Key Points in Respiratory Examination

Key Points in Respiratory Examination General Inspection Gives an idea if they are well, unwell but compensating or decompensating towards a respiratory failure Alertness The first thing that you notice How well or ill the child is Is there a difficulty in breathing? Level of alertness How interested they are with their surroundings Posture Ability to speak Tired or lethargic Happens are the illness becomes more severe Patients with a difficulty breathing are more comfortable in the upright position Patients who are breathless speak in little words or avoid speaking. Speaking may make children cough Respiratory Examination Breathing shallower when becoming tired Need to assess: Noisy breathing Respiratory rate Work of breathing Use of accessory muscles Oxygen saturation Heart rate Listening to the chest Noisy breathing Runny nose -> coryza Feature of bronchiolitis Wheezing Bronchiolitis Asthma Viral induced asthma Comes from lower airways Asthma -> constricted Bronchiolitis -> secretions Stridor Comes from larynx Harsh sounds due to narrowing of upper airways Happens in: Croup Harsh cough and hoarse voice Foreign body aspiration Anaphylaxis Bacterial tracheitis Epiglottis Grunting When infants close their glottis to generate expiratory pressure to keep alveoli open when they have lots of secretions Sign of respiratory distress in significant respiratory distress Respiratory Rate If distressing can assess through clothing Respiratory rate goes up to compensate In children with bronchoconstriction such as in bronchitis or asthma -> expiration is prolonged Hence keep an eye out for expiration Work of breathing Assess for recessions and use of accessory muscles Recessions: Caused by soft chest wall being pulled in during inspiration E.g. asthma, bronchiolitis Categorised Mild, moderate or severe Types of recession Tracheal tug Seen in upper airway obstruction E.g. croup Supraclavicular Prominent in upper airway obstruction Sternal Indicates severe respiratory distress Sterum is a large bone Indrawing requires significant effort Intercostal Indrawing between ribs Seen more clearly in infants Examples: E.g. croup Subcoastal Indrawing below the ribs Often occurs with intercostal recession Harder to detect in chubby infants Seen in both mild and severe cases across age groups Age related differences Neonates Recession is common even if not severely unwell Requires experience to judge severity Older children Less likely to show recession due to firmer chest wall Recession indicates more severe distress Accessory Muscles Use of other muscles to help inflate the chest Forced diaphragm movements -> cause abdominal breathing -> pull on sternomastoid muscles in the neck -> head bobbing Nasal flaring Not strictly accessory muscle Because baby tries to open up all possible airway space it can SaO2 and Heart rate Oxygen saturation Detect early signs of hypoxia Cyanosis is a late and a serious sign Normal range in a health child 98-100% If less than 92% -> give supplemental oxygen If less than 90% -> rapid deterioration as per oxygen dissociation In response to oxygen, it should rise quickly to 100% If not well -> child is severely hypoxic and unwell Heart Rate Tachycardia -> compensation for respiratory distress Bradycardia -> pre-arrest sign in severe respiratory failure Age specific norms Always check normal heart rate ranges for ages Auscultations Audible wheeze Often heard without a stethoscope Wheeze and air entry have a poor correlation with illness severity Small chest seizes cause sounds to transmit widely Difficult to make localisations Crying Many cry during auscultation This reduced accuracy In bronchiolitis Typically – wet and wheezy chest Diagnosis – clinical – CXR is rarely needed In pneumonia Fast respiratory rate Crepitations Wet, crackly sounds over affected lungs – indicate secretions/infections More detectable in children over 3 Need careful auscultation Peak Flow Measurement Difficult in children Less likely to concentrate and cooperate when they are ill