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Systematic Examination of the Respiratory System - Pediatrics Posting

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1. BEFORE YOU BEGIN - Bedside Assessment

• Medications/oxygen delivery device (mask, nasal prongs - note flow rate), IV lines, nebulization equipment
• Is the child awake, alert, running around, or lying motionless?
• Is the child in distress? Any audible cough, wheeze, or stridor?
• Who is with them? (Caregiver presence matters)
• Use the Pediatric Assessment Triangle (PAT):
  • Appearance (TICLS: Tone, Interactiveness, Consolability, Look/Gaze, Speech/Cry)
  • Work of Breathing (retractions, nasal flaring, grunting, abnormal sounds)
  • Circulation to the skin (pallor, mottling, cyanosis)

Critical note: A child with epiglottitis sits upright, neck extended, drooling. Making such a child lie down or cry can precipitate complete airway obstruction. Defer full examination to a controlled setting if the child is gravely ill.

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2. GENERAL INSPECTION (From the End of the Bed)

• Nutritional status: Failure to thrive (suggestive of chronic hypoxia, CF, severe asthma)
• Level of consciousness/alertness: Irritability is an early sign of poor perfusion; lethargy is more ominous
• Posture:
  • Sniffing position: head slightly extended, attempting to align airway axes - seen in upper airway obstruction
  • Tripod position (sitting forward, hands on knees): ominous sign of severe respiratory distress
• Respiratory pattern: Rate, rhythm, depth. Note if abdominal or thoracic breathing
  • In infants < 6 months, breathing is normally diaphragmatic (abdominal)
  • Predominant thoracic breathing in infants suggests peritonitis/diaphragmatic pathology
• Audible sounds without stethoscope: stridor, wheeze, grunting

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3. VITAL SIGNS - Normal Pediatric Respiratory Rates

• SpO2: Pulse oximetry adds objective data on oxygenation status
• Temperature: Infants/young children have a larger surface area-to-mass ratio and lose heat rapidly; maintain a warm environment during examination

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4. HANDS

• Clubbing: Grade I-IV; seen in CF, bronchiectasis, empyema, cyanotic congenital heart disease, interstitial lung disease
• Peripheral cyanosis (blue fingers/toes)
• Capillary refill time: > 2 seconds is abnormal
• Tremor/flap: CO2 retention flap (asterixis) - rare in children, seen in severe hypercapnia
• Digital splinter hemorrhages: subacute bacterial endocarditis with pulmonary involvement

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5. FACE

• Central cyanosis: Blue discoloration of lips/tongue/mucous membranes - indicates severe hypoxemia (SpO2 typically < 85%)
• Nasal flaring: Widening of alae nasi with each breath - a sign of increased work of breathing, attempting to decrease airway resistance
• Allergic facies: Allergic shiners (dark circles under eyes), nasal crease (from upward rubbing = "allergic salute"), mouth breathing
• Pursed-lip breathing: Increases expiratory positive pressure; seen in obstructive airways disease
• Eyes: Horner syndrome (ptosis, miosis, anhidrosis) - may indicate apical lung pathology (Pancoast tumor - rare in children)

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6. NECK

Tracheal Position

• Deviated toward the lesion: Lung collapse (atelectasis), pneumonectomy, pulmonary fibrosis
• Deviated away from the lesion: Tension pneumothorax, massive pleural effusion, large mediastinal mass
• Tracheal tug (downward movement on inspiration): Severe hyperinflation, tension pneumothorax

Neck Lymph Nodes

Accessory Muscle Use

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7. CLOSE INSPECTION OF THE CHEST

Shape and Deformities

• Barrel chest (AP:lateral diameter > 1): Hyperinflation - chronic asthma, CF, emphysema
• Pectus excavatum (funnel chest): Concave sternum; may restrict lung expansion
• Pectus carinatum (pigeon chest): Convex sternum; associated with chronic childhood asthma, Marfan syndrome
• Harrison's sulcus: Horizontal groove at the lower chest margin (line of diaphragmatic attachment) - caused by prolonged respiratory distress in infancy (chronic asthma)
• Scoliosis/kyphosis: Restricts chest expansion

Retractions (Signs of Increased Work of Breathing)

• Suprasternal: Above the sternal notch - upper airway obstruction
• Supraclavicular: Above the clavicles
• Intercostal: Between the ribs
• Subcostal: Below the costal margin
• Sternal (in infants): Soft cartilage allows inward movement of the sternum

Signs of Impending Respiratory Failure

• Head bobbing: Neck muscles assist respiration
• Seesaw (paradoxical) breathing: Abdomen moves outward while chest moves inward during inspiration - sign of respiratory muscle fatigue and impending failure
• Grunting: Expiratory sound made by exhaling against a closed glottis to increase FRC and prevent alveolar collapse - represents impending respiratory failure in infants

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8. PALPATION

Chest Expansion

1. Place hands on the child's chest, inferior to the nipples
2. Wrap fingers around each side of the chest
3. Bring thumbs together in the midline so they touch
4. Ask child to breathe deeply - observe thumb movement

• Pneumonia/consolidation
• Pleural effusion
• Pneumothorax
• Lung collapse (atelectasis)
• Fibrosis

Apex Beat

• Normally felt at the 4th-5th intercostal space, midclavicular line
• Displaced laterally: cardiomegaly, mediastinal shift
• Difficult to feel: hyperinflation, obesity, pericardial effusion

Tactile (Vocal) Fremitus

• Increased fremitus: Increased parenchymal density - consolidation, lung collapse with patent bronchus
• Decreased fremitus: Fluid or air outside lung - pleural effusion, pneumothorax, pleural thickening

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9. PERCUSSION

Cardiac and Liver Dullness

• Liver dullness: right lower chest anteriorly (pushed down in hyperinflation)
• Cardiac dullness: left parasternal - may be obliterated in severe hyperinflation

Diaphragm Level

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10. AUSCULTATION

Normal Breath Sounds

Added/Adventitious Sounds

Vocal Resonance

• Increased resonance: Consolidation (egophony - "e" sounds like "a")
• Decreased resonance: Pleural effusion, pneumothorax
• Whispering pectoriloquy: Whispered "1-2-3" heard clearly through stethoscope - consolidation
• Aegophony (bronchophony): Voice transmitted more clearly than normal - consolidation

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11. POSTERIOR CHEST

1. Inspect: Scars (thoracotomy, VATS, chest drain sites), deformities, spinal curves
2. Assess posterior expansion: Hands at the level of the 10th rib, thumbs at the spine
3. Percuss: From upper to lower zones symmetrically
4. Auscultate: From apex to base, comparing sides

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12. ADDITIONAL FINDINGS TO LOOK FOR IN PEDIATRIC RESPIRATORY EXAM

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13. TO COMPLETE THE EXAMINATION

• Check growth parameters (weight, height, head circumference) - failure to thrive in CF/asthma
• Examine ENT (upper respiratory tract - rhinitis, tonsils, adenoids)
• Review SpO2, peak flow (in older children), and spirometry
• Look at sputum (purulent - infection; mucoid - asthma)
• Review CXR, CBC, CRP
• Assess immunization status (pertussis, measles, H. influenzae, pneumococcal vaccines)
• Check inhaler technique if the child is on inhalers

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Key Pediatric Respiratory Pearls

1. Never make a child lie down if epiglottitis is suspected - it can precipitate complete obstruction
2. Infants are obligate nasal breathers - nasal obstruction alone can cause significant distress in neonates
3. Abdominal breathing is normal in infants - paradoxical/seesaw breathing is pathological
4. Grunting in a neonate = impending respiratory failure; do not overlook it
5. Percussion is often less reliable in small infants due to the small chest and transmitted resonance
6. Clubbing in children - always think CF, bronchiectasis, cyanotic heart disease first
7. Auscultate over the trachea and neck to help localize the site of airway obstruction (upper vs lower)
8. Stridor localizes to larynx/trachea; wheeze localizes to small/medium airways

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