The Unseen Symphony: Decoding the Body’s Whispers
Every breath you take is a secret message. Right now, as you read these words, your body is whispering its most intimate truths. But are you listening?
In the world of healthcare, practitioners face a daily paradox.
We’re surrounded by cutting-edge technology, yet our most powerful diagnostic tool remains deceptively simple: the art of observation.
The ability to truly see, hear, and feel the subtle rhythms of a patient’s breathing can sometimes be as valuable as any MRI or blood test.
So, as a practicing respiratory therapist, even though I‘m not in day to day clinical practice, it’s still essential that I keep refreshing on common processes, practices, and exploring new data, technologies, and treatment methods.
Respiratory therapy covers a wide range of patient needs, from managing ventilators in critical care to using non-invasive devices like open oxygen masks (like the Oxy2Mask).
Staying current ensures I’m prepared for both extremes, whether it’s fine-tuning oxygen delivery or adjusting ventilator settings in a life-threatening situation.
Non-invasive oxygen delivery methods, like the Oxy2Mask, are continuously evolving to improve patient comfort and outcomes, and as a respiratory therapist, it’s key to understand these advancements and how they fit into the broader spectrum of patient care.
By staying updated, I’m not only reinforcing my skills but also preparing to deliver the best possible care. It’s about having the versatility to handle whatever comes up—whether the patient needs a ventilator or just some oxygen through a flexible-flow device.
I see it as both a personal responsibility and an opportunity to grow.
The more I know, the better I can tailor treatment plans that balance comfort with effectiveness, making sure patients are getting exactly what they need at that moment.
It’s all about being ready, no matter what tool or therapy you’re working with.
With that in mind, I wanted to take a step back, and take a fresh look at how to conduct a respiratory assessment that goes far beyond the textbook – a fresh look that may transform you into a master decoder of the body’s most vital symphony.
I’ll cover the basics and then get into more detailed topics as we go.
Step 1: Master Basic Respiratory Exam Techniques
1. Observe General Appearance and Posture
Start by observing the patient. Notice if they seem comfortable or if there’s any sign of discomfort. Patients often develop specific postures when experiencing respiratory distress, such as sitting upright or leaning forward.
Using an open oxygen mask like the Oxy2Mask can make the process of observing and assessing a patient’s comfort and respiratory status easier in several ways:
- Clear Visual Cues: With the Oxy2Mask, the open mask design allows for a better view of the patient’s facial expressions, making it easier to detect signs of discomfort or distress, like grimacing or labored breathing. You can also quickly notice if they are struggling with the mask itself, which might happen with more restrictive, traditional designs. Also confirm that the patient’s chest looks uniform left and right, and that the tracheal position is in midline.
- Patient Posture: Since the Oxy2Mask provides oxygen more comfortably to your patient, you can observe their natural body posture more accurately. Patients often sit upright or lean forward when experiencing respiratory distress, and the less restrictive design of the open mask ensures these positions aren’t hindered by bulky equipment.
- Communication: The open nature of the mask facilitates better communication with the patient. They can talk more easily, helping you gauge whether they’re experiencing shortness of breath or discomfort. This is crucial when determining their respiratory status without invasive or restrictive equipment.
- Reduced Anxiety: Many patients feel claustrophobic with traditional masks, which can cause additional stress and affect their respiratory status. The open design of the Oxy2Mask can minimize this anxiety, making it easier to assess their true respiratory function without the added stress of an uncomfortable device.
Take Note of Distress Indicators
Look for distress indicators like rapid breathing, use of accessory muscles, or nasal flaring. These may reflect underlying issues and need further examination.
2. Inspect Breathing Patterns
During this step, watch how the patient breathes over one minute. This task measures both the rate and quality of breathing.
Determine Respiratory Rate
Count how many breaths the patient takes in a minute. Normal adults usually breathe 12 to 20 times a minute. Mark any deviations from this range, as they might indicate anomalies.
Examine Rhythm and Symmetry
Check the rhythm to see if breaths are evenly spaced. Both sides of the chest should rise and fall evenly. Uneven chest movement could hint at a problem like pneumothorax or pleural effusion.
3. Palpate the Chest
Position your hands on the patient’s chest/back to evaluate for any deformities, masses, or tenderness.
Fremitus Evaluation
Feel for vibrations when the patient speaks. This is called fremitus. Place the ulnar aspect of your hand on the patient’s back or chest in the intercostal spaces, alternating left and right sides as you ask the patient to say “ninety-nine.” Increased vibrations might mean consolidation in the lung, while decreased vibrations can point to pleural effusion or some other type of obstruction.
4. Percussion for Resonance
Percussion helps assess if there are abnormal masses or fluid collections in the thorax. Use your fingers to tap on various parts of the chest and access both front and back.
Percussion Technique
Place the middle finger of your non-dominant hand firmly across the chest, targeting the intercostal space. With your opposite hand, use a snapping wrist motion to tap the middle finger. A normal lung should sound resonant. Abnormal sounds, like dullness, may suggest a mass or fluid.
Utilize Patterns
Use the “5-7-9 rule” detailed by Stanford Medicine 25. These numbers represent the normal locations of the liver edge, where percussion notes change indicating liver dullness, which can hint at lung issues if dullness is found higher than expected.
5. Auscultate Lung Sounds
This step involves carefully listening to lung sounds using a stethoscope, which is crucial for identifying abnormal lung changes.
Stethoscope Placement
Place the stethoscope’s diaphragm across different sections of the chest and back. Listen to sounds from above the clavicles to below the scapulae on each side, asking your patient to deep breathe, listening for full breath cycles in each location, and alternating between the left and right positions. Compare the quality and symmetry of sounds across corresponding points on both sides of the chest.
Detecting Abnormal Sounds
Focus on spotting adventitious sounds like wheezes or crackles. Wheezes may signal airway obstruction, commonly due to asthma or COPD, while crackles can indicate fluid in or around the lungs, such as in heart failure or pneumonia. The American Lung Association underscores this by stressing the importance of detecting abnormal sounds for early intervention and treatment of respiratory conditions.
Each step in mastering these basic techniques builds your foundation for a thorough respiratory examination. Equip yourself to make informed decisions for future patient evaluations.
Step 2: Follow Breathing Assessment Protocols
1. Inspect Skin Colour
Observe for Cyanosis and Pallor
Start by checking the patient’s skin colour. Cyanosis, a bluish tint to the skin and mucous membranes, can indicate low oxygen levels. Pallor, or unusual paleness, might suggest anemia or poor circulation. Always compare these findings with the patient’s baseline skin tone, as variations exist across different ethnicities. Check areas where colour is more evident, such as lips, nail beds, and inner eyelids.
Note Skin Abnormalities
Look closely for other skin changes like rashes, bruising, or edema. These can give clues about underlying health conditions. Document any findings in the patient’s record. Use a consistent method to ensure accuracy across different patients and follow-up assessments.
2. Assess Work of Breathing
Accessory Muscle Use and Nostrils
Observe the patient’s neck and shoulders for accessory muscle use. This indicates increased effort needed to breathe. Look for nostril flaring, a sign of respiratory distress, especially in children. Also, check for retractions, where the skin pulls in around the ribs or neck. These are clear markers of increased work of breathing.
Measure Breathing Depth and Effort
Assess the depth of each breath by watching chest and abdomen movements. Shallow breaths can point to lung or muscular issues and require medical attention. Be alert to labored breathing, where the patient cannot complete sentences without pausing. While assessing, record each observation systematically to guide future treatment and management.
3. Cough and Sputum
Does your patient have a cough? Is it regular or infrequent?
Are there particular triggers for your patient’s cough?
Is it dry and hacky, or wet and productive?
If it’s the latter, then ask your patient about the frequency of their cough, are they expectorating sputum effectively or swallowing it? Swallowing too much phlegm can sour a patient’s stomach and possibly affect appetite, so a patient should always be encouraged to expectorate sputum.
Quantifying Sputum Production
If your patient says they have a productive cough, ask for them to specifically quantify how much sputum they’re coughing up in tablespoons/day. This way, you’ve set a baseline for future assessments to see if their condition has changed. Also, is their sputum thick or thin, easy to expectorate or difficult? Does a patient’s sputum have a distinct smell? Sputum colour is also critical as a marker for your patient’s condition. Normally, sputum should be clear, or possibly tan in colour for a patient with a chronic respiratory condition such as COPD. Bright yellow sputum can be indicative of a fresh infection, sometimes occurring even before other signs and symptoms of illness appear. Green sputum may also be a sign of infection, but also can be indicative of clearance of older, less used airways due to obstruction or consolidation.
I used to always tell my patients, if we’ve changed your medications for airway clearance and you start coughing up more green phlegm, that could be a good sign of clearing out some lung areas that otherwise would have remained obstructed. Brown sputum – like coffee grounds may be indicative of blood, as are streaky red flecks in a patient’s sputum, and should be immediately reported to the patient’s physician.
4. Monitor Oxygen Saturation
Pulse Oximeter Readings
Use a pulse oximeter to measure oxygen saturation, known as SpO2. This quick and non-invasive tool provides insights into how effectively oxygen is delivered to the body’s tissues. Normal readings for healthy individuals are generally above 90%. Lower readings suggest the need for immediate intervention.
Identify and Respond to Low Levels
When levels dip below 90%, it can indicate hypoxemia, requiring immediate attention. Ensure that the correct pulse oximeter probe is placed on a person’s finger, ear, or toe to avoid false readings. Recheck the device’s accuracy if the readings seem off. Knowing how to respond, such as by providing supplemental oxygen, can be critically important.
Effective SpO2 Troubleshooting
Obtaining consistently accurate SpO2 tracings can be a bit of an art, with many factors to consider.
Besides placing the correct probe in the correct location, there are many other variables that can affect SpO2 accuracy.
If your patient has poor circulation to their extremities – the old “cold hands, warm heart” situation, this can be for a number of reasons including cardiac function impairment, or Reynaud’s disease – but it likely will mean inaccurate SpO2 tracings. You can try to warm their hands with a heated blanket or place their hand in their armpit for a few minutes, but I always carried an ear lobe probe while doing assessments, and while you would think that the ear lobes are not the most important place for the brain to tell the heart to pump blood, they are right next to your head, which is definitely an important place to pump blood, and your earlobes are more centrally located than the extremities of the patients hands or feet.
Patient movement can also affect SpO2, so try to have your patient’s hand with the SpO2 probe stay still during assessment. This can be tricky with conditions such as Parkinson’s or other forms of tremor, or if you’re performing a 6 minute walk test – but during a walk, ask your patient to keep the probe hand still by either asking them to keep it by their side, or by placing their hand naturally on their chest, to avoid the normal ‘arm swing’ that occurs when we walk.
Possibly the biggest factor affecting SpO2 accuracy is the presence of nailpolish. Because we typically use finger probes to obtain SpO2 readings by shooting InfraRed and Red light through the nail bed to determine “how red the patient’s blood is”, nail polish definitely gets in the way and can interfere with the path of light through the finger, and hence, through the capillaries of the extremities. I mentioned we are directing InfraRed and Red light through the finger probe – what colour on the light spectrum is most nail polish representative of? You got it… RED! But even if your patient clear coats their nails, this creates an extra barrier that the light from the finger probe could have trouble traversing reliably, and so, to obtain accurate SpO2’s, nail polish should be removed if using a finger probe. And don’t even get me started about fake nails! Get out your earlobe probe if that is the case and don’t even try getting readings on fake nails! For all your nail polish patients, carry some guaze and nail polish remover and kindly ask, for the accuracy of the test, if one or two fingers can have their nail polish removed. You’ll get more accurate SpO2’s this way, and improved insight into your patient’s oxygen carrying capacity.
Advanced Tips for Conducting Clinical Respiratory Evaluation
After you’ve performed your thorough respiratory assessment, if you believe your patient requires elevated levels of oxygen in order to improve saturations and reduce a patient’s dyspnea and other respiratory symptoms, then using an open mask like the Oxy2Mask can unlock several advanced techniques for respiratory therapists (RTs) that are harder to achieve with a stack of other, more traditional oxygen masks.
Greater Oxygen Delivery Flexibility
One of the biggest advantages lies in its ability to deliver oxygen more efficiently while allowing greater flexibility. The Oxy2Mask’s design ensures optimal oxygen flow without the need for constant adjustments, which may be the case with other traditional masks that have a narrower range of deliverable FiO2. This gives RTs the ability to fine-tune oxygen delivery in real time, responding to patient needs without being constrained by the limitations of a more closed system. As a result, oxygen therapy can be administered more effectively, improving patient outcomes and reducing the risk of over- or under-oxygenation.
Patient Safety
The open nature of Oxy2Mask also means patients are able to release their expired CO2 out of the mask more easily than traditional, closed in oxygen masks. This means that your patients are less likely to rebreathe CO2, which, over time, can be toxic and detrimental to patients’ health, and even cause respiratory failure in severe cases. Traditional masks have mandatory minimum flows that are required to both power the mask and to wash out expired CO2, and if these minimum flows are not met in error, this could have grave consequences for your patients. Oxy2Mask’s open style allows for no minimum mandatory flows needed, making it less error-proned and one of the safest masks available to patients today.
Reduce Resistance or Non-compliance with Oxygen Therapy
Comfort is another area where the Oxy2Mask offers significant advantages. Traditional masks often cause patients to feel hot, claustrophobic, or anxious, which can lead to resistance or non-compliance with oxygen therapy. The open design of the Oxy2Mask reduces these psychological barriers, enabling patients to tolerate oxygen therapy for longer periods without distress.
This is especially important for patients who don’t need full ventilatory support but require supplemental oxygen. By enhancing patient comfort, RTs can focus on more advanced aspects of care without constantly needing to reassure or readjust equipment for the patient.
Improve Patient/RT Communication
Communication between the RT and patient is also significantly easier with the Oxy2Mask. With traditional closed in masks, patients often struggle to be heard, making it harder for therapists to get real-time feedback on symptoms like shortness of breath or discomfort. The open nature of the Oxy2Mask makes verbal communication much easier, allowing RTs to assess how well a patient is tolerating the treatment in real time. This ease of communication can lead to more accurate adjustments in care, as the RT can respond immediately to patient-reported symptoms and needs.
Reduce Mask Changes
From a workflow perspective, the Oxy2Mask simplifies the transition between different oxygen therapy modalities. With other masks, there may be a need to switch between various types of oxygen delivery devices as patient needs change, which can be time-consuming and disruptive. The Oxy2Mask allows for a smoother, quicker transition between different oxygen levels or different oxygen levels due to its wide range of delivered FiO2 between 24%-90%. This makes it easier for RTs to manage patients who may fluctuate between needing low-flow oxygen and higher-flow oxygen throughout their treatment, providing more dynamic and responsive care.
Standardize and Streamline Oxygen Therapy Logistics
Beyond patient-specific benefits, the Oxy2Mask also has advantages for the hospital or clinic in terms of logistics and resource management. Using a single, versatile device reduces the need to stock multiple types of masks, cutting down on storage requirements and potential confusion when selecting the right equipment. The standardization around a more flexible device like the Oxy2Mask can streamline operations and save costs, as fewer mask types need to be maintained or replaced.
Why This Matters
These skills are crucial in the real-world setting of diagnosing respiratory issues. Accurate respiratory assessments can be the difference between a timely intervention and a missed diagnosis. The ability to discern normal from abnormal breathing patterns can help in early detection of serious conditions like COPD or asthma which, when overlooked, can lead to worsening of the patient’s state.
Healthcare professionals must perform detailed examinations as part of standard physical assessments. This ensures a holistic understanding of a patient’s respiratory status.
Looking at reliable diagnostic guides and the latest research helps practitioners stay on top of their game. It is also essential in aligning with current healthcare standards.
For those seeking real-time data, utilizing sources like the RESP-NET dashboard for hospitalization rates or the CDC’s reports on COVID-19, influenza, and RSV is critical. This helps understand current trends and provides a context for various respiratory conditions encountered daily, allowing healthcare professionals like RRT’s to also protect themselves in the midst of providing the best care possible.
Staying informed with these resources ensures high standards of care and sharpens skills for effective patient management. As clinical settings grow increasingly complex, these skills become non-negotiable for any practitioner aiming to excel in respiratory care.
Conclusion
Mastering respiratory assessments is a pivotal skill that transforms patient care. You’ve learned to observe, palpate, and listen with precision, turning abstract symptoms into concrete data. This knowledge isn’t just about ticking boxes; it’s about seeing the full picture of a patient’s health.
Remember, every breath tells a story. Your trained eye and ear can now decode these vital narratives, potentially saving lives. But this is just the beginning. As you apply these techniques, you’ll develop an intuition that goes beyond textbook knowledge.
Challenge yourself to perfect each step, from the basic inspection to advanced lung function tests. Each assessment you perform hones your skills further. Embrace the responsibility that comes with this expertise. You’re not just conducting tests; you’re opening doors to better diagnoses and treatments.
Your journey in respiratory care is ongoing. Keep learning, stay curious, and never underestimate the power of a thorough breathing assessment. Your patients are counting on your expertise. Are you ready to breathe new life into your practice?
If you want more information on trying out the Oxy2Mask open oxygen mask, connect with me via email or on LinkedIn today!