Part II Examination of the Newborn and Older Child
4 Examination of the Older Child
4.10 Respiratory System Examination
4.10.2 Examination of the Chest
(a) Shape: Look for any abnormal chest shape—e.g., pectus excavatum (funnel chest) or pectus carinatum (pigeon chest).
(b) Chest wall abnormalities and deformities
• Harrison’s sulcus
– Costal cartilages are retracted, with flaring lower ribs at the costal margin. It may suggest chronic airway obstruction or left-to-right car-diac shunt [37].
• Rachitic rosary
– Costochondral junction swelling, which may occur in rickets, in scurvy, and sometimes in achondroplasia
180
(c) Asymmetry
(d) Scars: Look for scars of median sternotomy or left or right thoracotomy, and carefully inspect for scars of previous chest drains.
(e) Movement: Compare movement of both sides of the chest in the full respi-ratory cycle.
(f) Breathing pattern
• Rapid, shallow respiration with prolonged expiration occurs in asthma or bronchiolitis.
• Kussmaul respirations (rapid, regular, deap, sighing respirations) suggest metabolic acidosis (e.g., diabetic ketoacidosis).
• Cheyne–Stokes respirations: respirations with increasing and then decreas-ing depth and rate, alternatdecreas-ing with periods of apnea or hypopnea.
(g) Respiratory rate: Count the respiratory rate within 1 full minute, and see whether it is normal for the given age (see Box 4.7).
(h) Watch for signs of respiratory distress (see Table 4.9):
• Tachypnea and tachycardia
• Nasal flaring
• Grunting, wheezing, or stridor
• Chest recessions/retractions (subcostal, intercostal, suprasternal)
• Tracheal tug
• Hyperinflation
• Use of accessory muscles of respiration (mainly the sternocleidomastoid, scalene, and abdominal muscles); note any head bobbing in babies.
• Abdominal paradoxical movement
• Cyanosis and pallor
• Difficulty in speaking, drinking, or walking
• Hypotension
• Tachypnea can be defined as an abnormally increased respiratory rate.
• According to the World Health Organization (WHO), the cutoff line for tachypnea in different age groups is as follows:
– >60 breaths/min in infants aged less than 2 months – >50 breaths/min in infants aged 2 months to 1 year – >40 breaths/min in children older than 1 year of age [1]
Box 4.7: Tachypnea
4 Examination of the Older Child
2. Palpation
(a) Palpation and percussion are not done routinely in infants or younger children.
(b) You can do them in particular situations, such as:
• Assessment of hyperinflation
• Detection of the upper border of the liver
• Confirmation of signs of collapse, consolidation, or effusion (c) Mediastinal deviation
• Tracheal deviation
– Palpate the trachea in the suprasternal notch by using your index fin-ger. Tracheal deviation to any side indicates certain pathology (e.g., tension pneumothorax, unilateral effusion, or thoracic mass) [35].
• Apex beat
– Use your palm to localize the apex beat at the fourth intercostal space in the mid-clavicular line.
– A mediastinal shift (e.g., pneumothorax or pleural effusion) can lead to apex beat displacement [35, 38].
(d) Chest expansion
• Assess maximum chest expansion from the front by placing your hands firmly on the child’s chest.
• Your fingers should just grasp the sides of the child’s chest, and your outstretched thumbs should be at the level of the nipples and just touch each other at the midline, but they should not touch the chest.
• Ask the child to take a deep, big breath after full inhalation and exhalation.
• Your thumbs will act as “calipers.” The distance your thumbs move sym-metrically away from each other during inspiration determines the degree of chest expansion. It is usually about 3–5 cm in school-aged children [1, 20].
• To measure chest expansion posteriorly, repeat the same method on the child’s back, but your thumbs should be at T10 level.
• Hyperinflation and restrictive lung disease can reduce chest expansion symmetrically.
Table 4.9 Grades of respiratory distress [40, 41]
Mild Moderate Severe
• Tachypnea
• Mild chest recessions/
retractions
• Feeding and speech are not affected
• Tachypnea
• Recessions are moderate or severe
• Struggles to feed
• Cannot speak in full sentences
• Tachycardia
• Gasping
• Head bobbing
• Inability to speak
• Frightened
• Cyanotic, pale
• Quiet or agitated
• Hypoxic, even with oxygen
• Chest may be silent
• Consciousness may be impaired
182
(e) Tactile vocal fremitus
• Fremitus means the palpable vibrations transmitted through the bronchi and bronchioles to the chest wall as the child is speaking [28].
• If the child is aged more than 5 years, ask him/her to repeat “ninety-nine”
while you place the palmar bases of your fingers (or the ulnar aspect of both hands) on either side of the chest. Feel for vibrations, comparing side to side and repeat the same posteriorly.
• In a crying infant, you can assess vocal fremitus by palpation of the trans-mitted sounds over the chest [1].
• Vocal fremitus may be increased as in consolidation, decreased as in col-lapse, or absent as in pleural effusion [35, 37].
3. Percussion
(a) Explain to the child what you are going to do.
(b) Percussion should be gentle.
(c) Press firmly on the surface to be percussed, using your left middle finger (it should be hyperextended), and then strike its middle phalanx by the tip of your right middle finger at a right angle to it.
(d) Movement of your hand should be quick, sharp, and coming from the wrist.
(e) Avoid any other contacts between your hands and the child’s chest.
(f) Percuss anteriorly and posteriorly, and start from the upper to lower chest.
(g) Compare side by side.
(h) Percuss the clavicle directly.
(i) A normal lung gives a resonant percussion note; a hyperresonant note suggests pneumothorax or emphysema; a dull note may indicate consolidation, col-lapse, fibrosis, or pleural thickening; a stony, dull note suggests effusion [5].
4. Auscultation
(a) If the child is old enough, tell him/her what you are going to do.
(b) Do not start auscultation through the clothing.
(c) Use the bell or diaphragm of a pediatric stethoscope for auscultation. The low-pitched sounds of the chest are better heard with the bell. Furthermore, the bell is smaller and warmer than the diaphragm, and it allows less surface noise [1].
(d) Ask the child to breathe through his/her mouth.
(e) Auscultate anteriorly and in the axillae, comparing side to side while listen-ing from the upper to the lower chest.
(f) Repeat the auscultation from the back in a similar way.
(g) Try to assess the following:
• Air entry: Is the air entry bilaterally equal?
• Breath sounds: Assess the quality and amplitude of the breath sounds, identifing the length of inspiratory and expiratory phases and the presence of any gap between them.
– Normal breath sounds are vesicular
Low-pitched sounds, with no distinct interval between inspiration and expiration
4 Examination of the Older Child
– Bronchovesicular breath sounds (prolonged expiration)
Similar to vesicular, no gap between inspiration and expiration but characterized by a prolonged expiration
Suggests bronchopneumonias, asthma, or emphysema – Bronchial breath sounds
High-pitched sounds with a tubular quality, characterized by equal inspiratory and expiratory phases with a gap in between
Suggests consolidation, fibrosis, or atelectasis – Diminished or absent breath sounds
May suggest a bronchial obstruction, severe bronchitis, collapse pleu-ral effusion, pneumothorax, or a foreign-body inhalation.
• Added Sounds
– Transmitted upper-airway sounds
These are harsh sounds transmitted from the upper airway to the chest, such as gurgling. They are common in infants and toddlers [1, 37].
If you hear coarse, variable crackles in the chest, placing your stetho-scope on the side of the child’s neck may help you to know whether these sounds are transmitted or not. The conducted sounds will be louder over the neck [37].
– Rhonchi
Continuous, musical, high-pitched expiratory sounds indicate narrow-ing of the distal airway, due to mucosal edema, excessive mucus, or bronchospasm [1].
– Crackles (rales formally)
Discontinuous, non-musical, moist sounds result from the opening and closing of the bronchioles. Crackles may be fine or coarse.
Fine inspiratory crackles suggest an alveolar or bronchiolar disease, such as pulmonary edema or fibrosing alveolitis.
Coarse inspiratory or expiratory crackles can be heard in pneumonia or bronchiectasis.
If you heard crackles, ask the child to cough, and recheck to hear whether it is cleared or not.
– Pleural friction rub
A loud creaking sound indicates pleural irritation, as in pleurisy.
It is uncommon in children [37].
• Vocal Resonance
– Vocal resonance refers to the character of the patient’s voice that is heard over his/her chest with the stethoscope.
– If the child is old enough, ask him/her to say, “ninety-nine” while you auscultate his/her chest. Listen to the areas of the chest symmetrically to assess the amplitude and quality of vocal resonance.
– Normally, the patient’s voice is heard faintly and indistinctly. It becomes louder and clearer over areas of consolidation.
184
– The changes in vocal resonance that may be seen in certain diseases are:
Bronchophony (bronchiloquy): The patient’s voice is heard louder than normal over areas of consolidation.
Whispering pectoriloquy
Ask the child to whisper “ninety-nine” while you are listening over the auscultation areas. If the voice becomes louder and clearer, this is called
“whispering pectoriloquy,” which occurs in the case of airless lungs, such as lobar pneumonia [28, 37].
Egophony
Ask the child to say “ee” while you are listening over the area of abnor-mally located bronchial or bronchovesicular breath sounds. In some cases, such as lobar pneumonia, the voice will be heard as “ay” (as in say) [28, 37].
– Vocal resonance provides the same information as vocal fremitus, so it is sufficient to perform one of them [37].