Clinical Examination of Pediatric Respiratory System

Clinical Examination of Pediatric Respiratory System

1. CLINICAL EXAMINATION OF
RESPIRATORY SYSTEM
Dr. Harish Kumar Singhal
Associate Professor
University College of Ayurved
Dr. S. R. Rajasthan Ayurved University, Jodhpur
Email:[email protected]

2. INTRODUCTION
Disease of the respiratory system account for up to a third
of deaths in most countries and for major proportion of
visits to the doctor and time away from work or school. As
every aspect of diagnosis in medicine, the key of success is a
clear and carefully recorded history; symptoms may be trivial
or extremely distressing, but either may indicate serious and
life threatening disease.
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3. CARDINAL SYMPTOMS
Cough
Cold
Fever
Expectoration
Hemoptysis
Breathlessness
Wheeze
Chest pain
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4. COUGH
Cough may be dry or it may be productive
How long has the cough been present, lasting few day accompanied by
cold less significance
Lasting for several weeks which is first sign of allergic bronchitis or
malignancy
Dry cough at night may be an early symptom of asthma, as may cough
which comes in the spasms lasting several minutes.
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5. Some time cough aggravated by anything e.g. dust , pollen or
cold air.
Increased activity of airways seen in asthma and in some
normal children for several weeks after viral respiratory
infections.
Ask whether cough is mild or sometimes severe type
coughing may be followed by vomiting.
Nocturnal cough is common due bronchitis, bronchial asthma
postnasal discharge ,gastro esophageal reflux disease left heart
failure
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6. BREATHLESSNESS
Everyone become breathless on strenuous exertion which is
usually normal.
Breathlessness inappropriate to the level of physical exertion
even occurring at rest is called Dyspnea.
Its mechanisms are complex not understood completely
because it is not due to lowered blood oxygen tension
(hypoxia) or raised in blood carbon dioxide tension
(hypercapnia)
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7. SPUTUM
Sputum produced or not , what does it look like i.e. color and how much it
produced. with
People with asthma may produced very small amount of thick or jelly like sputum.
Eosinophils may accumulate in the sputum in asthma causing a purulent appearance
even no infection is present.
In severe lung damage in infancy and in the childhood, amount of sputum produced
daily often exceeded a cup full but in RAD less produced
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8. HAEMOPTYSIS
It mean the coughing of blood in the sputum ,never be dismissed
without very careful evaluation of patient.
Potentially serious significance of blood in sputum is well known,
and fear often leads patients to not mention and ask very
carefully.
There is any blood in the sputum, is it free or altered blood and
how often it has been seen& for how long.
Blood may be coughed up alone or sputum may be blood stained,
some time difficult for the patient to recognize and asked about
epitasis or melaena.
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9. SURFACE ANATOMY
The bifurcation of trachea corresponds to angle of Louis anteriorly and 4
th
thoracic spine posteriorily.
The angle of Louis is a transverse bony ridge at the junction of the body of
sternum and the manubrium sterni.
Ribs & intercostals spaces are best counted downwards from angle of Louis
A line drawn form 2
nd
thoracic spine to the 6
th
rib in the midclavicular line
corresponds to the major interlobar fissure or upper border of lower lobe
of the lung.
The boundary between the upper and middle lobes is marked by a
horizontal line drawn from sternum at the level of 4
th
costal cartilage to
meet the major interlobar fissure line on the right side of chest.
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10. The greater part of each lung is seen from behind and
composed of the lower lobe .
The middle and upper lobes on the right side and upper lobe
on the left occupy most of area in the front side of chest .
Mostly upper and lower lobes are accessible to physical
examination anteriorly and posteriorily respectively .
All the lobes are accessible in the axillary area .
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11. ANTERIOR SURFACE OF LUNGS
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12. POSTERIOR SURFACE OF LUNGS
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13. GENERAL PHYSICAL EXAMINATION
Face.
General appearance .
Built and nutrition .
Nails and conjunctiva .
Neck and JVP.
Lymphadenopathy .
Axillary area and upper limb.
Abdomen umbilicus.
Genital organs & inguinal area.
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14. Assess child is comfortable, tachypneic or dyspneic.
Note accessory muscle of respiration and alae nasi are working
or not .
Temperature, temperature and respiration .
Anemia, cyanosis jaundice & ENT examination.
Oral cavity, throat, nasal discharge, acute and chronic infection of
ear and nose .
Other point noted in general assessment are physique, voice,
clubbing and venous pulse .
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15. ACUTE RESPIRATORY FAILURE
Itischaracterizedbyimpendingrespiratoryfailureapprehension,
anxiety,worseningoftachypnea,Dyspnea,chestretractionsand
cyanosis.
Airentrytothelungsmaybeseverelycompromisedduetoupperair
wayobstruction.
Thebreathingmaybecomeslowshallowandgaspingorirregulardue
tocentralnervoussystemdepressionandneuromusculardisease.
Sometimeterminallywhenrespiratorymusclesbecomeexhausted
duetooverwork.
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16. INSPECTION
Theexposedchestshouldbeinspectedbystandingattheheadorfoot
sideofthepatientwitheyesatlevelofchest.
Thechild,however,isbestexaminedwhilesittingcomfortablyonastool
orstandingwitharmshangingbythesides.
Foranyobviousscarfromprevioussurgeryorinjuryortrauma.
Hollowing,bulging,flatteningorretraction.
Spine,shoulders,andsubcostalangle.
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17. SYMMETRY
Whether chest is bilaterally symmetrical or not. Note the
distance of medial borders of scapulae from midline on both
the sides which is useful to assess any asymmetry of the
chest.
Drooping of one shoulder may occur in patients with
fibrocaseous tuberculosis.
Look for localized bulge or retraction there is bulging of
intercostals spaces in cases of pleural effusion or empyema.
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18. SHAPE OF CHEST
It is nearly circular or cylindrical in infants.
Pigeon type chest or keeled chest found in rickets.
Funnel chest or precuts excavatum found in rickets, marfan
syndrome .
Barrel shaped chest is seen in emphysema.
Kyphosis or scoliosis lead to asymmetry and decrease size
of thoracic cage .
Bulging of chest found in pleural effusion .
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19. MOVEMENTS OF CHEST
The breathing in infants is mostly the abdominal or abdominothoracic .
When the diaphragm is paralyzed, the upper part of abdomen may be
drawn in with each inspiration.
In paralysis of intercostals muscles, there is very little expansion of chest
with abnormal expansion of abdomen with each inspiration.
The range of movements, respiratory lag on a particular side and in
drawing of Suprasternal, intercostals and subcostal spaces should be
looked for.
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20. POSITION OF TRACHEA AND APEX
BEAT
The position of trachea and apex beat should be localized.
The trachea is examined with child in supine position or sitting with
slight flexion of neck.
Place the index finger into the Suprasternal notch, and gently push it
backwards.
Normally the finger should touch the trachea in midline if trachea is
deviated, the finger will slide into the tracheo-sternomastoid space.
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21. Mediastinum is normally central ,shift of mediastinum can be detected by
noting the position of trachea & apex beat.
On inspection sternomastoid become more prominent on side to which
trachea is shifted .
In normal children trachea may be slightly deviated to the right side of chest
.
Trachea may be pulled due to collapse, fibrosis and the thickened pleura .
It may be pushed towards normal side by pleural effusion, pneumothorax
and a mass lesion.
Normally apex beat is in fifth left intercostal space &may shift with shift of
mediastinum ,central in bronchitis.
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22. PALPATION
The findings of inspection should be confirmed by the
palpation.
Look for any tender areas, crepitus (subcutaneous
emphysema, fracture rib) and assess any types of difference
of movements on two sides of chest .
Feel for any abnormal vibrations e.g.. rhonchi, friction rub,
coarse crackles and characteristic spongy feeling of
subcutaneous emphysema..
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23. POINTS TO BE NOTED ON PALPATION
Swelling .
Pain and tenderness .
Tracheal position .
Cardiac impulse .
Asymmetry .
Tactile vocal fremitus .
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24. PERCUSSION
Normal percussion note of chest is due to under lying lung
tissue containing normal amt. of air .
The pleximeter finger (middle finger of the non dominant
hand) should be placed in firm contact with the chest
The rest of the fingers should be lifted off from the chest
wall.
The pleximeter finger should be held parallel to the margin
of the organ to be outlined & move from resonant towards
the possible dull area.
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25. Impaired note –amount of air decrease
Dull note –consolidation, infiltration, lung collapse
Stony dull –pleural thickening, pleural effusion
Hyper-resonance:-
Pneumothorax
Emphysema
Large cavity
Congenital lung cyst
Emphysematous bullae
Eventuation of diaphragm
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26. AUSCULTATORY PERCUSSION
It is more reliable and informative than the
conventional percussion.
It can pick up small lesions up to 3 cm in diameter
especially hilar or any type of the meditational
lymph nodes, pulmonary infiltrates and patches of
pneumonia.
The patient sits up with arms resting on his thighs
and examiner sit or stands on either side of patient
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27. The examiner percusses over the manubrium sterni .
The tapping should be done lightly with the distal phalanx of
middle or index finger of dominant hand
The sound can be heard with the diaphragm piece of
stethoscope applied snugly by the other hand over the
posterior chest wall.
It must be ensured that percussion is applied with equal
intensity over same area of manubrium .
The stethoscope explores both lung fields by comparing the
intensity and quality of percussion .
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29. AUSCULTATION
The infants and young children are best auscultated while mother or father
supports the child against the security of her shoulders .
Auscultation must be done to note type of breathing , presence of any foreign
sounds .
The stethoscope should be firmly placed over the chest to prevent sounds
resulting from movement of chest .
Hair on chest wall may produce a crackling sound and may mistaken as rale.
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31. BREATH SOUNDS
Vesicular breath sounds
Bronchial breath sounds
Vocal fremitus &resonance –
Bronchophony
Whispering
Added sound –
Pleural rub
Wheezes
Crepts
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32. VESICULAR BREATH SOUNDS
The normal breath sounds produced in the alveoli are called
vesicular.
The inspiration is loud, high pitched and long, there is no
pause after the inspiration, expiration is low in intensity and
short in duration
It is followed by a pause .
In children, the normal breath sounds are peurile or harsh
vesicular with slightly prolonged expiration (broncho-
vesicular).
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33. BRONCHIAL BREATH SOUNDS
Inspiration is low in intensity, and is followed by a pause
while expiration is harsh, high pitched, loud and prolonged.
The duration of inspiration and expiration is almost
identical .
The sound have definite tubular quality.
It may be normally heard over the neck and thoracic spine
up to 4
th
thoracic vertebra.
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34. WHEEZES/RHONCHI BREATH SOUNDS
These are dry musical sounds produced due to narrowing of air passages.
The expiration is prolonged in case of wheezes .
They are monophonic in character when there is a localized obstruction of a
bronchus (foreign body, lymph node) .
It is polyphonic when there is generalized airway obstruction (asthma and
bronchitis).
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35. CONTD..
High pitched or sibilant rhonchi are produced in the bronchioles
& are audible during the end of inspiration or beginning of
expiration
They are better appreciated by placing the chest piece in front of
infant's mouth and nose.
Medium pitched rhonchi are produced in medium sized bronchi
and low pitched rhonchi are produced in large bronchi.
They are heard throughout both the phases of breathing and are
often audible even without the stethoscope .
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36. CAUSES
Bronchial asthma
Bronchitis
Chronic obstructive lung disease
Localized obstruction i.e. malignancy
Tropical eosinophilia
Cardiac failure
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37. CRACKLES OR CREPITATION OR RALES
They are produced by passage of air through the exudates
collected in the alveoli or bronchi.
Crepitations or fine crackles are produced by sudden
opening of previously closed airways or alveoli and audible
during the end of inspiration.
Medium pitched Crepitations are heard in patients with
bronchitis and resolving pneumonia .
Rales are audible throughout both the phases of respiration
and loud in intensity .
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38. CAUSES
Left heart failure –Rales are present
Inflammatory exudates –Bronchitis ,pneumonia
Lung abscess ,cavity and bronchiectasis
Pulmonary congestion, edema and fibrosis
Severe airway obstruction
Medium pitched crepits are found –bronchitis
Fine crepits –bronchopneumonia
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39. PLEURAL FRICTION RUB
Normally parietal pleura slides smoothly over the visceral
pleura in presence secretion there .
It is unaltered by cough c.f. crackles is more localized, and
augmented by snug contact of chest piece of stethoscope to
the chest wall.
Pleural friction rub is heard during the identical phases of
breathing inspiration and expiration and has a peculiar
superficial grating, creaking and leathery in the character.
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40. CHARACTERISTICS OF PFR
Rubbing .
Superficial sound close to ear .
Accentuated on pressing stetho to chest wall .
Audible even on holding the breath .
Confined to localized area .
Not altered by coughing .
Associated with local pain .
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41. VOCAL RESONANCE
Laryngeal vibration normally audible through the stethoscope as vocal resonance,
high pitched sounds not easily palpable can be picked up
It is examined by asking the patients to repeat the words one,one,one and
identical points on chest wall should be alternately auscultated rapidly .
Bronchophony increased vocal resonance when it is so loud that it appears sound
is being produced in ear pieces of stethoscope cavity consolidation .
VR diminished in pleural effusion &pneumothorax.
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42. INVESTIGATIONS
CBC & ESR .
Sputum examination .
X-ray chest .
Imaging –USG , CT scan , MRI .
Thoracocentesis .
Pleural biopsy .
Thoracoscopy .
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43. MICROSCOPIC
Lymphocytic predominance in chronic condition i.e.
Tuberculosis
Resolving pneumonia
Fungal infection
Carcinoma
Myxedema
Polymorphic predominance found in
 Acute bacterial infection
 Rheumatic fever .
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44. BIOCHEMICAL ANALYSIS
Proteins more than 3gm –exudates
Sugar diminished in rheumatoid arthritis
LDH increased in tuberculosis effusion
Amylase increased in pancreatitis rupture of esophagus and salivary gland
abscess
Adenosine deaminase activity is increased in tuberculosis pleural effusion
Hyaluronidase is increased in mesothelioma of pleura
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45. SPUTUM EXAMINATION.
Mucoid sputum found in chronic bronchitis when there is no active
infection .
Mucopurulent or purulent in bacterial infection e.g. bronchitis,
pneumonia and lung abscess .
Foul smelling in presence of anaerobic organisms.
Blood stained in pulmonary embolism or hypertension.
Under microscope presence of pus cell to rule out causative organisms
.
In pulmonary tuberculosis specialized techniques of laboratory
microscopy and culture are needed .
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46. LUNG FUNCTION TEST
Measuring size of lungs ,how easily air flows into and out of
the airways and how efficient the lungs are in process of gas
exchange ,
Spirometer can measure how much air can be exhaled after
a maximal inspiration.
Patients can breath air into lungs then blows out into
spirometer , total volume is called vital capacity .
Amount of air in lung at full inspiration is a measure of total
lung capacity &remaining at expiration is RV
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47. MINI PEAK FLOW METER
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