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Respiratory examination

Begin the respiratory assessment by counting the respiratory rate and simply observing the child’s breathing pattern. If the child is old enough to understand, don’t tell him you are counting his respirations, as that may alter his breathing pattern. Is the patient’s rate of breathing normal for his age? Is the rhythm of his breathing regular? Are his breaths especially shallow or deep? Is your patient’s breathing effortless, or does it take effort for him to breathe? Compare the inspiratory and expiratory phases of respiration. Are they equal? Note his posture. Patients in respiratory distress may have to sit upright to breathe or lean forward in what is called a tripod position. As you assess your patient’s respiration, consider other health issues that may affect his breathing. For example, trauma to the chest or abdomen, inflammation of abdominal organs, recent surgery, or increased abdominal pressure due to obesity can all affect a child’s ability to breathe. If the child is receiving oxygen, be sure to note the type of delivery device as well as the oxygen flow rate, measured in liters per minute. Then use an oximeter to measure his oxygen-saturation level.

Inspection

To inspect the chest, position the child (depending on the child’s age) either on the parent’s lap or on the examination table with all clothing above the waist removed. Inspect the chest for size, shape, symmetry, movement, breast development, and the presence of bony landmarks formed by the ribs and sternum. The chest should look symmetrical and move symmetrically with inspiration and expiration. If the chest is asymmetrically shaped, it is usually a result of two different structural deformities. If the sternum protrudes, increasing the anteroposterior diameter of the chest, pectus carinatum, or pigeon chest, may be present. If the lower part of the sternum is depressed, decreasing the anteroposterior diameter, pectus excavatum, or funnel chest, may be present. Scoliosis can also cause lateral deviation of the chest. If the child is experiencing respiratory distress, you may see retractions, which are depressions in parts of the chest (suprasternal, substernal, and/or intercostal areas) caused by the child using accessory muscles to breathe. Before completing this portion of the exam, don’t forget to look at the posterior thorax, noting any bony deformities. Abnormal spinal curvature, such as kyphosis or scoliosis, can make breathing difficult.

Infants. An infantís chest is typically barrel-shaped or circular, with the anterior-posterior (front-to-back) diameter equaling the lateral (side-to-side) diameter. As the child grows, the lateral diameter increases. The circumference of a newborn’s thorax is usually 30 to 36 cm and is approximately 2 cm smaller than the infant’s head circumference until 2 years of age. The chest wall is thin with very little musculature, and the ribs and the xiphoid process are quite prominent. In both newborn boys and girls, the breasts may look enlarged on the second or third day after birth due to the effects of maternal estrogen. Sometimes, a white fluid can be expressed. This usually disappears on its own within about a week. Because infants breathe through the nose rather than the mouth, you might see slight flaring of the lower costal margins. Also, because the diaphragm is the major respiratory muscle for infants, the abdomen will have a bulging appearance with inspiration. You will see very little thoracic movement.

Infants often have a normally irregular respiratory rhythm, so count their respiratory rate for 1 full minute, preferably while the infant is calm or asleep (for the most accurate rate). A normal respiratory rate for this age group is between 30 and 60 breaths per minute. An infant who has an abnormally rapid respiratory rate might have pneumonia, fever, pain, or a cardiovascular problem.

Toddlers/Preschoolers/School-age children. A toddler’s thorax still has a rounded appearance, but assumes a more oval shape as the child grows. A barrel-shaped chest is an abnormal finding in this age group and reflects a respiratory problem, such as asthma or cystic fibrosis. Because young children still use the diaphragm as the primary breathing muscle, you can count their respiratory rate by watching the abdomen rise with inspiration and fall with expiration. You should not see any sternal or intercostal retractions.

A normal respiratory rate for a toddler is between 25 and 30 breaths per minute; for children between the ages of 3 and 6 years, it averages between 21 and 24; and for children between the ages of 6 and 10 years, it averages 19 to 20. A sustained respiratory rate above 60 breaths per minute is a sign of respiratory distress and treatment must be started immediately. The child’s airway is narrow, and when the respiratory rate exceeds 60 beats per minute, gas exchange is impaired.

Adolescents. An adolescentís thorax is similar in shape to an adult’s, with a 1:2 anteroposterior-to-transverse diameter. A barrel-shaped chest is an abnormal finding in this age group and reflects a respiratory problem, such as asthma or cystic fibrosis. At this age, the diaphragm is no longer the primary muscle used for breathing, so you should not see the abdomen rising and falling with the respiratory cycle. Again, you should not see any sternal or intercostal retractions.

A normal respiratory rate for an adolescent is between 16 and 20 breaths per minute. Again, be aware of the signs of respiratory distress (tachypnea, retractions, and nasal flaring) and if you observe these, initiate treatment immediately.

Palpation

A thorough respiratory assessment includes palpation over the anterior and posterior chest to assess chest movement, respiratory effort, for any deformities of the chest wall, and tactile fremitus. To palpate, press gently with your fingertips all over the chest wall in a systematic fashion. Start above the clavicles anteriorly, palpating from side to side and moving inferiorly to the costal angle and laterally to the midaxillary line. As you palpate, note muscle mass, plus any bony defects, nodules, or masses. While palpating, observe the child’s facial expressions for signs of pain or tenderness and also ask an older child about any pain or tenderness as you palpate. Repeat on the posterior chest wall, starting above the scapulae and including the entire thorax to below the 12th rib and out to the midaxillary line. You should feel firm muscle tissue without nodules, bony abnormalities, or masses, and the child should report no tenderness.

Be sure to check lung expansion, either on the anterior or posterior surface of the thorax. Place your hands over the child’s ribs, with your thumbs close together at midline and your fingers spread. Ask the child to take a deep breath. With normal expansion, you will feel the rib cage expand smoothly and symmetrically under your hands, as your thumbs move apart.

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Infants. To palpate an infant’s thorax, encircle it with both of your hands. You should feel symmetrical movement with each respiratory cycle. If the thorax moves asymmetrically, evaluate for a diaphragmatic hernia or a pneumothorax. With your fingertips, palpate the chest for any tenderness, depressions, bulges, masses, or fractures. Be sure to palpate for crepitus as well, especially near the clavicles if the infant’s clavicle was injured during delivery.

To palpate for tactile fremitus, or vibrations produced by crying or talking, place the palms of your hands on each side of the infant’s chest and evaluate the quality and distribution of the vibrations. They should be palpable over the entire chest. If the sensation is decreased, this may indicate that air is trapped in the lungs, a common finding with asthma. Increased sensation might indicate lung consolidation, a common finding with pneumonia.

Toddlers/Preschoolers/School-age children. Place the palms of your hands on each side of the child’s chest to palpate the movement of the chest during the respiratory cycle. You should feel symmetrical movement bilaterally. With the tips of your fingers, palpate over the entire anterior and posterior chest, feeling for any depressions, bulges, masses, or fractures. Observe the child’s facial expressions to see if he has any pain or tenderness with palpation. Be sure to also check for crepitus, which can be an indication of a serious injury to the upper or lower airway. Crepitus can sometimes be palpated near a fracture.

Palpate for tactile fremitus in the same way as for an infant. Place the palms of your hands on each side of the child’s chest and ask him to repeat a couple of words or numbers. As the child repeats the words or numbers, move your hands over the anterior and posterior chest systematically, comparing the quality of the vibrations side to side. Again, if the sensation is decreased, it might be due to asthma. If the sensation is increased, evaluate for pneumonia.

Adolescents. Palpate for chest movement, respiratory effort, any deformities, and tactile fremitus on an adolescent in the same manner as for younger children. With this age group, though, in addition to observing facial expression, be sure to ask about pain or tenderness when you palpate the chest wall.

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Percussion

Percussion is sometimes performed to assess the resonance of the lungs and the density of underlying organs. Because of the use of x-rays to examine the lungs, percussion is not performed very often. If percussion is going to be part of the physical examination, it is done in the same manner regardless of the age of the child. When percussing the anterior and posterior chest, use a sequence that allows you to cover the entire chest and compare sounds bilaterally. The tone generated by lung percussion in infants, toddlers, and preschoolers is usually hyperresonance because of the thin chest wall. In older children, the tone generated should be resonance, which is a low-pitched, hollow sound.

Auscultation

Auscultation is performed over all lung fields to assess the quality and characteristic of breath sounds, to identify abnormal breath sounds, and to assess vocal resonance. It is performed in the same way for patients of all ages. As you listen, think about which lobe of the lung you are listening to, because you might hear abnormal lung sounds in just one lobe. Remember, the right lung has three lobes, while the left has two. To make lung sounds easier to hear, place an appropriate-size stethoscope directly on the child’s skin. Avoid listening through clothing and don’t allow clothing or bedding to rub against the stethoscope tubing since both can interfere with hearing lungs sounds. Ask the child to take deep breaths with his mouth open each time you move your stethoscope. The more air your patient moves, the easier it is to hear breath sounds. Be sure to have the child stop and rest if he becomes lightheaded.

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Auscultate with the diaphragm of your stethoscope over all areas of the anterior and posterior thorax, moving side to side and working your way from the top of the lungs to the bottom. If possible, use a pediatric stethoscope when listening to the chest of infants and young children. You should hear breath sounds over all lung tissue, and the quality of the breath sounds should be similar as you listen from side to side. When you listen to posterior lung sounds, ask the child to cross his arms in front of his chest. This pulls the scapulae apart and exposes more lung tissue. Be sure to listen to each full cycle of inspiration and expiration before moving your stethoscope, as just one part of the respiratory cycle might generate abnormal sounds.

Normal breath sounds vary according to the area of the lungs auscultated. For example, anteriorly over the trachea, you should hear a loud, high-pitched, hollow sound called a bronchial breath sound. It is abnormal to hear this sound over peripheral lung tissue, that is, away from the trachea and the large bronchi. Over the mainstem bronchi, which are relatively large-diameter airways, you should hear medium-pitched and quieter sounds, called bronchovesicular breath sounds. Note that the areas over which bronchovesicular breath sounds are expected are small, but are present both anteriorly and posteriorly. Over most of the lung tissue, you should hear soft, fine, breezy, low-pitched sounds called vesicular breath sounds. They are normally heard over peripheral lung tissue, which is formed by groups of alveoli and is where air exchange occurs.

Note the quality of the lung sounds and listen carefully for any abnormal, or adventitous, sounds, such as crackles, wheezes, and friction rubs. Crackles, which are sometimes called rales, are wet, popping sounds created by air moving through liquid or by collapsed alveoli snapping open on inspiration. They are most common at the end of inspiration. Wheezes are continuous sounds caused by air moving through constricted airways. Airways can be narrowed by a number of causes: the bronchial constriction that accompanies asthma, bronchial inflammation, mucous accumulation or mucous plugs, or tumors. Wheezes can be high-pitched, which is common with asthma, or low-pitched with almost a snoring quality. Mild wheezing is often limited to the expiratory phase of respiration, while more severe wheezing can be heard throughout the respiratory cycle. Wheezes can sometimes clear with coughing, so ask the child to take a deep breath and cough a couple of times, then listen again. A friction rub may result when the pleural membranes covering the lungs and lining the thoracic cavity are inflamed. A friction rub is a scratching or squeaking sound that persists throughout the respiratory cycle and does not clear with coughing.

In addition to abnormal breath sounds, you may also hear abnormal voice sounds, such as stridor, hoarseness, and cough. Stridor is a high-pitched sound typically generated when a larger airway is blocked by a foreign body or severe inflammation, such as croup. Hoarseness is usually heard when the larynx is inflamed and the child coughs to clear the airway. It is commonly heard when the child has a respiratory infection.

While auscultating, be sure to evaluate how well voice sounds are transmitted. Ask the child to repeat a series of words or numbers while you listen with your stethoscope over the entire chest, comparing the quality of sounds from side to side. A normal finding is for the words and syllables to be muffled and indistinct. If the child has a respiratory problem such as asthma or pneumonia, the vocal resonance quality changes in characteristic ways. These characteristic changes are called whispered pectoriloquy, bronchophony, and egophony. With whispered pectoriloquy, syllables are heard distinctly in a whisper. Bronchophony is the increased intensity and clarity of sounds while the words remain indistinct. Egophony is the transmission of the “eee” sound as a nasal “ay” sound.

 

References

Ball, J. W., & Bindler, R. C. (2003). Pediatric nursing: Caring for children (3rd ed.). Upper Saddle River, NJ: Pearson Education. Chapter 4.

Jarvis, C. (2004). Physical examination and health assessment (4th ed.). St. Louis, MO: Saunders. Unit 3.