Key Takeaways
- A thorough patient interview includes chief complaint, history of present illness (HPI), past medical history, medications, allergies, and social history
- Auscultation of the chest should be systematic: compare left to right, starting at the apices and moving to the bases
- Normal breath sounds include vesicular (over peripheral lung fields), bronchovesicular (over mainstem bronchi), and bronchial (over the trachea)
- Adventitious (abnormal) breath sounds include crackles (rales), wheezes, rhonchi, stridor, and pleural friction rub
- Inspection findings include respiratory rate, pattern, use of accessory muscles, chest symmetry, cyanosis, and clubbing
- Palpation assesses tactile fremitus, chest expansion symmetry, subcutaneous emphysema, and tracheal position
- Percussion reveals resonance (normal), hyperresonance (air trapping/pneumothorax), or dullness (consolidation/effusion)
- Heart sounds S1 and S2 are normal; S3 may indicate heart failure and S4 may indicate ventricular hypertrophy
Patient History & Physical Assessment
The foundation of respiratory care is accurate patient assessment. Before ordering tests or initiating treatment, the respiratory therapist must gather a comprehensive patient history and perform a focused physical examination. The TMC exam frequently tests your ability to interpret physical findings and link them to underlying conditions.
Patient Interview Components
A structured patient interview follows the SAMPLE framework:
| Component | Questions to Ask |
|---|---|
| S — Signs/Symptoms | What brings you in today? When did it start? How severe? |
| A — Allergies | Drug allergies, latex, environmental allergens |
| M — Medications | Current prescriptions, OTC drugs, inhalers, home O2 |
| P — Past Medical History | COPD, asthma, CHF, pneumonia, surgeries, intubation history |
| L — Last Oral Intake | When did you last eat or drink? (Important pre-procedure) |
| E — Events Leading Up | What were you doing when symptoms started? Any recent illness? |
Inspection Findings
Visual assessment provides critical initial data:
- Respiratory rate: Normal adult 12-20 breaths/min; tachypnea >20, bradypnea <12
- Breathing pattern: Regular vs. irregular; Cheyne-Stokes, Kussmaul, Biot's respirations
- Accessory muscle use: Sternocleidomastoid, scalene, intercostal retraction indicates distress
- Chest shape: Barrel chest (COPD), pectus excavatum, pectus carinatum, kyphoscoliosis
- Skin color: Cyanosis (central vs. peripheral), pallor, diaphoresis
- Digital clubbing: Chronic hypoxemia indicator (COPD, bronchiectasis, lung cancer, CF)
- Jugular venous distension (JVD): Right heart failure, tension pneumothorax, cardiac tamponade
- Pedal edema: Cor pulmonale, right or biventricular heart failure
Auscultation of Breath Sounds
Breath sound assessment is one of the most frequently tested topics on the TMC exam. Listen systematically, comparing side to side.
Normal Breath Sounds:
| Sound | Location | Characteristics |
|---|---|---|
| Vesicular | Peripheral lung fields | Soft, low-pitched, heard throughout inspiration with short expiration |
| Bronchovesicular | Over mainstem bronchi (between scapulae) | Medium pitch, equal I:E ratio |
| Bronchial (Tubular) | Over the trachea | Loud, high-pitched, longer expiratory phase |
Adventitious (Abnormal) Breath Sounds:
| Sound | Description | Common Causes |
|---|---|---|
| Crackles (Rales) | Fine or coarse popping/bubbling sounds | Pulmonary edema, pneumonia, atelectasis, fibrosis |
| Wheezes | High-pitched, musical, predominantly expiratory | Asthma, COPD, bronchospasm |
| Rhonchi | Low-pitched, rumbling, often clears with cough | Secretions in large airways, bronchitis |
| Stridor | High-pitched, primarily inspiratory | Upper airway obstruction, croup, epiglottitis, post-extubation |
| Pleural Friction Rub | Grating, creaking sound with both I and E | Pleuritis, pulmonary embolism |
| Diminished/Absent | Reduced or no sounds heard | Pneumothorax, pleural effusion, severe COPD, obesity |
Palpation and Percussion
Palpation findings:
- Tactile fremitus: Increased with consolidation (pneumonia), decreased with pneumothorax or pleural effusion
- Tracheal deviation: Away from a tension pneumothorax, toward atelectasis or pneumonectomy
- Subcutaneous emphysema: Crepitus under the skin indicates air leak (pneumothorax, barotrauma)
- Chest expansion: Asymmetric expansion suggests unilateral pathology
Percussion findings:
- Resonant: Normal lung tissue
- Hyperresonant: Pneumothorax, emphysema (air trapping)
- Dull: Consolidation (pneumonia), pleural effusion, atelectasis
- Flat: Large pleural effusion, massive atelectasis
A respiratory therapist auscultates fine, popping sounds at the lung bases that do not clear with coughing. These sounds are MOST consistent with:
A patient with suspected pneumothorax would MOST likely demonstrate which percussion finding over the affected side?
Which of the following are causes of INCREASED tactile fremitus? (Select all that apply)
Select all that apply
A high-pitched, inspiratory sound heard over the neck is MOST consistent with:
Match each abnormal breath sound to its most common clinical cause.
Match each item on the left with the correct item on the right