ECE Semester 2 Respiratory System

(Year 1) Guidebook

MAHSA UNIVERSITY
Faculty of Medicine
MBBS PROGRAM

STUDY GUIDE
RESPIRATORY SYSTEM

2015 - 2016

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ECE Semester 2 Respiratory System
(Year 1) Guidebook

EARLY CLINICAL EXPOSURE

RESPIRATORY SYSTEM
HISTORY TAKING AND PHYSICAL EXAMINATION SKILLS

INTRODUCTION
Diseases of the respiratory system account for up to a third of deaths in most countries and account for a
major proportion of visits to the doctor and time away from work or school. It accounts for approximately
4% of all hospital admissions and approximately 35% of all acute medical admissions. The common
respiratory symptoms are breathlessness, cough, hemoptysis, and chest pain.

As with any other disease, a good clinical history and examination are fundamental in patients with
respiratory disorders. When taking the history students need to be aware of environmental factors that can
either cause or aggravate the respiratory symptoms. This includes cigarette smoking, occupational
exposure, pets, dusts and allergens.

In this block, the history and physical examination skills will include:

1. Focused History Taking

The focused history taking session will ensure that the students are able to communicate with the
patient and get adequate information from the simulated patient presenting with respiratory
problems.

2. Physical Examination

A complete respiratory examination will be covered and this starts with general inspection before
concentrating on the thorax.

GENERAL OBJECTIVES

By the end of the block, you should have acquired the skills of history taking in a patient presenting with
respiratory problems and develop a proper examination technique of the respiratory system.

SPECIFIC OBJECTIVES

A. Focused History Taking

By the end of the block, you should have acquired the knowledge, skills and attitude
to demonstrate your ability to:

1. utilise a systematic and holistic approach to history taking.

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 2. elicit and record an appropriate clinical history from patients with respiratory symptoms.

3. obtain appropriate background information: past medical history, drug history, allergy, family
history and social information.
4. identify differential diagnoses by applying critical reasoning skills.

5. communicate effectively with the patient by being able to:

a. empathise via active listening skills and recognition of the nuances of non-verbal
communication.
b. build rapport and trust with the patient.

c. explain to the patient of confidentiality of information.

d. obtain appropriate valid consent, defining associated underpinning medical/legal

and ethical principles.
e. communicate information to others.

B. Focused Physical Examination

By the end of the block, you should have acquired the knowledge, skills and attitude
to demonstrate your ability to:

1. describe the components of respiratory system examination.

2. explain to the patient on the confidentiality of information.

3. conduct a respiratory system examination in a proper and acceptable manner.

4. gain appropriate valid consent, defining associated underpinning medical/legal and ethical
principles.
5. explain and share with the patient, using simple language, the findings of the examination.

REFERENCES
th
1. Douglas et al. (2009). Macleods Clinical Examination, 12 Edition, Elsevier Churchill
Livingstone.
nd
2. Michael Swash, Michael Glynn (2007). Hutchinsons Clinical Methods, 22 Edition, Saunders
Elsevier.
st
3. Niall Cox and TA Roper (2005). Clinical Skills, 1 Edition, Oxford University Press.

4. Nicholas J Talley and Simon O Connor (2006). Clinical Examination: A Systemic Guide to
th
Physical Diagnosis, 5 Edition, Elsevier Churchill Livingstone.
5. Kumar & Clark (2005). Clinical Medicine, 6th Edition, Elsevier Saunders.

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6. Respiratory system examination http://www.qub.ac.uk/cskills/respiratoryexamination.htm

7. The auscultation assistant breath sounds http://www.med.ucla.edu/wilkes/lungintro.htm

8. Vital signs and Chest Examination Module, University of Virginia

http://www.med-ed.virginia.edu/courses/pom1/pexams/VSandChestExam/

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 EARLY CLINICAL EXPOSURE
RESPIRATORY SYSTEM
GUIDE TO HISTORY TAKING

Performed Not Performed

Performed
but not Fully or
Competently
Competent Incompetent
2 1 0
A. Initiating the Session & Identifying the Reason(s)
for Patients Attendance
1. Introduction
a. Greet patient politely.
b. Shake his or her hand (if it seems appropriate).
c. Ask the patient to sit down.
d. Introduce yourself and your role.

2. Patient Identification
Identify the patients details which include:
a. Name
b. Age
c. Address
d. Date of Birth
e. Ethnic Group
f. Marital Status
g. Occupation

3. Consent
a. Explain what you are about to do and gain
the patients consent
b. Inform the patient of confidentiality
Patient information is generally held under legal
and ethical obligations of confidentiality.
Information provided in confidence should not be
used or disclosed in a manner that might identify
a patient/client without her consent.
c. Explain the need to take notes and ask if this is
acceptable.
4. Presenting Complaint(s)
Ask the patient on the presenting complaint(s).

B. Gathering Information & Defining the

Clinical Problem(s)
1. History of Presenting Complaint(s)
Get the following history:
a. Onset and duration
b. Characteristics of the cough: dry or productive.
If productive:
i. Foul smelling?
ii. Copious and mucopurulent?
iii. Foamy and pink-tinged?
iv. Rusty?
v. Copious, frothy, and saliva-like?
vi. Bloody?
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 Performed Not Performed
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c. Breathlessness?
obtain a quantitative account of
exercise tolerance at baseline and
during the current illness
d. Wheezing?
e. Chest pain?
Pleuritic chest pain is a common feature
of pneumonia, but be aware of the
possibility of a pulmonary embolus
f. Other relevant symptoms:
i. fever?
ii. malaise?
iii. myalgia?
iv. night sweats?
g. Hoarseness of voice?

2. Past Medical & Surgical History

Ask the patient about significant past medical & surgical
history:
a. Previous respiratory illness, including
pneumonia, tuberculosis or chronic bronchitis,
asthma respiratory investigations
b. Previous
e.g. bronchoscopy

3. Medication History
a. Ask about any prescribed medication, over
the counter medication
b. Ask specifically about antibiotics used to treat
this episode and the duration
c. Ask whether they are taking
immunosuppressive medication (e.g.
glucocorticoids)
4. Allergy
Ask about allergies or reactions to anything, including
medicines.

5. Family History
a. General enquiry Any family history of
any illness?
b. Any family member(s) with similar problem?

6. Social History
Ask for relevant social history
a. Occupational
detail occupational history especially
history of exposure to inorganic dusts such
as silica, coal dust and asbestos

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 Performed Not Performed
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b. Smoking if yes
i. duration?
ii. type of tobacco (cigarettes, cigars, pipe)?
iii. amount per day?
c. Alcohol if yes
i. duration?
ii. how much?
Convert the amount to equivalent units of
alcohol. 1 unit of alcohol is equivalent to:
1 small glass of wine
1 half pint of beer
1 short of spirit
iii. when did you last have a drink?
iv. whats the most you ever drink?
Use CAGE screening test to help detect problem
drinking
i. have you ever felt you should Cut down on
your drinking?
ii. have people Annoyed you by criticizing
your drinking?
iii. have you ever felt bad or Guilty about
your drinking
iv. do you ever have a drink first thing in the
morning to steady you or help a hangover
(an Eye opener)?
Positive answers to two or more
questions suggest problem drinking.
d. Travel and hobbies
Relevant clues may be provided by a
travel history and details of hobbies (e.g.
involving pets)
e. Housing
i. Enquire where the patient lives
ii. Basic amenities e.g. water and electricity
iii. Social problem with their housing
circumstances
f. Enquire if his/her symptoms have an impact on his
/ her lifestyle and work?

7. Review of Systems
Ask about important symptoms and disorders in other
system which include:
a. General
b. Eyes, ears, nose, mouth, throat
c. Cardiovascular
d. Hematological
e. Gastrointestinal
f. Genitourinary

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g. Musculoskeletal
h. Endocrine
i. Reproductive (women)
j. Neurological

C. Patients ideas, concerns and expectations

1. Ask about the patients main ideas, concerns and
expectations
a. What do you think is wrong with you?
b. What do you expect to happen to you while you are
in the hospital?
c. Is there something particular you would like us to
do?
d. Have you any questions?

D. Closing the Session

1. Is there anything else you would like to talk about?
2. Briefly summarize what the patient has told you
a. Allows patient to confirm that you have the
right story
b. Allow the patient to correct anything you
have misunderstood
c. Allow the patient to add anything that may
have been forgotten
3. Tell the patient what you are going to do next

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 EARLY CLINICAL EXPOSURE
RESPIRATORY SYSTEM
GUIDE TO PHYSICAL EXAMINATION SKILLS
EXAMINATION OF THE RESPIRATORY SYSTEM

Performed Not
Performed
but not Fully Performed or
Competently
Competent Incompetent
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A. Introduction, Patient Identification and Consent
1. Introduce yourself with a friendly greeting, giving your
name and status.
2. Confirm the patients identity.
Most patients in hospital have an identification bracelet,
which includes their name and hospital identification
number, as well as other important information. It is good
practice to verbally check with the patient their correct
details and also their identification bracelet.
3. Explain to patient what you are about to do and why.
4. Inform the patient of confidentiality.
Patient information is generally held under legal and ethical
obligations of confidentiality. Information provided in
confidence should not be used or disclosed in a manner that
might identify a patient/client without her consent.
5. Get a verbal consent from the patient.

B. Patients Position and Exposure

1. Ask the patient to get on to the bed and ask the patient to
remove all garments covering chest and arms. (If you are a
male student examining a female patient, please ensure a
chaperone is present and offer to cover the chest with a draw
sheet).
2. Position the patient lying in bed with enough pillows to
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support him or her at 45 (see Fig. 1)

C. Hand Washing
1. Wash your hands prior to examination.

D. Examination
This should be performed systematically.
1. General Appearance
Look , listen and note the following features
i. Tachypnea
ii. Count the respiration rate
iii. Usage of accessory muscles of respiration
(sternomastoids, strap muscles and
iv. platysma)
Stridor and hoarseness
v. Cyanosis
vi. Cough
vii. General environment e.g. look on the
bedside cabinet for sputum pots, nebulizers,
inhalers

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2. Hands
Pick up the patients hand.
i. Inspect both hands for:
a. clubbing
b. peripheral cyanosis
c. tar-stained fingers
d. muscles wasting
compression and infiltration by a
peripheral lung tumor of a lower trunk of
the brachial plexus results in wasting of the
small muscles of the hand.
ii. Palpate the radial pulse for pulse rate and rhythm and
consider if the pulse is bounding
Tachycardia and pulsus paradoxus are important
signs of severe asthma
iii. Measure the blood pressure (Refer to Semester
1 ECE Guidebook)
iv. Check for flapping tremor (asterixis) (see Fig. 2)
a. Ask the patient to dorsiflex the wrists
with the arms outstretched and to spread
the fingers.
A flapping tremor may occur with severe
carbon dioxide retention, usually due to
severe chronic obstructive pulmonary
disease. This is a late and unreliable sign.

3. Face, Eyes and Tongue

i. Inspect face for facial plethora (smoker, SVC
obstruction), eyes for Horners (small pupil /
miosis) accompanied by drooping of eyelid)
ii. Look at the tongue for cyanosis
iii. Look at the pharynx and tonsil
reddened pharynx and tonsillar enlargement
indicates URTI and tonsilitis

4. Jugular venous pressure (see examination of the

cardiovascular system).
a brief assessment may indicate the presence of cor
pulmonale or superior vena cava obstruction
i. Inspect right internal jugular vein for jugular venous
pressure.
ii. Check for hepatojugular reflux

E. Examination of the Chest

The chest should be examined anteriorly and posteriorly.
First the front of the chest and the axillae are assessed. The
examination is carried out in a sequence of inspection,
palpation, percussion and auscultation comparing the right
and the left side. Then the back of the chest is examined in
the same way.

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E1. Inspection
1. Inspect front of the chest from end of the bed,
assessing breathing pattern, chest shape and
movement.
i. Breathing pattern
a. Look for:
i. Pursed lips
ii. Accessory muscle use
iii. Intercostal recession
iv. Patient position leaning forward with
hands on knees
v. Cheyne-Stokes breathing
disturbance of respiratory rhythm in
which there is cyclical deepening and
quickening of respiration followed by
diminishing respiratory effort and
rate, sometime associated with a short
period of apnea. Often observed in
severely ill patients and particularly in
severe cardiac failure, narcosis drug
poisoning and neurological disorder
vi. Fast, deep breathing
ii. Chest appearance
a. Look for:
i. Barrel chest
AP diameter of the chest is increased
compared to the lateral diameter. Often
seen in patients with asthma or
emphysema
ii. Other abnormalities
1. Pectus excavatum (funnel chest)
developmental defect involving a
localized depression of the lower
end of the sternum
2. Pectus carinatum (pigeon chest)
an outward bowing of the sternum
and costal cartilages. May be a
manifestation of chronic
childhood respiratory illness
3. Kyphosis & Scoliosis
kyphosis - exaggerated forward
curvature of the spine
scoliosis- lateral bowing of the
spine

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 Performed Not
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iii. Chest drains
iv. General swelling of the neck and
supraclavicular regions
v. Evidence of previous radiotherapy
vi. Obvious scars from previous surgery
iii. Chest movement
a. Ask the patient to take a deep breath in and
then out through their mouth. Show the
patient what you want them to do: Please
take a deep breath in and out like this
b. Look for chest movement
i. Are they symmetrical or
diminished?
if they are diminished on one
side, that is likely to be the side
on which there is an abnormality

2. Inspect front of the chest and neck close up

i. Go back to the right hand side of the patient bed
ii. Examine more closely for any abnormalities seen
iii. Look for smaller pathology not easily visible
from the end of the bed
iv. Ask the patient to lift up their right arm and look
in the axilla for chest drain scar in the fourth, fifth
or sixth intercostals spaces in the mid-axillary line
v. Repeat the same for the left axilla
vi. Assess the expansion of the upper lobe by
observing the clavicle during tidal breathing (See
Fig 3 & 4)
E2. Palpation
Palpation of trachea and precordium
1. Palpate the trachea
0
i. Keep the patient positioned at 45 with their neck
relaxed against the pillow
ii. Tell the patient I need to feel your windpipe. Its a
little uncomfortable but Ill try to be gentle
iii. Use the tip of your right index finger; gently palpate
the patients neck about 2cm superior to the
suprasternal notch in the midline. The resistance that
you felt is the trachea (see Fig. 5)
iv. Palpate the space on either side and decide whether
the trachea is central or displaced. If displaced decide
whether it is displaced to the right or left.

2. Palpate the precordium

i. Ask the patient Is the front of your chest painful
or tender?

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 Performed Not
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ii. If the answer is yes, ask for permission to examine.
If permission is granted gently palpate the painful
spots and decide whether the painful spot is within a
hard bony area suggesting rib injury.
iii. If you have previously observed chest or neck
swelling suggesting subcutaneous emphysema,
gently palpate the area. If subcutaneous
emphysema is present you will feel a cracking
sensation under the hand.
iv. Palpate the apex beat (see examination of the
cardiovascular system)
displacement of cardiac apex beat indicates shift
of lower mediastinum

3. Palpation of chest expansion

i. Place your hands firmly on the chest wall with
fingers gripping their sides (the lower ribcage)
(See Fig. 6)
ii. Bring your thumbs together to meet in the
midline around the inferior part of the sternum
but not touching the chest
iii. Ask the patient to take a deep breath in and watch
your thumbs. If one thumb moves less than the
other, this indicates reduced chest expansion on that
side your thumb should move symmetrically, at least
5 cm apart.

4. Assess tactile vocal fremitus (TVF) on the front of chest

and axilla
i. Assess TVS at the apices
a. Place ulnar border of your right hand on the
patients right clavicle.
b. Ask the patient to say ninety-nine.
Whilst they are speaking concentrate on
the vibration transmitted to your right
hand.place the ulnar border of your right
c. Next
hand on the patients left clavicle and ask
the patient to say ninety-nine and again
assess the vibration transmitted; Is the
vibration the same on both sides?
d. If you are not sure, recheck.

ii. Assess TVF of the upper lobe

a. Place the flat of your right hand over the top
of the right side of the patients chest.
b. Ask the patient to say ninety-nine
concentrating on the vibration transmitted
to your right hand.

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c. Do the same on the patient left side
and consider if the two sides are equal.
d. If you are not sure, recheck.

iii. Assess TVF of lateral aspects of the lung

a. Ask the patient to abduct their arm.
b. Place the flat of your right hand on the
medial aspect of the patients right axilla.
c. Ask the patient to say ninety-nine
concentrating on the vibration transmitted
to your right hand.
d. Do the same for the left axilla, again
comparing the two sides.

E3. Percussion
1. Percuss front of chest and in the axilla, comparing the two
sides (See Fig 7: Sites for percussion: Anterior &
Posterior chest wall)
i. First percuss directly over the medial third of the
rd
patients right clavicle (only the medial 3 lies
overlies lung tissue) (See Fig. 9)
ii. Next percuss the left clavicle using the same
force, comparing the noise and sensation is one
side duller than the other?
iii. Percuss the lung apices (both right and left) by
placing the palmar surface of your left middle finger
across the anterior border of the trapezius muscle,
overlapping the supraclavicular fossa and
percussing downwards.
iv. Percuss the chest wall anteriorly; upper right, upper
left, middle right, middle left, lower right, lower left
always using the same force and comparing both
sides (See Fig. 10)
The percussion techniques have been taught in
Semester 1. Please see ECE Guidebook, Semester 1)
v. Ask the patient to abduct their right arm and then
percuss the right upper axilla and compare with the
left upper axilla; next percuss the right and then left
lower axilla.
vi. If at any point you think there might be a difference
but are unsure, repeat the percussion in that area.

E4. Auscultation
1. Auscultate for breath sounds over the chest and the axilla
i. Place your stethoscope over the patients chest
starting just above the right clavicle.
ii. Ask the patient to breath in deep and fast through
the mouth.

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iii. You may need to encourage the patient to
keep breathing by saying in out. in.
iv. out
After each breath move your stethoscope to the
next side, comparing both side.
v. Listen to the following sites: (See Fig. 11)
a. anteriorly from above the clavicle down to
th
the 6 rib (at the lung apices use the bell,
other areas use the diaphragm)
th
b. laterally from axilla to the 8 rib.
vi. At each site decide on the
a. intensity of the breath sound (normal or
reduce)
b. character of the breath sounds
(vesicular, bronchovesicular, bronchial)
c. presence or absence of added
sounds (crackles, wheeze, friction
vii. rub) an abnormality, listen longer in that
If you suspect
area and confirm whether this is true.

2. Assess vocal resonance (VR) at the front of the chest

and axilla.
i. Assess VR at the apices
a. Place the bell of the stethoscope over the
patients right supraclavicular fossa
b. Ask the patient to say ninety-nine
c. Whist they are speaking, concentrate on
the sound coming through the stethoscope.
d. Next place the bell over the left
supraclavicular fossa
e. Ask the patient to say ninety-nine again
f. Is the sound the same on both sides?
g. If you are not sure recheck

ii. Assess VR of the upper lobes

a. Place the diaphragm of the stethoscope over
the top of the right side of the patients
chest.
b. Ask the patient to say ninety-nine
concentrating on the sound transmitted
through the stethoscope.
c. Do the same on the patients left side
and consider if the two sides are equal.
d. If you are not sure recheck.

iii. Assess VR of the lateral aspect of lungs

a. Ask the patient to abduct their right arm
b. Place the diaphragm of the stethoscope on
the medial aspect of the patients right axilla

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 Performed Not
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c. Ask the patient to say ninety-nine
concentrating on the sound transmitted
through the stethoscope
d. Do the same for the left axilla, again
comparing the two sides

F. Examination of the back of the chest

1. Change the patient position to facilitate examination of the
neck and the back of the chest.
2. Ask the patient to sit forward. The ideal position is arms
crossed so that the scapulae are rotated laterally; (another
option is to ask the patient to sit with their hands on their
knees).
3. Explain that you now wish to examine the back of their chest.

F1. Inspection
1. Inspect the back of chest: assessing movement, chest shape
and other visible abnormalities.

F2. Palpation
1. Palpate for chest expansion posteriorly, comparing both sides.
i. Stand behind the patient on the right side of the bed.
ii. Do the same as the front, however you need to
concentrate over 2 areas i.e. lower lobes and
upper lobes.
a. Lower lobe:
i. Place your hand firmly on the chest
wall with fingers gripping their
sides and bring your thumbs
together to meet in the midline
around the lower thoracic spine but
not touching the chest.
ii. Ask the patient to take a deep
breath in and watch your thumbs.
If one thumb moves less than the
other, this indicates reduced chest
expansion on that side.
b. Upper lobe
i. Do the same again this time higher
up with the thumbs meeting around
T3 level.

2. Assess the tactile vocal fremitus (TVF) over the

posterior aspect of the chest, comparing the two sides.
i. Assess TVF of the upper lobes
a. Place the flat of your right hand over the top
of the right side of the patients chest and
repeat as for the front, comparing both sides

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ii. Assess TVF of lower lobes
a. Place the flat of your right hand over the
lower aspect of the right side of the
patients chest and repeat as above,
comparing both sides.

F3. Percussion (See Fig. 8 sites for percussion: Posterior chest

wall)
1. Percuss the back of the chest, comparing the two sides
i. Percuss the chest wall posteriorly; upper right, upper
left, middle right, middle left, lower right, lower left,
always using the same force and comparing the
sides as you go.

F4. Auscultation
1. Auscultate the breath sounds over the back of the chest,
comparing the two sides.
i. Use the diaphragm and auscultate over the
chest; upper right, upper left, middle right,
middle left, lower right, lower left.

2. Assess vocal resonance over the back of the chest,

comparing the two sides.
i. Use the diaphragm and assess vocal resonance
over the chest; upper right, upper left, middle right,
middle left, lower right, lower left.

G. Completing the examination

1. Inform the patient that you have completed the examination.
2. Tell the patient to dress up.
3. Wash your hands.
4. Dry your hands using paper towels.
5. Discard the paper towels into the domestic waste bin.

H. Documentation
1. Record your findings.
2. Inform the patient of the findings.

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 Fig. 1: Respiratory System
Examination:
Positioning the patient
Elsevier Tally & OConner:
Clinical Examination 5E

Fig. 2: Asterixis: Hand and arm position for observing Fig. 3: Inspecting upper lobe expansion: Expiration
the flapping tremor of CO2 retention Elsevier Tally & OConner: Clinical Examination 5E
Churchill Livingstone: Macleods Clinical Examination
12E

Fig. 5: Examining for tracheal shift

Fig. 4: Inspecting upper lobe expansion: Inspiration Churchill Livingstone: Macleods Clinical Examination
Elsevier Tally & OConner: Clinical Examination 5E 12E

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 Fig. 6: Assessing chest expansion from the front. A) Expiration. B) Inspiration
Churchill Livingstone: Macleods Clinical Examination 12E

Fig. 7: Site for percussion: Anterior & Lateral chest Fig. 8: Site for percussion: Posterior chest wall
wall Churchill Livingstone: Macleods Clinical
Churchill Livingstone: Macleods Clinical Examination Examination 12E
12E
 Fig. 10: Percussion: Plexor finger poised and
Fig. 9: Direct percussion
Elsevier Tally & OConner: Clinical strikes the pleximeter finger
Examination 5E Elsevier Tally & OConner: Clinical Examination 5E

Fig. 11: Auscultation areas: Anterior and lateral chest wall

Elsevier Tally & OConner: Clinical Examination 5E
 EARLY CLINICAL EXPOSURE
RESPIRATORY SYSTEM
GUIDE TO PROCEDURAL / PRACTICAL SKILLS
PEAK EXPIRATORY FLOW RATE MEASUREMENT

A peak flow meter is a portable, hand-held device that is used to measure the fastest rate of air
(airflow) that a person can blow out from their lungs. It records airflow in liters per minute
(l/min). Peak flow measurement is a procedure in which the maximum flow rate of expired air
is measured. The measurement obtained is called the peak expiratory flow rate (PEFR). Peak
flow measurement using a peak flow meter is particularly useful for individuals with asthma.
During an asthma flare-up, the large airways in the lungs begin to narrow. This slows the speed
of air leaving the lungs. A peak flow meter, when used properly, can reveal narrowing of the
airways well in advanced of an asthma attack.
Peak flow measurements are reduced in diseases causing
airways obstruction such as asthma and COPD. A
diagnosis of asthma may be indicated by greater than 20
per cent daily fluctuations (diurnal variation) in PEFR
for at least three days in any seven over a two-week
period in patients with a history of recurrent episodes of
dyspnea and/or wheezing. Regular peak flow
monitoring, with a record kept of the readings over time,
may also help detect decreased lung function and signs
of an impending asthma attack before symptoms
develop. It is particularly useful in the self-management
of asthma by patients.
A normal peak flow rate is based on a person's age, height and gender and varies with the time of day. A
nomogram, from which PEFR can be predicted, is shown in Appendix 2. In men, readings up to 100
L/min lower than predicted are within normal limits. For women, the equivalent figure is 85 L/min.

GENERAL OBJECTIVES
By the end of the block, you should be able to perform a peak expiratory flow rate measurement on a
patient.

a. explain to the patient / family on the technique and purpose of measuring a peak
expiratory flow rate
b. perform a peak expiratory flow measurement
EQUIPMENT and MATERIALS
a. Bronchodilators

b. Nebulizer machine

i. medication cup

ii. mouth piece or mask

iii. air tube

iv. compressor

c. Peak flow meter

d. Gauze

REFERENCES
a. How to use a nebulizer http://respiratory-supplies.medical-supplies-equipment-
company.com/PPF/page_ID/174/article.asp
b. Peak flow meter http://www.peakflow.com/top_nav/home/index.html

c. Asthma UK http://www.asthma.org.uk/
 EARLY CLINICAL
EXPOSURE
RESPIRATORY
SYSTEM
GUIDE TO PROCEDURAL / PRACTICAL SKILLS
PEAK EXPIRATORY FLOW RATE (PEFR) MEASUREMENT

Performed Not
Performed
but not Fully Performed or
Competently
Competent Incompetent
2 1 0
A. Introduction
1. Introduce yourself with a friendly greeting, giving your
name and status.

Patient Instruction and Consent

1. Explain to the patient what you are about to do and why.
2. Explain to the patient on PEFR measurement
techniques, emphasizing that the test may be repeated up
to 3 times.
Performing PEFR measurement
1. Attach a new mouthpiece to the peak flow meter.
2. Make sure that the sliding pointer (red pointer) on the peak
flow meter is reset to the zero mark.
3. Ask the patient to stand up & hold the peak flow meter in a
horizontal position.
4. Make sure that the patient does not place his / her fingers over
the sliding pointer.
5. Ask the patient to place the mouthpiece in the mouth and to
make a tight seal with their lips around the mouth piece
(See Fig. 1)
6. Ask the patient now to take a deep breath in and make
sure that a tight seal around the mouthpiece is maintained.
7. Now ask the patient to blow out as hard and as fast as
they can.
8. Note the number where the sliding pointer has stopped on the
scale.
9. Reset the pointer to 'zero'.
10. Repeat this routine 3 times.
You will know you have done the technique correctly
when the three readings are close together.

Recording and Interpretation

1. Record in the patients progress note: (Please use the
attached Progress Notes Sheet Appendix C).
a. Date and time
b. The highest of the 3 readings
2. Plot the reading on the PEFR chart (Appendix D)
3. Interpret the result Refer to PEFR normal value
(Appendix E)
4. Inform the patient of the result.
Fig. 1
 Appendix C

PUSAT NAME:

PERUBATAN REGISTRATION NO:

MAHSA
PROGRESS NOTES WARD: BED:

DATE NOTES (Every entry must be signed)