Pediatric Respiratory System Examination Guide

1. Inspection

1.1 Respiratory Rate

Technique for Counting Respiratory Rate:

1. Ensure the child is calm and settled. If possible, count while the child is unaware, as awareness may alter their breathing pattern.
2. Observe the rise and fall of the chest or abdomen. In infants, abdominal breathing is more prominent.
3. Count for a full 60 seconds to get an accurate rate. If the child's breathing is very irregular, count for 2 or 3 minutes and calculate the average per minute.
4. Note any pauses in breathing or periodic breathing patterns.

Normal and Abnormal Respiratory Rates:

Age Group	Normal Rate (breaths/min)	Tachypnea (breaths/min)	Bradypnea (breaths/min)
0-2 months	40-60	>60	<40
2-12 months	25-40	>50	<25
1-5 years	20-30	>40	<20
6-12 years	15-25	>30	<15
12-18 years	12-20	>25	<12

Conditions Associated with Abnormal Respiratory Rates:

• Tachypnea (increased rate):
  • Respiratory infections (e.g., pneumonia, bronchiolitis)
  • Asthma exacerbation
  • Anxiety or pain
  • Metabolic acidosis (e.g., diabetic ketoacidosis)
  • Fever
  • Congestive heart failure
• Bradypnea (decreased rate):
  • Central nervous system depression (e.g., increased intracranial pressure, drug intoxication)
  • Hypothyroidism
  • Severe hypothermia

1.2 Chest Shape and Symmetry

Technique for Assessing Chest Shape:

1. Position the child appropriately: sitting upright for older children, supine for infants.
2. Observe the chest from the front, sides, and back if possible.
3. Note the overall shape, paying attention to the sternum, ribs, and any visible deformities.
4. Assess for symmetry by comparing the left and right sides of the chest.

Normal Chest Shape:

A normal chest is symmetrical with a 1:1 anteroposterior to lateral diameter ratio. The sternum should be midline and not protruding or sunken.

Abnormal Chest Shapes and Associated Conditions:

Abnormal Shape	Description	Associated Conditions
Barrel chest	Increased anteroposterior diameter, giving a rounded appearance	Chronic obstructive pulmonary disease (rare in children) Severe persistent asthma Cystic fibrosis
Pectus excavatum	Sunken or concave sternum	Congenital defect Marfan syndrome Ehlers-Danlos syndrome
Pectus carinatum	Protruding sternum (pigeon chest)	Congenital defect Marfan syndrome Rickets
Asymmetrical chest	One side of the chest appears larger or more prominent	Pneumothorax Pleural effusion Atelectasis Scoliosis
Harrison's sulcus	Horizontal groove along the lower chest wall at the diaphragm insertion	Chronic airway obstruction Rickets

1.3 Breathing Pattern

Technique for Assessing Breathing Pattern:

1. Observe the child's breathing for at least one full minute.
2. Note the rhythm, depth, and effort of breathing.
3. Assess for any abnormal patterns or use of accessory muscles.

Normal and Abnormal Breathing Patterns:

Pattern	Description	Associated Conditions
Normal	Regular, effortless breathing with minimal chest wall movement	Healthy state
Kussmaul breathing	Deep, rapid breathing	Metabolic acidosis (e.g., diabetic ketoacidosis)
Cheyne-Stokes respiration	Alternating periods of hyperpnea and apnea	Severe neurological disorders, congestive heart failure
Biot's respiration	Irregular breathing with periods of apnea	Increased intracranial pressure, meningitis
Sighing respiration	Frequent sighs or deep breaths	Anxiety, hyperventilation syndrome

1.4 Use of Accessory Muscles

Technique for Assessing Accessory Muscle Use:

1. Observe the neck, chest, and abdominal muscles during breathing.
2. Look for visible contractions of sternocleidomastoid, scalene, and intercostal muscles.
3. Note any suprasternal, supraclavicular, or intercostal retractions.

Interpretation of Accessory Muscle Use:

• Mild: Subtle use of accessory muscles, minimal retractions
• Moderate: Visible use of neck muscles, clear retractions
• Severe: Prominent use of all accessory muscles, marked retractions

Associated Conditions:

• Asthma exacerbation
• Bronchiolitis
• Pneumonia
• Upper airway obstruction (e.g., croup)
• Congenital heart disease with pulmonary overcirculation

1.5 Presence of Cough or Audible Breath Sounds

Technique for Assessing Cough and Audible Sounds:

1. Listen for any spontaneous cough or audible breathing during the examination.
2. If no spontaneous cough is present, ask the child (if old enough) to cough.
3. Note the character of the cough and any associated sounds.

Types of Cough and Associated Conditions:

Cough Type	Description	Associated Conditions
Barking cough	Harsh, seal-like bark	Croup
Wet, productive cough	Cough with audible secretions	Pneumonia, bronchitis, bronchiectasis
Dry, hacking cough	Nonproductive, irritating cough	Viral upper respiratory infections, asthma
Paroxysmal cough	Repeated, violent coughs followed by a whooping inhalation	Pertussis (whooping cough)

Audible Breath Sounds and Associated Conditions:

• Wheeze: High-pitched whistling sound, associated with airway narrowing (e.g., asthma, bronchiolitis)
• Stridor: Harsh, monophonic sound heard on inspiration, indicating upper airway obstruction (e.g., croup, foreign body aspiration)
• Stertor: Low-pitched snoring sound, suggesting nasopharyngeal obstruction
• Grunting: Expiratory sound made by partial closure of the glottis, often seen in respiratory distress

2. Palpation

2.1 Chest Expansion

Technique for Assessing Chest Expansion:

1. Place your hands on the child's chest, with thumbs meeting in the midline.
2. Ask the child to take a deep breath (for older children) or observe normal breathing in infants.
3. Feel for the symmetry and extent of chest expansion.

Interpretation of Findings:

• Normal: Symmetrical expansion on both sides
• Reduced expansion on one side:
  • Pneumothorax
  • Pleural effusion
  • Atelectasis
  • Pneumonia
• Bilateral reduced expansion:
  • Severe asthma
  • Bronchiolitis
  • Neuromuscular disorders affecting respiratory muscles

2.2 Tactile Fremitus

Technique for Assessing Tactile Fremitus:

1. Place the palmar surface of your hands on the child's chest wall.
2. Ask the child to say "ninety-nine" or make a humming sound (for older children).
3. Feel for the vibrations transmitted through the chest wall.
4. Compare the intensity of vibrations between different areas of the chest.

Interpretation of Findings:

• Normal: Equal fremitus on both sides
• Increased fremitus:
  • Consolidation (e.g., pneumonia)
  • Compressed lung tissue (e.g., around a tumor)
• Decreased or absent fremitus:
  • Pleural effusion
  • Pneumothorax
  • Emphysema
  • Obstructed bronchus

2.3 Masses or Areas of Tenderness

Technique for Assessing Masses or Tenderness:

1. Gently palpate the entire chest wall, including the sternum and ribs.
2. Note any areas of swelling, masses, or tenderness.
3. Observe the child's reaction to palpation.

Interpretation of Findings:

• Localized tenderness:
  • Rib fracture
  • Costochondritis
  • Muscle strain
• Masses:
  • Lymphadenopathy
  • Neoplasms (rare in children)
  • Subcutaneous emphysema

3. Percussion

3.1 Technique for Percussion

1. Position the child appropriately: sitting up for older children, supine for infants.
2. Place the middle finger of your non-dominant hand firmly against the chest wall.
3. Using the middle finger of your dominant hand, strike the middle phalanx of the placed finger with a quick, sharp motion.
4. Percuss symmetrically on both sides of the chest, moving from top to bottom.
5. Compare the sounds between left and right sides and between different areas of the chest.

3.2 Types of Percussion Notes

Percussion Note	Description	Normal Location	Associated Conditions if Abnormal
Resonant	Loud, low-pitched, hollow sound	Normal lung tissue	N/A (normal finding)
Hyperresonant	Louder and lower pitched than resonant	None	Pneumothorax, emphysema, severe asthma
Dull	Soft, high-pitched, short duration	Over the heart (cardiac dullness)	Pleural effusion, pneumonia, atelectasis
Flat	Very soft, high-pitched, similar to percussing thigh	None	Large pleural effusion, thoracic tumors
Tympanic	Musical, drum-like quality	Over the stomach	Large pneumothorax, large lung bullae

3.3 Special Percussion Techniques

3.3.1 Diaphragm Excursion

1. Percuss downward on the back until the note changes from resonant to dull (diaphragm level).
2. Mark this point and ask the child to take a deep breath.
3. Percuss again to find the new diaphragm level.
4. Measure the distance between the two points (normal is 3-5 cm in children).

Interpretation: Decreased excursion may indicate restrictive lung disease, pneumonia, or pleural effusion.

3.3.2 Chest Expansion

1. Place your hands on the child's back with thumbs at the level of the 10th rib.
2. Ask the child to take a deep breath and observe thumb separation.
3. Normal expansion is 3-5 cm in children.

Interpretation: Asymmetrical or decreased expansion may indicate various respiratory or pleural conditions.

4. Auscultation

4.1 Technique for Auscultation

1. Use an appropriately sized stethoscope for the child's age.
2. Warm the stethoscope before placing it on the child's skin.
3. Ask older children to take slow, deep breaths through an open mouth.
4. For infants and young children, listen during normal breathing.
5. Auscultate symmetrically on both sides of the chest, comparing left to right.
6. Listen to at least one full respiratory cycle in each location.
7. Pay attention to inspiratory and expiratory sounds separately.

4.2 Breath Sounds

Breath Sound	Description	Normal Location	Associated Conditions if Abnormal
Vesicular	Soft, low-pitched, heard throughout inspiration and early expiration	Most of the lung fields	N/A (normal finding)
Bronchovesicular	Medium-pitched, heard equally during inspiration and expiration	Over the main stem bronchi	Consolidation if heard elsewhere
Bronchial	Loud, high-pitched, tubular quality	Over the trachea	Pneumonia, atelectasis if heard over lung fields
Diminished	Decreased intensity of normal breath sounds	None	Pneumothorax, pleural effusion, severe asthma, obesity
Absent	No audible breath sounds	None	Large pneumothorax, large pleural effusion, complete airway obstruction

4.3 Adventitious Sounds

Adventitious Sound	Description	Timing	Associated Conditions
Crackles (Rales)	Discontinuous, brief, popping sounds	Usually inspiratory	Pneumonia, pulmonary edema, bronchiolitis, interstitial lung disease
Wheezes	Continuous, musical sounds	Usually expiratory	Asthma, bronchiolitis, foreign body aspiration
Rhonchi	Low-pitched, snoring-like sounds	Inspiratory or expiratory	Secretions in large airways, chronic bronchitis
Stridor	Harsh, monophonic, high-pitched sound	Inspiratory	Croup, epiglottitis, foreign body in upper airway
Pleural friction rub	Creaking or grating sound	Throughout respiratory cycle	Pleuritis, early pneumonia

4.4 Special Auscultation Techniques

4.4.1 Whispered Pectoriloquy

1. Ask the child to whisper "ninety-nine" or "toy boat" while you auscultate.
2. Compare the clarity of the whispered words between different areas of the chest.

Interpretation: Increased clarity over a specific area suggests consolidation (e.g., pneumonia).

4.4.2 Egophony

1. Ask the child to say "E" while you auscultate.
2. Listen for a change in the sound to resemble "A".

Interpretation: Presence of egophony suggests consolidation or pleural effusion.

4.4.3 Bronchophony

1. Ask the child to say "ninety-nine" in a normal voice while you auscultate.
2. Compare the clarity and intensity of the spoken words between different areas of the chest.

Interpretation: Increased clarity and intensity suggest consolidation.

5. Interpretation of Findings

5.1 Integrating Examination Findings

When interpreting the results of a pediatric respiratory examination, it's crucial to consider all findings together, along with the patient's history and any available diagnostic tests. Here are some common patterns:

Clinical Picture	Possible Findings	Potential Diagnosis
Obstruction	Prolonged expiration Wheezes Hyperresonant percussion Decreased breath sounds	Asthma, bronchiolitis, foreign body aspiration
Consolidation	Dull percussion note Bronchial breath sounds Crackles Increased tactile fremitus	Pneumonia, atelectasis
Pleural Effusion	Dull or flat percussion note Decreased or absent breath sounds Decreased tactile fremitus	Parapneumonic effusion, empyema
Upper Airway Obstruction	Stridor Barking cough Suprasternal retractions	Croup, epiglottitis, foreign body aspiration

5.2 Common Pediatric Respiratory Conditions

Condition	Key Examination Findings	Additional Notes
Asthma	Expiratory wheezing Prolonged expiration Hyperresonant chest	May have normal exam between exacerbations
Bronchiolitis	Tachypnea Fine crackles Wheezing	Most common in infants <2 years
Pneumonia	Tachypnea Crackles Dull percussion Bronchial breath sounds	May have fever and cough
Cystic Fibrosis	Persistent cough Crackles Digital clubbing	Chronic disease with recurrent infections

6. Age-Specific Considerations

6.1 Neonates (0-28 days)

• Higher respiratory rates (40-60 breaths/min) are normal
• Obligate nose breathers - nasal obstruction can cause significant distress
• Periodic breathing is common and normal
• Retractions may indicate respiratory distress

6.2 Infants (1-12 months)

• Respiratory rate gradually decreases (normal 25-40 breaths/min)
• Chest wall is very compliant - may see significant retractions with mild distress
• Diaphragmatic breathing is predominant
• Breath sounds may be transmitted from upper airways

6.3 Toddlers and Preschoolers (1-5 years)

• May be uncooperative - distraction techniques are helpful
• Normal respiratory rate: 20-30 breaths/min
• Can often elicit cough on command
• May be able to perform simple breathing maneuvers

6.4 School-Age Children (6-12 years)

• Generally cooperative for full examination
• Normal respiratory rate: 15-25 breaths/min
• Can usually perform all breathing maneuvers
• Able to describe symptoms more accurately

6.5 Adolescents (13-18 years)

• Examination similar to adults
• Normal respiratory rate: 12-20 breaths/min
• Privacy during examination is important
• Consider impact of respiratory conditions on daily activities and quality of life

7. Red Flags and Emergency Situations

The following signs and symptoms warrant immediate attention and possible emergency intervention:

• Severe respiratory distress: marked retractions, grunting, nasal flaring
• Cyanosis (central)
• Altered mental status or drowsiness
• Inability to speak or feed due to breathlessness
• Respiratory rate >60 breaths/min in any age group
• Asymmetrical chest movements or breath sounds (possible tension pneumothorax)
• Signs of impending respiratory failure: gasping, paradoxical breathing

8. Documentation and Follow-up

After completing the respiratory examination:

1. Document all findings systematically, including normal and abnormal results
2. Summarize the overall respiratory status
3. Develop a differential diagnosis based on examination findings and clinical history
4. Consider additional investigations if needed (e.g., chest X-ray, pulmonary function tests)
5. Plan appropriate follow-up based on the child's condition
6. Communicate findings and plans clearly with the child (if age-appropriate) and caregivers

Note: This guide is for educational purposes only. Always correlate clinical findings with patient history and additional diagnostic tests when necessary. Consult with a pediatric specialist for complex cases or when in doubt.