Respiratory Assessment

Respiratory conditions can affect breathing by damaging the lungs or causing mucus accumulation. To ensure appropriate treatment, it is essential to perform a comprehensive respiratory assessment that includes both subjective and objective evaluation. This approach provides a holistic understanding of the patient’s baseline function and condition[1][2].

A thorough respiratory assessment not only offers insight into the severity of the disease but also identifies factors that may influence the patient’s ability to breathe effectively. This is especially crucial in physiotherapy for developing individualized treatment plans that promote optimal lung function and quality of life.

Subjective Assessment

The subjective assessment allows patients to express their symptoms in their own words. It helps the clinician tailor the objective evaluation and treatment plan according to individual needs [3][4].

Patient’s Main Concerns

• Identify the patient’s chief complaints and how these affect daily activities.

• Explore the patient’s expectations and goals for therapy.

History of Present Illness (SITAR Method)

Use the SITAR framework for a structured clinical exploration:

S – Site:Where are the symptoms located? Is there any radiation of pain or discomfort?

I – Intensity:How severe are the symptoms? (Rate 1 – 10)

T – Type:What type of discomfort does the patient describe (e.g., pressure, burning, stabbing)?

A – Aggravating Factors:Which actions or postures worsen the symptoms (e.g., physical activity, lying flat)?

R – Relieving Factors:What reduces the symptoms (e.g., rest, upright position, medication)?

Additional Aspects

Onset: Did symptoms appear suddenly or develop gradually?

Duration: How long have the symptoms persisted? Are there daily or seasonal fluctuations?

Character: Describe the quality and severity of the symptoms.

Current Status: Is the condition improving, stable, or worsening?

Impact on ADL: How do the symptoms affect activities of daily living (e.g., dressing, walking, hygiene)?

Previous Episodes: Has the patient experienced similar episodes in the past?

Previous Treatment: Which treatments or medications have been tried, and what was their effect?

Past Medical History

• Previous respiratory, nasal, or throat conditions

• Hospital admissions for pulmonary disease

• Use of ventilatory support or breathing devices

• Known respiratory diagnoses: asthma, bronchiectasis, COPD, tuberculosis, bronchitis, emphysema

• Other chronic illnesses: heart disease, cancer, thromboembolic disorders

• Allergies and vaccination status (e.g., pneumococcal or influenza)

• Comorbidities: diabetes mellitus, hypertension, tuberculosis

Surgical History

List any previous thoracic or respiratory surgeries, such as:

• Endoscopy

• Tracheostomy

• Lobectomy

Personal and Social History

Sleep: Assess quality and sleep pattern. Poor sleep may indicate nocturnal dyspnea or orthopnea.

Appetite and Weight Loss: Evaluate recent changes that may suggest systemic illness.

Bowel and Bladder Function: Note any relevant changes that may reflect systemic involvement.

Smoking History: Include quantity (pack-years) and duration.

Exercise Tolerance: How far can the patient walk before symptoms arise? Has physical activity decreased?

Home Environment: Check for exposure to dust, humidity, mold, or poor ventilation.

Financial Situation: Determine ability to obtain medications or attend therapy.

Social Support: Evaluate the availability of family or community assistance.

Cardinal Respiratory Symptom – Cough

Onset

Sudden: May indicate acute irritation, infection, or allergen exposure.

Gradual: Often suggests chronic disorders such as asthma, COPD, or tuberculosis [5].

Duration

Acute (< 3 weeks): Typically caused by the common cold, influenza, or acute bronchitis [6].

Persistent (> 3 weeks): Requires further evaluation for post-viral cough or gastro-oesophageal reflux.

Chronic (> 8 weeks): Associated with asthma, COPD, or chronic sinusitis [7].

Nature of Cough

Dry / Non-productive: May indicate early infection, allergy, or airway irritation.

Wet / Productive: Suggests infection or excessive mucus production in the airways.

Type of Sputum

Mucoid: Clear or whitish — commonly seen in asthma or early bronchitis.

Mucopurulent: Yellow or green — suggests bacterial infection or tuberculosis (TB).

Frothy: White and bubbly — often linked with pulmonary edema.

Rust-colored: Blood-tinged — seen in lobar pneumonia or tuberculosis.

Odor

Foul-smelling: Indicates anaerobic infection, such as lung abscess or bronchiectasis.

Productivity

Assess whether the patient can effectively expectorate mucus, as this is key to evaluating airway clearance.

Sputum

Mengde

• Normal: Rundt 100 ml trakeobronkiale sekreter produseres daglig og fjernes ubevisst.

• Økt: Kan indikere infeksjoner, kroniske luftveissykdommer eller pulmonale tilstander.

Sputum Color and Possible Causes

Color	Possible Cause
Blood-streaked	Inflammation of the larynx, trachea, or bronchi; lung cancer; ulceration.
Pink	Blood originating from alveoli and small peripheral bronchi.
Large amounts of blood	Cavitary tuberculosis (TB), lung abscess, bronchiectasis, pulmonary infarction, pulmonary embolism.
Green or greenish	Possible infection.
Rust-colored	Pneumococcal bacteria, pulmonary tuberculosis.
Brownish	Chronic bronchitis (greenish/yellowish/brown) or chronic pneumonia (white-brown).
Yellow purulent	Presence of pus – often due to Haemophilus infection.
Yellow-green (mucopurulent)	Bronchiectasis, cystic fibrosis, pneumonia.
Whitish-gray	Chronic allergic bronchitis.
White, milky, or opaque (mucoid)	Viral infection or allergy (e.g., asthma).
White frothy	Early phase of pulmonary edema.
Pink frothy	Severe pulmonary edema.
Black or black spots	Smoke inhalation (fires, tobacco, heroin), coal dust exposure.

Dyspnea (Shortness of Breath)

Shortness of breath should always be interpreted in relation to the patient’s functional capacity to assess the severity of the condition.

Key Aspects to Evaluate

• Exercise tolerance: How many stairs can the patient climb, or how far can they walk before dyspnea occurs?

• Dyspnea at rest: May suggest serious conditions such as pulmonary fibrosis or fluid accumulation.

• Paroxysmal nocturnal dyspnea (PND): Breathlessness awakening the patient at night may indicate heart failure.

• Ankle swelling or recent weight gain: May signal fluid retention, often associated with heart failure.

Activity-related Onset

• Sudden onset: Pneumothorax, pulmonary embolism, or deep vein thrombosis (DVT).

• Constant dyspnea: Pulmonary fibrosis or pleural effusion.

Dyspnea Grading Scales

New York Heart Association (NYHA)

Grade	Description
I	No symptoms and no limitation in ordinary physical activity.
II	Mild symptoms such as angina and slight limitation in daily activities.
III	Marked limitation of activity due to symptoms, even with minimal exertion.
IV	Severe limitation; symptoms present even at rest, often bedridden.

Modified Medical Research Council (MMRC) Scale

Grade	Description
0	No dyspnea except with strenuous exercise.
1	Dyspnea when walking uphill or quickly on level ground.
2	Walks slower than peers or stops after about 15 min on level ground.
3	Stops after a few minutes of walking on level ground.
4	Dyspnea with minimal activity (e.g., dressing) or too breathless to leave the house.

American Thoracic Society (ATS) Dyspnea Scale

Grade	Description
0	No breathlessness, even on hills or stairs.
1	Mild dyspnea on flat ground or gentle slope.
2	Moderate; walks slower than others of the same age.
3	Severe; stops after walking ~100 m.
4	Very severe; experiences marked breathlessness even at rest.

Modified Borg Dyspnea Scale

Score	Perceived Breathlessness
0	No difficulty at all
0.5	Very, very slight (barely noticeable)
1	Very slight
2	Slight
3	Moderate
4	Somewhat severe
5	Severe
7	Very severe
9	Very, very severe (almost maximal)
10	Maximal

Chest Pain

Chest pain in respiratory patients often originates from the musculoskeletal system, pleura, or tracheal inflammation, since the lung parenchyma and small airways contain no pain fibers.

Common Causes of Chest Pain

• Pleuritic pain: Caused by inflammation of the pleura.

• Tracheitis: Inflammation of the trachea.

• Musculoskeletal pain: Due to strain on the chest wall.

• Angina pectoris: Reduced blood flow to the myocardium.

• Pericarditis: Inflammation of the pericardial sac.

Pain Relief Techniques

• Application of heat therapy

• Splinting (supporting the chest wall during coughing)

• Analgesic medication as indicated

Incontinence

Coughing and huffing increase intra-abdominal pressure, which may cause urine leakage, especially in patients with pre-existing pelvic floor weakness.

Other Associated Symptoms

Fever (Pyrexia)

Indicates possible infection or inflammation within the body.

Headache

Morning headache may suggest CO₂ retention during sleep, often linked to poor ventilation or obstructive sleep disorders.

Peripheral Edema

Swelling of extremities, commonly associated with right-sided heart failure.

Chills

May indicate systemic infection or inflammatory response.

Weight Loss

Often related to chronic disease, malignancy, or severe respiratory disorders.

Palpitations

May reflect oxygen deficiency, stress, or underlying cardiac pathology.

Nausea and Vomiting

Possible indicators of systemic involvement or medication side effects.

Gastroesophageal Reflux Disease (GERD)

Can exacerbate respiratory symptoms such as cough or dyspnea.

Objective Examination

When the subjective assessment is complete, it guides what to examine during the objective assessment. A thorough, detailed objective exam is essential to design an individually tailored treatment plan focused on the client’s specific presentation and needs.

General Observations

• General condition: Overall health and appearance.

• Breathing pattern: Signs of labored breathing, use of accessory muscles, or asymmetry of chest movement.

• Skin status: Cyanosis, pallor, rashes, or scars.

• Positioning: Positions that relieve breathlessness (e.g., sitting forward‐leaning).

Focused Observations

Chest Wall

• Shape and symmetry.

• Intercostal or epigastric retractions.

Breath Sounds

• Auscultation: Crackles, wheezes, or diminished/absent breath sounds.

Percussion

• Hyperresonance (air), dullness (fluid/consolidation), or normal resonance.

Heart Rate & Rhythm

• Tachycardia, bradycardia, or arrhythmias.

SpO₂ Levels

• Pulse oximetry to assess oxygen saturation.

Functional Tests

• Walking test (e.g., 6-Minute Walk Test): Endurance and functional capacity.

• Cough effectiveness: Ability to clear secretions.

• Dyspnea scales: Borg scale for perceived breathlessness.

Palpation

• Thoracic expansion: Symmetry of chest wall movement during inspiration.

• Muscle tone/tenderness: Restrictions affecting breathing mechanics.

Clinical Tests

1. Spirometry: FEV₁, FVC (obstructive vs. restrictive patterns).

2. Peak Flow Meter: Peak expiratory flow (often for asthma monitoring).

General Examination

Vital Signs

• Temperature: Detect fever, hypothermia, or metabolic disturbance.

• Pulse: Rate, rhythm, volume, symmetry (tachycardia, bradycardia, arrhythmias).

• Respiratory rate: Normal 12–16 breaths/min; note tachypnea, bradypnea, hyperventilation.

• Blood pressure: Systolic/diastolic for hypotension, hypertension, circulatory failure.

• Oxygen saturation (SpO₂): Hypoxemia vs. adequate oxygenation.

General Appearance

1. Body weight/BMI: Nutritional status and body mass.

2. Height: For BMI and reference equations (e.g., predicted spirometry).

3. Nails: Clubbing (chronic lung/heart disease).

4. Eyes:

   • Pallor (anemia)

   • Plethora (elevated hemoglobin)

   • Icterus (jaundice—hepatic/hematologic disorders)

5. Mouth & tongue: Central cyanosis (hypoxemia/circulatory failure).

6. Jugular venous pressure (JVP): Elevated in right-sided heart failure, chronic lung disease, or dehydration.

7. Peripheral edema: Low albumin, venous insufficiency, lymphatic dysfunction, or steroid effect.

8. Pressure sores: Especially in bedbound patients—reflect circulatory/nutritional status.

Chest Inspection

1. Shape & Structure

   • Transverse diameter > AP diameter: Normal.

   • Kyphosis: May indicate restrictive lung disease.

   • Kyphoscoliosis: Restrictive ventilatory impairment.

   • Pectus carinatum: “Pigeon chest.”

   • Barrel chest (hyperinflation): AP ≈ transverse; often with horizontal ribs.

   
   

   Breathing Pattern

   Normal rhythm

   • I:E ratio: ~1:1.5 to 1:2.

   Abnormal patterns

   • Bradypnea: Low rate.

   • Tachypnea: High rate.

   • Hyperventilation: Increased rate and depth.

   • Prolonged expiration: I:E ≈ 1:3 to 1:4.

   • Pursed-lip breathing: Suggests obstructive disease.

   • Kussmaul respirations: Metabolic acidosis.

   • Cheyne–Stokes: Drugs, heart failure, or neurological causes.

   • Ataxic breathing: Cerebellar dysfunction.

   • Apneustic breathing: Brain injury.

Critical Care Patients

1. Ventilation mode: e.g., supplemental O₂, intermittent positive pressure ventilation.

2. Ventilation route: Face mask, nasal cannula, endotracheal tube, tracheostomy.

3. Level of consciousness: Glasgow Coma Scale (GCS).

4. Central venous pressure (CVP) & pulmonary artery pressure (PAP): Fluid status and cardio-pulmonary function.

Diagnostic Investigations

Diagnostic testing is essential to identify and evaluate respiratory disorders and to guide optimal treatment strategies.

1) Spirometry

Simple test of ventilatory capacity. Key indices:

• FEV₁: Forced expiratory volume in 1 second.

• FVC: Forced vital capacity.

• PEFR: Peak expiratory flow rate.

Indications: Diagnose/monitor asthma, COPD, and restrictive lung disease. Compare to predicted normals (age, sex, height, ethnicity).

2) Arterial Blood Gases (ABG)

Accurate assessment of oxygen uptake (O₂) and CO₂ elimination; acid–base status.

Parameter	Normal Range
pH	7.35–7.45
PaO₂	10.7–13.3 kPa (80–100 mmHg)
PaCO₂	4.7–6.0 kPa (35–45 mmHg)
HCO₃⁻	22–26 mmol/L
Base Excess (BE)	−2 to +2

Indications: Evaluate oxygenation and ventilation in respiratory/metabolic acidosis/alkalosis and mixed disorders.er som respiratorisk acidose, metabolsk alkalose, og andre syre-base-forstyrrelser.

3) Chest X-ray (CXR)

Early imaging for suspected respiratory disease; visualizes lungs, heart, and adjacent structures.

Diagnostic uses:

• Pneumonia: Infiltrates.

• Emphysema: Hyperinflation, flattened diaphragms.

• Mass/nodules: Tumors or solitary/multiple nodules.

• Pleural effusion: Fluid accumulation.

• Rib fractures: Fracture lines.

• Tuberculosis: Cavities or infiltrates.

• Heart failure: Cardiomegaly, pulmonary congestion.

Clinical Significance

Combining spirometry, ABG, and CXR provides complementary insights into ventilatory function, gas exchange, and structural pathology—supporting diagnosis, monitoring, and targeted intervention planning.

Sources:

1. Mikelsons, C. (2008). The role of physiotherapy in the management of COPD. Respiratory Medicine: COPD Update, 4(1), 2–7 Available at https://www.semanticscholar.org/paper/The-role-of-physiotherapy-in-the-management-of-COPD-Mikelsons/e333d7621a7fddb06be0ff219e2336c352fe335c

2.  Cross J, Harden B, Broad MA, Quint M, Paul Ritson MC, Thomas S. Respiratory physiotherapy: An on-call survival guide. Elsevier Health Sciences; 2008 Nov 25.

3.  Hough A. Physiotherapy in respiratory care: a problem-solving approach to respiratory and cardiac management. Springer; 2013 Nov 11.

4.  Main E, Denehy L. Cardiorespiratory Physiotherapy: Adults and Paediatrics 5th Edition. Elsevier; 2016 Jul 5.

5. Raj, A. A., & Birring, S. S. (2007). Clinical assessment of chronic cough severity. Pulmonary Pharmacology & Therapeutics, 20(4), 334–337.

6.  NHS Cough Available at:https://www.nhs.uk/conditions/cough/ (Accessed 22nd November 2020)

7. Mayo Clinic. Chronic Cough. Available athttps://www.mayoclinic.org/diseases-conditions/chronic-cough/symptoms-causes/syc-20351575 (Accessed 22nd November 2020)

8. Heart Online. Rating of perceived exertion: Borg scales. Available at: https://www.sralab.org/sites/default/files/2018-04/Rating_of_perceived_exertion_-_Borg_scale.pdf (Accessed 22nd November 2020)

9. Miller MR, Hankinson J, Brusasco V et al (2005) Standardisation of spirometry. Eur Respir J 26(2):319–338