer additions or changes to the patient’s treatment plan.

References

Butler, T. J. (2013). Laboratory exercises for competency in respiratory care. Philadelphia, PA, PA: F.A. Davis. 

Trayes KP, Studdiford JS, Pickle S, Tully AS. Edema: diagnosis and management. Am Fam Physician. 2013 Jul 15;88(2):102-10. PMID: 23939641.

Lim, S. J., Kim, J. Y., Lee, S. J., Lee, G. D., Cho, Y. J., Jeong, Y. Y., Jeon, K. N., Lee, J. D., Kim, J. R., & Kim, H. C. (2018). Altered Thoracic Cage Dimensions in Patients with Chronic Obstructive Pulmonary Disease. Tuberculosis and respiratory diseases, 81(2), 123–131. https://doi.org/10.4046/trd.2017.0095

About Anne Wandycz BS, RRT-NPS-ACCS 4 Articles
Anne is a staff Respiratory Therapist at Children's Specialized Hospital, Toms River, NJ as well as an adjunct instructor in the Respiratory Care program at Brookdale Community College, Lincroft, NJ.