With the patient sitting, examine the patient's anterior and posterior chest. Chest inspection allows you to see visible external signs of respiratory function. Assess the front, back, and sides of the chest for any scars, wounds, or lesions. Look for symmetry of chest wall movement. Observe the duration of the inspiratory/expiratory cycle. Prolonged expiration occurs when an individual has difficulty expelling air, as is often seen in patients with emphysema. Note the patient's respiratory pattern and breathing rhythm. In a healthy adult, inaudible respirations should occur between 12 and 20 times each minute. Look to see if the patient uses accessory muscles of respiration. Observe for intercostal retractions, nasal flaring, or pursed lip breathing, all of which indicate airflow obstruction and poor ventilation. Intercostal retractions are visible indentations between the ribs as the intercostal muscles aid in breathing. Nasal flaring describes intermittent outward movements of the nostrils with each inspiration. Pursed lip breathing refers to partial closure of the lips to allow air to be expired slowly.

Inspect the neck for contraction of the sternocleidomastoid or other accessory muscles of respiration during inspiration.  Normally, none of these signs are present. Look at the patient's posture. A patient with chronic obstructive pulmonary disease (COPD) will lean forward and prop himself up with his arms to improve breathing. Postural changes may also be seen with thoracic deformities such as scoliosis and kyphosis. Observe the patient's level of consciousness. Confusion or changes in mental status are important signs of potential respiratory problems.

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Intercostal retractions, nasal flaring, and pursed lip breathing indicate airflow obstruction and poor ventilation.

Note the patient's age and it's impact on respiratory function. As people age, their capacity for exercise decreases. The chest wall becomes stiffer and harder to move, respiratory muscles may weaken, and the lungs lose some of their elastic recoil. The speed of breathing out with maximal effort gradually decreases. Skeletal changes associated with aging may accentuate the dorsal curve of the thoracic spine, producing kyphosis and increasing the anterior-posterior diameter of the chest.

In any health care setting, you can use some practical ways of assessing concerns about shortness of breath in a patient who can ambulate. One simple and useful assessment method is to walk with the patient down a hallway or from one room to another or ask the patient to perform an activity such as climbing stairs. By observing the patient doing these activities, you can observe changes in the rate, effort, and sounds of the patient's respiratory pattern. Assessing forced expiratory time is another practical means of observing respiratory function, especially in a patient who may have COPD. Ask the patient to take a deep breath in and then to breathe out as quickly and completely as possible, with the mouth open. While the patient is doing a forced expiration, listen over the trachea and time the audible expiration. A forced expiratory time of over 6 seconds suggests obstructive pulmonary disease.

Normal findings for chest inspection include:

Infants and children have faster respiratory rates than adults. A normal respiratory rate for a newborn ranges from 30 to 60 breaths per minute. By one year of age, the respiratory rate drops to between 20 and 40 per minute. The respiratory rate continues to drop as a
child ages. By approximately age 16, a teenager has a respiratory rate similar to that of an adult.

Rapid, shallow breathing is called tachypnea. Tachypnea is seen in patients with restrictive lung disease such as kyphosis, and in situations where pleuritic chest pain prohibits full expansion of the chest wall. Restrictive lung disease refers to changes in the chest structure that prohibit full chest expansion. Rapid deep breathing, known as hyperpnea or hyperventilation, occurs as a result of physical exercise, anxiety, and metabolic acidosis. Kussmal breathing, characterized by slow, deep breaths, occurs in patients with diabetic acidosis and coma. Bradypnea, or a much slower than normal respiratory rate, is seen in patients with drug-induced respiratory depression, and increased intracranial pressure. Cheyne-Stokes breathing occurs when there are periods of deep breathing alternating with periods of apnea. A Cheyne-Stokes breathing pattern may be seen in a patient with heart failure, drug-induced respiratory depression, uremia, or brain damage. Ataxic breathing, also known as Biot's breathing, is characterized by unpredictable irregularity. Biot's breathing may be seen in patients with respiratory depression and brain damage at the level of the medulla.

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A rapid respiratory rate or tachypnea may be seen in patients with restrictive lung disease or in patients with pleuritic chest pain.

The Online version of Clinical Methods, 3rd edition The History, Physical, and Laboratory Examinations
is a comprehensive resource for examining each body system as well as an understanding of the underlying basic science and the clinical implications of abnormal data.

Please review Chapter 11Dyspnea, Orthopnea, and Paroxysmal Nocturnal Dyspnea