Respiratory Examination in Children

Respiratory Examination in Children Component What to do/rationale Basics Activity/alertness Distress Colour Growth Obvious Oxygen, IVI, dysmorphic features, spacers Cyanosis Pallor SOB Weight Syndrome features Stature -> tall/short Syndromic facial features Audible sounds Cough with wheeze -> asthma, viral induced wheeze Productive cough -> lower respiratory tract infection Barking cough -> croup, laryngomalacia Dry cough -> allergies, TB Hoarse voice -> laryngitis Hot potato voice -> peritonsillar abscess Acute stridor -> croup, foreign body, bacterial tracheitis, epiglottitis Chronic stridor -> laryngomalacia, subglottic stenosis Mobility aids Feeding tubes Oxygen Environment Monitors Sputum cubs Medications Colour Tremor Eczema Clubbing Pulse rate Resp rate Hands Newborns -> 40 to 60 1 week to 3 months -> 30 to 50 3 months to 2 years -> 30 to 40 2 to 10 years -> 14 to 24 More than 10 -> 12 to 20 Blood pressure General appearance Nasal flaring/grunting -> increased work of breathing Micrognathia -> undersized jaw Genetic conditions e.g. Pierre Robin, Noonan, Marfan Eyes Conjuctive pallor -> anaemia Nose Deviated nasal septum -> nasal obstruction Nasal polyp -> atopy, asthma and cystic fibrosis Engorged turbinates -> allergic conditions Mouth Ask child to see how long their tongue is and how big their mouth is – to hook the child Face Central cyanosis -> persistent pulmonary hypertension, bronchospasm, lower respiratory tract infection Cleft palate Throat Inspect with a pen torch and a tongue depressor Usually left to the end as it is will likely upset them Tonsillar hypertrophy Recurrent tonsilitis and airway obstruction Ears Otoscope Tympanic membrane Inflamed or bulging -> otitis media -> accompanies viral upper respiratory tract infections Hearing aids -> primary ciliary dyskinesia Trachea Should be central in a child Deviates towards pneumothorax and large pleural effusions Deviates towards lobar collapse and pneumonectomy Done for children older than 7 Cervical lymph nodes Neck Scars Deformities Extra noises Visible signs of increased work of breathing General signs: Difficulty speaking or feeding Expiratory grunting -> increasing positive end expiratory pressure Recession: Tracheal tug Supraclavicular recession Intercostal recession Subcostal recession Use of accessory muscles: Close chest Nasal flaring inspection Abdominal breathing Head bobbing Pectus excavatum -> caved in or sunken appearance of the chest E.g. Marfan syndrome Pectus carinatum -> protrusion of the sternum and the ribs E.g. Noonan syndrome Asymmetry of chest wall movement Pneumothorax or consolidation Harrison’s sulcus Indrawing of the chest wall from long term diaphragmatic tug – Associated with poorly controlled asthma Chest hyper-expansion (barrel chest) Associated with asthma and chronic respiratory tract obstruction Apex beat Do with fingers placed horizontally across the chest Should be on 5 th intercostal space in midclavicular line Causes of displaced apex beat: Leftward displacement -> cardiomegaly, right pleural effusion, right tension pneumothorax Rightward displacement -> dextrocardia, diaphragmatic hernia, left pleural effusion, left tension pneum Chest expansion Palpation Place hands on the chest inferior to the nipples Wrap fingers around either side if the chest Bring thumbs together in the midline so they touch Observe movement of the thumbs Reduced movement of thumbs indicates reduced chest expansion on the affected side, causes: Lung collapse Pneumonia Restrictive lung disease Note symmetry Percuss both anterior and posterior chest Areas to percuss: Supraclavicular region -> lung apices Infraclavicular region Chest wall -> percuss over 3 rd to 4 Percussion th locations bilateral Axilla Types of percussion notes: Resonant -> normal finding Dullness -> increase tissue density -> consolidation, tumor, lobar collapse Stony dullness -> pleural effusion Hyper-resonance -> decrease tissue density -> pneumothorax Air entry in all areas and extra sounds QUALITY Vesicular – normal quality of breath Bronchial Harsh sounding Similar to auscultating over the trachea Inspiration and expiration are equal and there is a pause between Associated with consolidation Harsh breath sounds from upper airways are readily transmitted to the upper chest in infants May be misinterpreted as abnormal added sounds VOLUME Quiet – reduced airway entry Pleural effusion, pneumothorax When presenting say reduced breath sounds rather than reduced air entry Auscultation ADDED SOUNDS Wheeze Continuous, coarse and whistling sound produced in the respiratory airways Asthma and bronchiectasis Stridor High pitched extra thoracic breath sounds From turbulent airflow though the upper airways Coarse crackles Discontinuous, brief, popping lung sounds Pneumonia, bronchiectasis and pulmonary edema Find end inspiratory crackles Similar to noise generated when separating velco Pulmonary fibrosis Heart auscultation Liver Back Sacral edema