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:

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

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:

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:

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

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:

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

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

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

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

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.

3.3.1 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.

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.

4.4.1 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.

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: