Respiratory examination in paediatrics

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The library does not have a dedicated paediatrics clinical examination textbook in this collection, so I will draw on my comprehensive medical knowledge to give you a thorough answer.

Respiratory Examination in Paediatrics

General Approach

Gain the child's trust before touching. Use toys, distraction, or the parent's lap.
Order of examination is flexible - opportunistic auscultation first when the child is quiet is perfectly acceptable.
Observe from a distance before approaching; much information comes from inspection alone.
Always examine with adequate exposure of the chest (front and back).

1. General Inspection (Before Touching)

Overall

Feature	What to Look For
Comfortable at rest vs. distressed	Agitation, crying, inability to feed
Posture	Tripod position (leaning forward, hands on knees) - severe airways obstruction
Colour	Cyanosis (central - tongue/mucous membranes), pallor, plethora
Audible sounds	Stridor (inspiratory - upper airway), wheeze (expiratory - lower airway), grunting (expiratory - severe disease, maintains PEEP)

Nutritional Status and Growth

Weight and height on centile chart
Failure to thrive is a red flag in chronic respiratory disease (e.g., cystic fibrosis, severe asthma)

2. Hands and Peripheries

Sign	Significance
Clubbing (loss of angle, drumstick appearance)	Cystic fibrosis, bronchiectasis, chronic suppurative lung disease, lung abscess, empyema
Cyanosis (peripheral)	Low cardiac output, cold
Pulse oximetry	SpO2 - the "5th vital sign" in children

3. Respiratory Rate (Most Important Vital Sign)

Always count for a full 60 seconds. Normal ranges:

Age	Normal Respiratory Rate (breaths/min)
Neonate (0-1 month)	40-60
Infant (1-12 months)	30-50
Toddler (1-2 years)	25-35
Pre-school (2-5 years)	25-30
School-age (5-12 years)	20-25
Adolescent (>12 years)	15-20

WHO defines tachypnoea (a key sign of pneumonia) as:

60/min in infants <2 months
50/min in 2-12 months
40/min in 1-5 years

4. Inspection of the Chest

Shape and Symmetry

Barrel chest (increased AP diameter): chronic hyperinflation - asthma, cystic fibrosis, bronchiolitis
Harrison's sulcus: horizontal groove at the level of the diaphragm insertion - chronic respiratory obstruction (historically rickets; also seen in asthma)
Asymmetry: scoliosis, pneumothorax, pleural effusion, collapse, pectus excavatum/carinatum
Pectus carinatum (pigeon chest): sometimes associated with asthma
Pectus excavatum (funnel chest): usually innocent but can restrict lung expansion

Recession/Retractions (Signs of Increased Work of Breathing)

These indicate the degree of respiratory distress - very important in children because the chest wall is compliant:

Type	Location	Severity
Subcostal	Below rib margin	Mild-moderate
Intercostal	Between ribs	Moderate
Sternal/substernal	Below sternum	Moderate-severe
Supraclavicular	Above clavicle	Severe
Tracheal tug	Downward tracheal movement on inspiration	Severe

Respiratory Pattern

Abdominal breathing: normal in infants; thoracic breathing takes over by age 5-6 years
Paradoxical breathing (chest moves in while abdomen moves out): diaphragm fatigue, neuromuscular disease
Asymmetric chest movement: collapse, effusion, pneumothorax

Nasal flaring

Alar flare on inspiration - sign of respiratory distress, especially in infants

5. Palpation

Position of trachea: deviation away from effusion/tension pneumothorax; towards collapse/fibrosis
Apex beat: mediastinal shift
Chest expansion: place thumbs at costal margins, fingers spreading around chest - thumbs should move apart equally. Reduced on the affected side in collapse, effusion, pneumothorax, consolidation
Tactile vocal fremitus: vibration felt with flat of hand when child says "ninety-nine" or "eee" - increased in consolidation, reduced/absent over effusion or pneumothorax. Less reliable in young children who cannot cooperate.

6. Percussion

Use quiet percussion in infants (1 finger on 1 finger)
Normal chest is resonant

Percussion Note	Condition
Dull	Consolidation, collapse, pleural effusion
Stony dull	Pleural effusion
Hyperresonant	Pneumothorax, hyperinflation
Liver dullness pushed down	Hyperinflation (asthma, bronchiolitis)

7. Auscultation

Use an appropriate-sized paediatric stethoscope diaphragm
Start wherever the child is least likely to object
Transmitted upper airway sounds are louder in children - always compare symmetrically

Breath Sounds

Sound	Character	Association
Vesicular	Normal, soft, rustling	Normal lung
Bronchial	Louder, harsh, expiration = inspiration	Consolidation
Reduced/absent	Quiet entry	Effusion, pneumothorax, collapse, severe obstruction

Added Sounds

Sound	Description	Association
Wheeze (ronchi)	Musical, expiratory > inspiratory	Asthma, bronchiolitis, foreign body
Inspiratory wheeze/stridor	High-pitched, heard at mouth	Croup, epiglottitis, foreign body, laryngomalacia
Crackles (crepitations)	Fine: pneumonia, pulmonary oedema; Coarse: bronchiectasis, secretions
Pleural rub	Creaking, leather-like, end of inspiration + beginning expiration	Pleuritis (rare in children)

Vocal Resonance

Ask child to say "ninety-nine" - increased over consolidation (bronchophony), absent over effusion
Whispering pectoriloquy: whispered voice heard clearly = consolidation

8. Special Paediatric Considerations

Age Group	Key Adaptations
Neonates	Periodic breathing normal (up to 10-15 sec pauses); grunting is serious; nasal flaring key sign
Infants (<1 year)	Obligate nasal breathers; abdominal breathing normal; transmitted sounds very loud
Toddlers (1-3 years)	Often uncooperative; opportunistic examination; cry changes breath sounds
Pre-school	Can follow simple commands; count RR when sleeping
School-age	Can fully cooperate; examination closer to adult approach

9. Completing the Examination

Oxygen saturation (pulse oximetry) - always
Peak flow in children >5 years (reversibility testing)
Temperature (fever suggests infection)
Lymph nodes: cervical, axillary - lymphadenopathy in infection, malignancy
ENT: nasal polyps (cystic fibrosis), allergic shiners, oropharynx
Abdomen: liver and spleen position (mediastinal shift), hepatomegaly in right heart failure, distension from air swallowing

10. Key Scoring Systems

Score	Used For	Components
PEWS (Paediatric Early Warning Score)	Deteriorating child	Behaviour, cardiovascular, respiratory
Respiratory Distress Assessment Score	Bronchiolitis	RR, recession, wheeze, SpO2, feeding
Modified Westley Croup Score	Croup severity	Stridor, retractions, air entry, cyanosis, consciousness
PRAM (Preschool Respiratory Assessment Measure)	Asthma severity	Suprasternal retraction, scalene muscle use, wheeze, air entry

Summary: Signs and Their Significance

Sign	Likely Diagnosis
Stridor + barking cough	Croup
Stridor + drooling + toxic	Epiglottitis
Wheeze + prolonged expiration	Asthma / bronchiolitis
Focal dullness + bronchial breathing	Consolidation (pneumonia)
Stony dullness + absent breath sounds	Pleural effusion
Hyperresonance + absent breath sounds	Pneumothorax
Clubbing + coarse crackles	Bronchiectasis / cystic fibrosis
Grunting + recession + cyanosis	Severe respiratory failure

This covers the full structured approach to paediatric respiratory examination. The key differences from adults are the age-specific normal values, the compliant chest wall causing prominent retractions, the loudness of transmitted sounds, the opportunistic approach in uncooperative children, and the greater reliance on inspection findings (recession, nasal flaring, grunting, colour) as markers of severity.

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