5. Detecting of respiratory expansion

I. INSPECTION

1. Expose patient adequately – ensure upper body is uncovered.

2. Observe from front and back.
3. Respiratory Pattern:

• Rate, rhythm, depth of breathing
• Use of accessory muscles (neck, intercostals, abdominal)

4. Chest Shape:

• Normal: symmetrical, anteroposterior < transverse
• Abnormal:
• Barrel chest – emphysema/COPD
• Pigeon chest – pectus carinatum
• Funnel chest – pectus excavatum
• Kyphosis, scoliosis

5. Chest Movement:

• Symmetry – observe lagging or reduced movement on one side
• Paradoxical movement – flail chest

6. Signs of respiratory distress:

• Nasal flaring, intercostal/subcostal retractions

• Tripod posture (leaning forward for ease of breathing)
• Orthopnea (unable to lie flat)

7. Other clues:

• Cyanosis (lips, fingers)
• Clubbing of fingers
• Audible wheeze or stridor

II. PALPATION

A. Tracheal Position

• Place index finger in the suprasternal notch.
• Trachea should be midline.
• Deviation may suggest:
• Pulled toward pathology: fibrosis, collapse
• Pushed away: tension pneumothorax, massive pleural effusion

B. Chest Expansion

1. Posterior:

• Place both hands over the lower posterior chest (10th rib level)
• Thumbs should meet at the midline
• Ask patient to take deep breath – thumbs should move symmetrically outward

2. Anterior:

• Place hands under the clavicles or around the lower anterior ribs
• Observe for symmetry of expansion

C. Symmetrical Breathing Movement Assessment

Upper Zones:

• Hands placed on trapezius, thumbs pointing toward C7 (find C7 by palpating vertebrae)
• Fingers placed in infraclavicular area
• Ask patient to breathe – assess for symmetrical expansion

Lower Zones:

• Hands placed around 10th intercostal space, thumbs parallel to the spine
• Ask patient to inhale – assess symmetrical rising of both hands

D. Vocal Fremitus (Tactile Fremitus)

• Use ulnar edge of hands or palmar surface
• Ask patient to say “ninety-nine” (English) or “33” (Bulgarian)
• Place hands symmetrically in multiple spots:
• Posterior: paravertebral and parascapular areas (at least 6 spots)
• Anterior and lateral if needed
• Interpretation:
• Increased fremitus → consolidation (e.g., pneumonia)
• Decreased fremitus → pleural effusion, pneumothorax

E. Fractured Ribs Check

• Gently palpate each rib for tenderness or crepitus
• Ask if there’s pain or involuntary flinching
• Confirm with chest X-ray if fracture suspected