Respiratory Therapist (TMC – CRT/RRT)

The patient history is the foundation of respiratory assessment. It provides context for all subsequent diagnostic findings and treatment decisions. A thorough history identifies risk factors, establishes symptom timelines, and reveals comorbidities that influence respiratory function.

Document the primary reason for the patient encounter in the patient's own words. Common respiratory chief complaints include dyspnea, cough, sputum production, hemoptysis, chest pain, and wheezing. Quantify symptoms when possible using standardized scales.

Characterize symptoms using the OLDCARTS mnemonic: Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing, and Severity. For dyspnea, determine whether it occurs at rest or with exertion, its progression over time, and associated symptoms. For cough, identify whether it is productive or nonproductive, the character of sputum, and triggers.

Document previous respiratory conditions including asthma, COPD, pneumonia, tuberculosis, lung cancer, pulmonary embolism, and interstitial lung disease. Record prior hospitalizations, intubations, and mechanical ventilation episodes. Note surgical history, particularly thoracic and abdominal procedures that affect respiratory mechanics.

List all current medications including inhalers, nebulizers, oxygen therapy, and systemic drugs. Document adherence patterns and technique for inhaled medications. Identify medications that cause respiratory side effects such as beta-blockers, ACE inhibitors, and aspirin.

Record drug allergies with specific reactions. Document environmental allergies including dust, pollen, mold, and animal dander. Note latex allergies for procedural planning.

Smoking history is calculated in pack-years: packs per day multiplied by years smoked. Document current smoking status, quit date if applicable, and exposure to secondhand smoke. Record occupational exposures to dust, chemicals, fumes, and asbestos. Identify alcohol and substance use patterns. Document living conditions and home environment including heating sources, humidity, and potential allergens.

Note family history of asthma, COPD, cystic fibrosis, alpha-1 antitrypsin deficiency, lung cancer, and tuberculosis. Genetic conditions affecting the respiratory system often cluster in families.

Conduct a systematic review beyond respiratory symptoms. Cardiovascular symptoms such as edema and orthopnea suggest heart failure contributing to dyspnea. Neurological conditions affect respiratory drive and airway protection. Gastrointestinal symptoms may indicate aspiration risk.

Dyspnea is the subjective sensation of breathing discomfort. The Modified Medical Research Council Dyspnea Scale grades breathlessness from 0 (dyspnea only with strenuous exercise) to 4 (too breathless to leave the house or breathless when dressing). The Borg Scale rates perceived exertion from 0 to 10. Distinguish between acute dyspnea requiring immediate intervention and chronic dyspnea requiring long-term management.

Acute cough lasts less than 3 weeks and is commonly caused by viral upper respiratory infections. Subacute cough lasts 3 to 8 weeks and often follows respiratory infections. Chronic cough persists beyond 8 weeks and requires systematic evaluation. Common causes of chronic cough include upper airway cough syndrome, asthma, and gastroesophageal reflux disease.

Document sputum quantity, color, consistency, and odor. Clear or white sputum suggests noninfectious causes. Yellow or green sputum indicates neutrophilic inflammation but does not reliably distinguish viral from bacterial infection. Rust-colored sputum is associated with pneumococcal pneumonia. Pink frothy sputum suggests pulmonary edema. Foul-smelling sputum indicates anaerobic infection or abscess.

Hemoptysis is the expectoration of blood from the respiratory tract. Distinguish true hemoptysis from hematemesis and nasopharyngeal bleeding. Massive hemoptysis exceeds 200 to 600 mL in 24 hours depending on the definition used. Common causes include bronchitis, bronchiectasis, lung cancer, tuberculosis, and pulmonary embolism.

Pleuritic chest pain is sharp, localized, and worsens with inspiration. It suggests pleural inflammation from pneumonia, pulmonary embolism, or pleuritis. Distinguish from cardiac chest pain, which is typically substernal, pressure-like, and may radiate to the arm or jaw. Musculoskeletal chest pain is reproducible with palpation.

Observe respiratory rate, pattern, and depth. Normal adult respiratory rate is 12 to 20 breaths per minute. Tachypnea exceeds 20 breaths per minute. Note use of accessory muscles including sternocleidomastoid, scalene, and intercostal muscles. Observe for pursed-lip breathing, nasal flaring, and retractions. Assess chest symmetry and shape. Barrel chest with increased anteroposterior diameter suggests hyperinflation from COPD or asthma. Note cyanosis, clubbing, and peripheral edema.

Assess chest expansion symmetry by placing hands on the posterior thorax and observing movement during deep breathing. Reduced expansion on one side suggests pneumothorax, pleural effusion, or atelectasis. Palpate for tactile fremitus by having the patient say "ninety-nine" while feeling the chest wall. Increased fremitus indicates consolidation. Decreased fremitus suggests pleural effusion, pneumothorax, or emphysema. Palpate for subcutaneous emphysema, tracheal position, and point tenderness.

Percussion produces resonant sounds over normal lung tissue. Hyperresonance indicates air trapping from COPD, asthma, or pneumothorax. Dullness suggests consolidation, pleural effusion, or atelectasis. Diaphragmatic excursion is assessed by percussing from resonance to dullness during inspiration and expiration. Normal excursion is 3 to 5 cm bilaterally.

Normal breath sounds include vesicular sounds heard over peripheral lung fields and bronchial sounds heard over large airways. Adventitious sounds include crackles, wheezes, rhonchi, stridor, and pleural friction rubs. Fine crackles are discontinuous, high-pitched sounds associated with atelectasis, pulmonary fibrosis, and early pneumonia. Coarse crackles are lower-pitched and suggest secretions in larger airways. Wheezes are continuous, musical sounds caused by airway narrowing. Expiratory wheezes are associated with asthma and COPD. Inspiratory wheezes suggest upper airway obstruction. Rhonchi are low-pitched, continuous sounds that often clear with coughing and indicate secretions in large airways. Stridor is a high-pitched inspiratory sound indicating upper airway obstruction. Pleural friction rub is a creaking sound from inflamed pleural surfaces rubbing together.