PEADS 45 alert conscious respiratory distress cyanosis RR HR SPO2 temperature BP radial pulse pallor jaundice nasal flaring central cyanosis oral thrush adenoid facies raised JVP tracheal position lymphadenopathy peripheral cyanosis clubbing pitting edema muscle wasting scars deformities [harrison sulcus] nasal flaring recession [ subcoastal /intercoastal] accessory muscle use tracheal position tracheal deviation apex beat chest expansion tactile vocal fremitus resonant dull hyper resonant stony dullness airentry breath sounds added sounds wheeze crackles stridor pleural rub VOCAL RESONANCE pedal edema sacral edema HOW TO COMMENT ON THIS POSITIVE AND NEGEATIVE COMPONENT
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Paediatric respiratory examination: how to present positive and negative findings
Present in this order:
- General condition and vital signs
- General physical examination
- Respiratory system examination
- Relevant cardiovascular signs, especially heart failure
- Summary and localisation
Do not list every sign as “negative.” Group normal findings into one concise sentence, then state the important positives clearly.
1. General condition and vitals
Normal example
A 4-year-old child is alert, conscious, and comfortable at rest. The child is afebrile and haemodynamically stable, with age-appropriate respiratory rate and heart rate. Oxygen saturation is 98% on room air. Peripheral pulses are well felt with good volume.
If abnormal
The child is alert but irritable and in respiratory distress, with tachypnoea, tachycardia, and oxygen saturation of 89% on room air. Temperature is 38.5°C. Blood pressure is maintained. Radial pulses are palpable and of good volume.
Use actual values, then interpret them:
RR 56/min, which is tachypnoea for age.
2. General physical examination
Suggested presentation format
The child is conscious and cooperative. There is/there is no pallor, icterus, clubbing, lymphadenopathy, pedal oedema, or sacral oedema. There is/there is no central cyanosis. Peripheral cyanosis is absent/present. Nutritional status is adequate, with no muscle wasting. No scars or chest-wall deformities are seen. JVP is not raised, where assessable.
Specific positives
| Finding | How to comment |
|---|---|
| Pallor | “Mild pallor is present.” |
| Jaundice | “There is no icterus.” |
| Central cyanosis | “Central cyanosis is present, seen over the tongue and oral mucosa.” |
| Peripheral cyanosis | “Peripheral cyanosis is present over the fingers/toes, with no central cyanosis.” |
| Clubbing | “Grade II digital clubbing is present.” |
| Lymph nodes | “No significant cervical or axillary lymphadenopathy.” |
| Oedema | “Bilateral pitting pedal oedema is present up to the ankles.” |
| Sacral oedema | “Sacral oedema is absent.” |
| Muscle wasting | “There is visible wasting of the temporalis and interossei muscles.” |
| Harrison sulcus | “Bilateral Harrison sulci are present, suggesting longstanding increased work of breathing/chest-wall indrawing.” |
| Scars | “No scars of thoracotomy, chest drain insertion, or previous surgery are seen.” |
| Adenoid facies | “Adenoid facies is present, with persistent open-mouth breathing and nasal speech.” |
| Oral thrush | “Oral candidiasis is present as removable white plaques over the tongue/buccal mucosa.” |
| Raised JVP | “JVP is raised.” In small children this is often difficult to assess, so say “JVP was not reliably assessable.” |
Do not call blue nail beds alone “central cyanosis.” Central cyanosis must be assessed on the tongue and oral mucosa.
3. Signs of respiratory distress
State these early because they determine severity.
The child has respiratory distress, evidenced by tachypnoea, nasal flaring, subcostal and intercostal recessions, and use of accessory muscles of respiration. There is no grunting or head bobbing.
Or, if absent:
There is no tachypnoea, nasal flaring, chest recession, grunting, head bobbing, or use of accessory muscles. The child is not in respiratory distress.
Chest recession may be described specifically as:
- Suprasternal recession
- Supraclavicular recession
- Intercostal recession
- Subcostal recession
In infants, subcostal recession is often easiest to appreciate.
Respiratory system examination
Inspection
The chest is symmetrical, with no scars, sinuses, dilated veins, chest-wall deformity, or asymmetry of movement. Trachea is central. Chest expansion is equal bilaterally.
If abnormal
There is reduced movement of the right hemithorax. The trachea is deviated to the left. Chest expansion is reduced on the right side.
Interpret the trachea carefully
- Deviation away from affected side: large pleural effusion, tension pneumothorax, large mass.
- Deviation towards affected side: collapse, fibrosis, post-pneumonectomy.
- Central trachea does not rule out pulmonary disease.
Palpation
Chest expansion is equal bilaterally. Tactile vocal fremitus is normal and equal on both sides. The apex beat is in the left fifth intercostal space, medial to the midclavicular line.
In younger children, tactile vocal fremitus and vocal resonance may be difficult or unreliable. You can say:
Tactile vocal fremitus was not reliably assessed because of the child’s age/lack of cooperation.
Positive comments
- “Expansion is reduced over the left lower chest.”
- “Tactile vocal fremitus is increased over the right infrascapular area.”
- “Tactile vocal fremitus is reduced over the left lower zone.”
- “Apex beat is displaced to the left.”
Percussion
Percussion note is resonant throughout both lung fields.
How to state abnormal findings
| Percussion note | Presentation | Common implication |
|---|---|---|
| Dull | “Percussion is dull over the right infrascapular and infra-axillary areas.” | Consolidation, collapse, pleural thickening |
| Stony dull | “There is stony dullness over the left lower zone.” | Pleural effusion |
| Hyper-resonant | “The right hemithorax is hyper-resonant.” | Pneumothorax, hyperinflation |
| Reduced resonance | “There is impaired resonance over the right lower zone.” | Effusion or consolidation |
Always add site and side.
Auscultation
Air entry and breath sounds
Air entry is equal bilaterally. Vesicular breath sounds are heard throughout, with no added sounds.
Or:
Air entry is reduced in the left lower zone. Bronchial breath sounds are heard over the right infrascapular area.
Added sounds
| Finding | How to comment | Usual significance |
|---|---|---|
| Wheeze | “Polyphonic expiratory wheeze is heard bilaterally.” | Diffuse lower-airway obstruction, such as asthma/bronchiolitis |
| Localised wheeze | “A monophonic wheeze is heard over the right lung.” | Localised bronchial obstruction, including foreign body |
| Crackles | “Fine end-inspiratory crackles are heard over both basal areas.” | Alveolar/interstitial process |
| Coarse crackles | “Coarse crackles are heard over the right lower zone.” | Secretions, bronchiectasis, pneumonia |
| Stridor | “Inspiratory stridor is audible at rest.” | Upper-airway obstruction. This is an urgent sign if associated with distress, cyanosis, or reduced consciousness. |
| Pleural rub | “A pleural friction rub is heard over the right lower lateral chest.” | Pleurisy, pneumonia, pulmonary infarction |
Also note timing:
- Inspiratory or expiratory
- Fine or coarse
- Localised or bilateral
- Persistent after coughing or not
Vocal resonance
Vocal resonance is normal and equal bilaterally.
Or:
Vocal resonance is increased over the right lower zone.
Vocal resonance is reduced over the left lower zone.
Interpretation:
- Increased vocal resonance: usually consolidation.
- Reduced vocal resonance: pleural effusion, pneumothorax, obstruction, or thick chest wall.
Again, in a small child:
Vocal resonance was not reliably assessable due to age and cooperation.
Ready-to-use normal respiratory examination comment
The child is alert, conscious, and comfortable at rest. Vital signs are stable for age, with normal oxygen saturation on room air. There is no pallor, icterus, central or peripheral cyanosis, clubbing, lymphadenopathy, pedal oedema, sacral oedema, or muscle wasting. There are no scars or chest-wall deformities, including Harrison sulcus.There is no nasal flaring, chest recession, grunting, or use of accessory muscles. The trachea is central and the apex beat is normally located. Chest expansion is equal bilaterally. Percussion note is resonant throughout. Air entry is equal on both sides with vesicular breath sounds. There are no added sounds. Vocal resonance is normal and equal bilaterally.There is no clinical evidence of respiratory distress, consolidation, pleural effusion, pneumothorax, or heart failure.
Example: child with pneumonia and right lower-zone consolidation
The child is alert but febrile and tachypnoeic, with mild respiratory distress. There is no pallor, icterus, cyanosis, clubbing, lymphadenopathy, or peripheral oedema.There is nasal flaring and right-sided reduced chest movement, with subcostal and intercostal recession. The trachea is central. Chest expansion is reduced on the right lower chest. Tactile vocal fremitus is increased over the right infrascapular area. Percussion is dull in the right lower zone. Air entry is reduced, with bronchial breath sounds and inspiratory crackles in the right infrascapular and infra-axillary regions. Vocal resonance is increased in the same area.These findings are suggestive of right lower-lobe consolidation.
Example: pleural effusion
The child has tachypnoea with reduced movement of the left hemithorax. The trachea is deviated to the right. Chest expansion is reduced on the left. Tactile vocal fremitus and vocal resonance are reduced over the left lower zone. There is stony dullness to percussion, markedly reduced air entry, and absent breath sounds over the left lower chest.These findings are consistent with a large left pleural effusion.
Example: asthma / lower-airway obstruction
The child is alert but in respiratory distress, with tachypnoea, nasal flaring, subcostal recession, and use of accessory muscles. There is no central cyanosis. The chest is hyperinflated with reduced bilateral chest expansion. Percussion note is hyper-resonant bilaterally. Air entry is globally reduced, with bilateral widespread polyphonic expiratory wheeze.These findings suggest acute lower-airway obstruction, such as acute asthma. A “silent chest” with very poor air entry is a severe, life-threatening sign.
One-line summary pattern for exams
This is a child with [severity of distress], with examination findings localising to the [side and zone], suggestive of [syndrome/diagnosis], with or without clinical features of hypoxaemia or heart failure.
Example:
This is a child with moderate respiratory distress and signs of right lower-zone consolidation, most consistent with right lower-lobe pneumonia, without clinical evidence of heart failure.
MAKE A CHART STEP, POSITIVE COMMENTING, NEGATIVE COMMENTING IMPLICATIONS
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Royal Children's Hospital respiratory examination chest signs children nasal flaring recession cyanosis
Paediatric respiratory examination chart
| Step / item | Positive commenting | Negative commenting | Implications |
|---|---|---|---|
| General appearance | “Child is alert but irritable/lethargic.” | “Child is alert, conscious, and comfortable at rest.” | Irritability may reflect hypoxaemia or distress. Drowsiness, poor response, or exhaustion suggests impending respiratory failure. |
| Respiratory distress | “Child is in respiratory distress.” State the signs: tachypnoea, nasal flaring, recession, grunting, accessory-muscle use. | “There are no clinical features of respiratory distress.” | Indicates severity of respiratory illness. Severe distress requires urgent assessment. |
| Respiratory rate | “RR is 56/min, tachypnoeic for age.” | “Respiratory rate is appropriate for age.” | Tachypnoea occurs in pneumonia, bronchiolitis, asthma, metabolic acidosis, fever, and heart failure. A normal or slow RR in a tiring distressed child can be ominous. |
| Heart rate | “Heart rate is 150/min, tachycardic for age.” | “Heart rate is appropriate for age.” | Tachycardia may result from fever, hypoxaemia, dehydration, distress, or sepsis. Bradycardia in a hypoxic child is pre-terminal. |
| SpO₂ | “SpO₂ is 89% on room air.” | “SpO₂ is 98% on room air.” | Low saturation indicates hypoxaemia. Interpret with the child’s clinical appearance and oxygen requirement. |
| Temperature | “Child is febrile, temperature 38.8°C.” | “Child is afebrile.” | Fever supports infection but absence of fever does not exclude serious infection, especially in young infants. |
| Blood pressure | “BP is low for age.” | “BP is maintained for age.” | Hypotension is a late sign of shock in children. |
| Radial pulse / perfusion | “Radial pulses are weak, with prolonged capillary refill.” | “Radial pulses are well felt, equal, and of good volume.” | Weak pulses suggest poor perfusion, dehydration, sepsis, or cardiac dysfunction. |
| Pallor | “Mild pallor is present.” | “No pallor.” | Anaemia, chronic disease, or poor perfusion. Severe anaemia can worsen breathlessness. |
| Jaundice | “Icterus is present.” | “No icterus.” | May suggest haemolysis, liver disease, or systemic illness. Usually not a primary respiratory sign. |
| Central cyanosis | “Central cyanosis is present over the tongue and oral mucosa.” | “No central cyanosis.” | Indicates significant hypoxaemia or a right-to-left cardiac shunt. Urgent assessment is required. |
| Peripheral cyanosis | “Peripheral cyanosis is present over the extremities, with/without central cyanosis.” | “No peripheral cyanosis.” | May result from cold exposure or poor peripheral perfusion. Alone, it does not confirm hypoxaemia. |
| Nasal flaring | “Nasal flaring is present.” | “No nasal flaring.” | Increased work of breathing, especially important in infants. |
| Subcostal/intercostal recession | “Subcostal and intercostal recessions are present.” | “No chest-wall recession.” | Increased work of breathing. Suprasternal or sternal recession suggests more severe distress. |
| Accessory-muscle use | “There is use of accessory muscles of respiration.” | “No accessory-muscle use.” | Significant increased work of breathing, often asthma or severe lower respiratory illness. |
| Grunting / head bobbing | “Expiratory grunting/head bobbing is present.” | “No grunting or head bobbing.” | Grunting suggests severe alveolar disease or respiratory distress. Head bobbing in infants can indicate fatigue. |
| Oral thrush | “Oral thrush is present as white removable plaques.” | “No oral thrush.” | May occur after inhaled corticosteroids, antibiotic use, or immunosuppression. |
| Adenoid facies | “Adenoid facies is present, with open-mouth breathing.” | “No adenoid facies.” | Suggests chronic nasal obstruction, often adenoidal hypertrophy. |
| Lymphadenopathy | “Cervical lymphadenopathy is present.” | “No significant cervical lymphadenopathy.” | Infection, tuberculosis, lymphoma, or other systemic disease depending on context. |
| Clubbing | “Grade II digital clubbing is present.” | “No clubbing.” | Chronic suppurative lung disease, bronchiectasis, cystic fibrosis, interstitial lung disease, cyanotic congenital heart disease. |
| Pedal / sacral oedema | “Bilateral pitting pedal oedema and sacral oedema are present.” | “No pedal or sacral oedema.” | Suggests right heart failure, fluid overload, nephrotic syndrome, or hypoalbuminaemia. |
| Muscle wasting | “There is visible muscle wasting.” | “No muscle wasting.” | Chronic illness, malnutrition, tuberculosis, malignancy, or chronic respiratory disease. |
| Scars | “A right thoracotomy/chest-drain scar is present.” | “No chest scars.” | Previous cardiothoracic surgery, chest tube, trauma, or empyema treatment. |
| Chest deformity / Harrison sulcus | “Bilateral Harrison sulci are present.” | “No chest-wall deformity or Harrison sulcus.” | May reflect longstanding increased work of breathing or rickets. |
Chest examination
| Step / item | Positive commenting | Negative commenting | Implications |
|---|---|---|---|
| Tracheal position | “Trachea is deviated to the left/right.” | “Trachea is central.” | Deviation away from pathology: large pleural effusion, tension pneumothorax. Deviation towards pathology: collapse, fibrosis. |
| Apex beat | “Apex beat is displaced to the left/right.” | “Apex beat is in the normal position.” | Displacement may occur with mediastinal shift, cardiomegaly, hyperinflation, large effusion, or collapse. |
| Chest shape | “Chest is hyperinflated/barrel-shaped.” | “Chest shape is normal.” | Hyperinflation can occur in asthma, bronchiolitis, or chronic obstructive airway disease. |
| Chest movement | “Right/left chest movement is reduced.” | “Chest movement is symmetrical bilaterally.” | Reduced movement suggests collapse, consolidation, pleural effusion, pneumothorax, pain, or splinting. |
| Chest expansion | “Chest expansion is reduced on the left lower chest.” | “Chest expansion is equal bilaterally.” | Unilateral reduction suggests focal lung or pleural pathology. Bilateral reduction may occur in severe asthma, hyperinflation, or neuromuscular weakness. |
| Tactile vocal fremitus | “Tactile vocal fremitus is increased over the right lower zone.” | “Tactile vocal fremitus is equal bilaterally.” | Increased in consolidation. Decreased in pleural effusion, pneumothorax, and major airway obstruction. In very young children it may be unreliable. |
| Percussion: resonant | Not applicable as a positive pathology finding: “Percussion note is resonant throughout.” | “No areas of impaired resonance, dullness, or hyper-resonance.” | Normal air-filled lung. |
| Percussion: dull | “Percussion note is dull over the right lower zone.” | “No dullness to percussion.” | Consolidation, collapse, or pleural thickening. |
| Percussion: stony dull | “There is stony dullness over the left lower zone.” | “No stony dullness.” | Strongly suggests pleural effusion. |
| Percussion: hyper-resonant | “The right hemithorax is hyper-resonant.” | “No hyper-resonance.” | Pneumothorax, unilateral air trapping, or hyperinflation. |
| Air entry | “Air entry is reduced over the left lower zone.” | “Air entry is equal bilaterally.” | Reduced locally: effusion, pneumothorax, collapse, consolidation, foreign body. Globally reduced: severe asthma, poor respiratory effort. |
| Breath sounds | “Bronchial breath sounds are heard in the right infrascapular area.” | “Vesicular breath sounds are heard bilaterally.” | Bronchial breathing suggests consolidation if heard away from the trachea. Absent breath sounds can indicate effusion, pneumothorax, or severe obstruction. |
| Wheeze | “Bilateral polyphonic expiratory wheeze is present.” | “No wheeze.” | Diffuse lower-airway obstruction, such as asthma or bronchiolitis. A unilateral monophonic wheeze raises concern for foreign body or focal obstruction. |
| Crackles | “Fine inspiratory crackles are heard over both basal areas.” | “No crackles.” | Pneumonia, bronchiolitis, pulmonary oedema, interstitial disease, or bronchiectasis depending on pattern and location. |
| Stridor | “Inspiratory stridor is audible at rest.” | “No stridor.” | Upper-airway obstruction. Stridor at rest with distress, cyanosis, drooling, or altered consciousness is an emergency. |
| Pleural rub | “A pleural friction rub is heard over the right lower lateral chest.” | “No pleural rub.” | Pleural inflammation, often with pneumonia, pulmonary infarction, or pleurisy. |
| Vocal resonance | “Vocal resonance is increased over the right lower zone.” | “Vocal resonance is equal bilaterally.” | Increased in consolidation. Decreased in pleural effusion or pneumothorax. Often difficult to assess reliably in young children. |
Short reporting template
The child is alert/conscious and is comfortable/in respiratory distress. The child is afebrile/febrile, with RR ___/min, HR ___/min, SpO₂ ___% on room air, and BP ___, appropriate/not appropriate for age. There is/are no pallor, icterus, central cyanosis, clubbing, lymphadenopathy, or peripheral oedema.There is/are no nasal flaring, chest recession, grunting, or accessory-muscle use. The trachea is central, apex beat is normally placed, and chest expansion is equal bilaterally. Percussion note is resonant. Air entry is equal bilaterally with vesicular breath sounds. There are no added sounds. Vocal resonance is normal.Summary: No clinical evidence of respiratory distress, focal consolidation, pleural effusion, pneumothorax, or heart failure.
Signs such as recession, nasal flaring, cyanosis, reduced chest expansion, reduced air entry, and abnormal respiratory rate are recognised markers of respiratory compromise in children in the Royal Children’s Hospital guideline.
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