As a respiratory therapist, you will evaluate, treat and care for patients with lung and chest conditions. Students of respiratory medicine may understandably believe that the most important part of the evaluation is listening to the patient's breath sounds, but auscultation alone is not enough.
In addition to auscultation, a thorough understanding of the chest evaluation will help identify and diagnose specific problems. This examination should be performed systematically, beginning with visualization (what you can see with your eyes alone), followed by palpation and percussion (what you can feel when you touch the patient).
To perform a thorough examination of the chest, it is best if the room is well lit and, if possible, the patient should sit up straight with legs positioned to the side of the bed so that the anterior and posterior chests can be viewed. Of course, this is not always possible. In this case, it is sufficient to have the patient lying in bed in an elevated position.
The examination begins with entering the patient's room and greeting him/her, and continues throughout the visit. The first thing to look for is any sign of respiratory distress or exacerbation. This may be evident in the patient's position, such as when the patient is in a "tripod position" or bending over to breathe more easily. You may notice contractions, spaces between the ribs and in the neck area that seem to be drawn in when the patient inhales, or puckered lips when the patient tries to control breathing. If the patient appears to be in pain, it is best to address acute problems before proceeding with the evaluation.
RT should examine the shape and appearance of the chest. First note the AP diameter. an increase in AP diameter (the distance between the anterior and posterior chest) will tell the RT that the patient may have COPD. loss of pulmonary elasticity and chronic hyperinflation, which are diagnostic markers, will result in an increase in AP diameter or what we call a "barrel chest". Also of shape and appearance is a sternal deformity, such as a funnel chest that looks "sunken" in the chest or a pectoral chest that looks "inflated". Is there a visible mass in the neck or chest? Does the patient have a chest tube? Is there a significant abnormal curvature of the spine? Any of these findings may lead to respiratory distress.
When interviewing a patient, it is important to quietly observe the condition of his skin. Cyanosis of the skin is a clue that the patient's blood is lacking sufficient oxygen, while sunken edema of the extremities may point in the direction of heart failure. Erythema, a potentially itchy and painful rash on the skin, may be an alert that the patient has a viral or bacterial infection. A patient's skin can give us a lot of information about what is happening in the chest cavity.
Talking with the patient also helps the RT assess the patient's level of consciousness as well as breathing patterns and frequency. Does the patient get short of breath from answering questions? Is the patient behaving appropriately? Does it appear that the patient is performing self-care, such as grooming? Using only observation and examination, the RT can learn a lot before proceeding.
Palpation is the next step in the advanced chest assessment. Palpate the trachea first, making sure it is in the midline. Any deviation from the midline is indicative of a disease process in the chest. Abnormal chest pressure due to a large pleural effusion or pneumothorax can cause the trachea to shift. On continued palpation, the RT may feel a subcutaneous emphysema, which occurs when air is trapped under the skin and feels somewhat "rice crispy" to the touch. Subcutaneous emphysema is usually caused by a tear of some kind in the lung tissue.
Palpation is an important skill to assess the patient's breathing symmetry and volume. Placing the hands in a butterfly shape on the back chest wall and moving them toward the base of the rib cage as the patient is asked to breathe deeply allows the respiratory therapist to see if the lungs are equally expanded and symmetrical bilaterally. Palpation also allows the patient to feel the vibrations transmitted through the chest cavity when breathing and speaking. Detecting changes in the vibrations felt under the respiratory therapist's hand (called fremitus) and depending on how much they increase or decrease can determine whether there is solidity or air trapping in the chest cavity and aid in the diagnosis of lung disease.
After palpation is complete, the next step is to percuss the patient. Percussion produces an audible sound that can be interpreted as separating fluid, air, or substantial material in the chest cavity. It is performed by placing the distal portion of the middle finger firmly on the area of the chest being evaluated and then tapping the fingernail with the fingers of the other hand. The respiratory therapist can determine the condition of the chest cavity by comparing the sounds heard on each side (e.g., air produces a sound similar to a drum, fluid produces a low sound, and lung solids produce a dull sound).
A complete chest evaluation will be done by listening to the patient's breath sounds and comparing what you hear to what you previously found. With these findings, the RT will be able to identify the patient's progress and/or provide additions or changes to the patient's treatment plan.