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Methods of Examination of Children with Respiratory System Diseases

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1. History Taking (Anamnesis)

• Duration and onset of symptoms (acute vs. chronic/recurrent)
• Cough: character (dry, productive, barking/croupy, staccato), timing (nocturnal, post-exercise), severity
• Dyspnea: at rest vs. on exertion; positional (orthopnea suggests cardiac/pleural disease)
• Wheeze, stridor, noisy breathing
• Fever, rhinorrhea, sore throat (viral URTI preceding LRT involvement)
• Cyanosis episodes

• Gestational age, birth weight (prematurity → chronic lung disease of prematurity)
• Neonatal respiratory distress, ventilator use
• Feeding difficulties (aspiration, gastro-oesophageal reflux)

• Recurrent chest infections, prior hospitalisation/ICU admissions
• Asthma, atopy (eczema, allergic rhinitis)
• Immunisation status (pertussis, measles, Haemophilus influenzae, pneumococcus)
• TB contact or travel history

• Parental asthma, atopy, cystic fibrosis
• Smoking in household (passive smoke)
• Pets, mould, dust mites, recent sick contacts
• Day-care attendance (increased exposure to respiratory viruses)

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2. Inspection Techniques

Respiratory Rate Counting

Chest Shape Assessment

• Normal: Elliptical cross-section; AP:transverse diameter ≈ 1:2 in older children
• Barrel chest (increased AP diameter): air trapping in chronic asthma, bronchiolitis, cystic fibrosis
• Pectus excavatum (funnel chest): depression of lower sternum; can compress lungs
• Pectus carinatum (pigeon chest): protrusion of sternum; seen in chronic respiratory disease
• Harrison's sulcus: transverse groove along the lower costal margin caused by chronic increased work of breathing (rickets, chronic asthma)
• Kyphoscoliosis: reduces lung volume and causes restrictive pattern
• Asymmetry: one side flattened (collapse, fibrosis) or bulging (large effusion, tension pneumothorax)

• Breathing pattern: abdominal (normal in infants/toddlers), costal (older children/adults); paradoxical chest movement suggests flail chest or respiratory muscle weakness
• Cyanosis: central (tongue/mucous membranes) vs. peripheral; indicates severe hypoxaemia

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3. Types of Pathological Breathing

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4. Recognition of Respiratory Distress Signs

Nasal Flaring

• Rhythmic widening of the nares on inspiration
• Increases the cross-sectional area of the nasal airway, reducing resistance
• Common in infants and young children with pneumonia, bronchiolitis, or upper airway obstruction

Retractions (Indrawing)

The lower in the chest wall, the more severe the distress. Subcostal and lower sternal retractions ("abdominal indrawing") suggest severe disease. — ROSEN's Emergency Medicine

Grunting

• Expiratory sound produced by partial closure of the glottis during exhalation
• Acts as auto-PEEP: maintains functional residual capacity (FRC) and prevents alveolar collapse
• Indicates significant lung disease (neonatal RDS, pneumonia, pulmonary oedema, severe bronchiolitis)
• Always a serious sign requiring urgent assessment

Accessory Muscle Use

• Sternocleidomastoid, scalene, and trapezius recruitment on inspiration
• Causes head bobbing in infants (SCM use moves the head with each breath)

Tripod/Sniffing Position

• Child leans forward on outstretched arms (tripod) or juts chin forward (sniffing)
• Optimises airway patency; seen in severe croup, epiglottitis, foreign body

Summary — PAT Work of Breathing Assessment

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5. Palpation

Chest Expansion

• Normal: equal and full bilateral expansion
• Unilateral reduction: Pneumothorax, consolidation, effusion, atelectasis, endobronchial obstruction on that side
• Bilateral reduction: Generalised hyperinflation (asthma), bilateral disease, neuromuscular weakness

In small infants, expansion is assessed by observation rather than hand placement.

Vocal (Voice/Tactile) Fremitus

• Less reliable in infants/toddlers; tremor and crying complicate assessment
• Confirm with percussion and auscultation

Tracheal Position

• Palpate the trachea in the suprasternal notch
• Deviation toward lesion: Collapse, atelectasis, fibrosis
• Deviation away from lesion: Tension pneumothorax, large pleural effusion

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6. Percussion

Comparative Percussion

Topographic (Boundary) Percussion

• Anterior: 2nd–6th rib
• Lateral: axillary region down to 8th rib
• Posterior upper border: at level of C7 (lung apex)
• Lower border posteriorly: approximately T10 at rest

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7. Pathological Percussion Sounds

• Consolidation: dull + increased fremitus + bronchial breathing
• Pleural effusion: stony dull + absent fremitus + absent breath sounds ± pleural rub above effusion
• Pneumothorax: hyperresonant/tympanitic + absent fremitus + absent breath sounds
• Atelectasis: dull + reduced expansion on that side + absent or reduced breath sounds

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8. Auscultation Technique and Normal Breath Sounds

• Use a paediatric stethoscope with a small diaphragm (or bell for low-pitched sounds)
• Child sitting upright if possible, arms slightly forward (to protract scapulae and expose posterior fields)
• Auscultate systematically: anterior → lateral → posterior, comparing sides at each level
• Ask cooperating children to breathe deeply through an open mouth; in infants, listen during quiet breathing and during crying for bronchovesicular sounds
• Warm the stethoscope chest piece before use

• Anterior: 2nd ICS midclavicular line bilaterally, 4th–5th ICS
• Lateral: mid-axillary line at 4th–6th ICS
• Posterior: above spine of scapula, between scapula and spine (interscapular), below scapula (infrascapular), basal angles

Normal Breath Sounds

In young infants, breath sounds are louder and more bronchial-sounding throughout the chest due to the thin chest wall — this is normal.

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9. Pathological Breath Sounds

Altered Transmission Sounds

Added/Adventitious Sounds

Wheezing

• High-pitched musical sound, predominantly expiratory (can be biphasic)
• Generated by turbulent flow through narrowed lower airways
• Causes: asthma (diffuse, bilateral, polyphonic), bronchiolitis, foreign body (focal, monophonic), cardiac failure
• Monophonic wheeze = single airway obstruction (foreign body, mucous plug)
• Polyphonic wheeze = generalised airway narrowing (asthma)

Crackles (Rales)

• Discontinuous, explosive sounds caused by sudden opening of collapsed small airways or by air bubbling through secretions
• Fine crackles (crepitations): High-pitched, late inspiratory; heard in pneumonia (alveolar), pulmonary oedema, fibrosis; do not clear with cough
• Coarse crackles: Low-pitched, early inspiratory and expiratory; secretions in larger airways (bronchiectasis, CF); may partially clear with cough

Stridor

• Harsh, high-pitched sound, predominantly inspiratory
• Generated by partial obstruction at or above the level of the larynx/extrathoracic trachea
• Inspiratory stridor: Supraglottic/glottic obstruction (croup, epiglottitis, foreign body, haemangioma)
• Expiratory stridor: Subglottic/upper tracheal (fixed obstruction)
• Biphasic stridor: Glottic/subglottic obstruction (fixed, critical)

Ronchi (Rhonchi)

• Low-pitched, snoring/musical sounds generated by secretions in larger airways
• Predominantly expiratory; may clear with coughing

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10. Pleural Friction Rub and Crepitus

Pleural Friction Rub

• Character: Creaking, grating, leathery sound — like two pieces of sandpaper rubbed together
• Timing: Heard in both inspiration and expiration, usually at the end of inspiration and beginning of expiration
• Location: Lower lateral chest wall (most common site of pleuritis)
• Mechanism: Inflammation of the parietal and visceral pleura causes loss of normal smooth serosal surface; friction during respiratory movements generates the sound
• Causes: Pleuritis (viral, bacterial pneumonia with pleural involvement), pulmonary embolism with infarction, systemic lupus erythematosus, tuberculosis, malignancy
• Key distinguishing feature: Does NOT change with coughing (unlike crackles); disappears when the patient holds their breath; disappears once effusion accumulates (fluid separates the pleural surfaces)

Subcutaneous Crepitus (Surgical Emphysema)

• Crackling sensation on palpation of the skin (like crushing cornstarch)
• Air in the subcutaneous tissues
• Causes: Pneumothorax with chest wall tracking, after thoracic trauma or procedure, spontaneous in children (after severe vomiting – Hamman's sign for pneumomediastinum)

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Summary: Examination Findings in Common Paediatric Respiratory Conditions

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