Paediatrics - Respiratory Examination

Question 1

Examination of the paediatric respiratory system

Inspection

Answer 1

After a general inspection, the following should be observed:

• respiratory rate and the movement of the diaphragm and chest wall, in normal breathing and with deeper breaths if appropriate.
• chest hyperinflation - specifically an increased anterior-posterior diameter may be noted
• there may be intercostal, subcostal or sternal recession. A long term sequal to this may be Harrison’s sulcus.
• nasal flaring may be present
• a tracheal tug is a subtle sign

Question 2

Examination of the paediatric respiratory system?

General Inspection

Answer 2

Features which may be noted on general inspection include:

• cyanosis - peripheral or central
• clubbing
• wheezing
• stridor
• hoarse voice

Question 3

Examination of the paediatric respiratory system

Palpation

Answer 3

• The chest expansion of a child can be observed in the same way as in an adult.
• However, note that in children the actual expansion of the chest is less during inspiration; the younger the child the more diaphragmatic the breathing.
• This is a consequence of the angle of the ribs to the spine; in young children the ribs are nearly horizontal, and the bucket handle effect of expansion in inspiration cannot occur.

The two important things to do on palpation are:

• check that the trachea is central
• ensure that the apex beat is in the correct place as lateral displacement may indicate lung collapse or fibrosis

Question 4

Examination of the paediatric respiratory system

Percussion

Answer 4

• Percussion is difficult in young children, and in very young children seldom yields useful information.
• It can also be rather frightening, and is best preceded with a jokey warning that you are going to make a noise like a drum.
• If percussed, signs of consolidation, pneumothorax, or collapse may be noted, and the upper border of the liver may be percussed out in order to identify overinflation.

Question 5

Examination of the paediatric respiratory system

Answer 5

Breath sounds and additional noises can also pose problems, and a careful listening is needed to note differences rather than absolute signs. This particularly applies to signs such as bronchial breathing; often this is a comparative finding in a small child, where most of the breathing would appear bronchial to the adult physician.

Specific sign may include:

• crepitations in bronchiolitis or rarely heart failure
• coarse intermittent noises secondary to debris from infections
• wheezing, and, often more helpful, prolonged expiratory time in asthma
• the silent chest is an emergency in an ill child

stridor may be heard in upper airway obstruction:

• subtle stridor on a noisy ward can be heard by holding the stethoscope near the mouth
• however, beware the child who wants to render the examiner deaf