Paediatric Respiratory Examination
A paediatric respiratory examination is a crucial part of the clinical assessment of a child. It requires a calm, systematic approach, often beginning with observation from the end of the bed to minimise distress. The focus is on a structured, top-to-toe assessment to identify subtle signs of respiratory distress and the underlying cause.
General Examination and Observation
Begin by observing the child’s overall state from a distance.
Breathing: Note if the child is comfortable at rest or breathless. Listen for any noisy breathing.
Stridor: A high-pitched, inspiratory sound often caused by upper airway obstruction (e.g., croup).
Stertor: A low-pitched, snoring sound from nasopharyngeal obstruction (e.g., adenoid hypertrophy).
Wheeze: A high-pitched, musical sound from lower airway obstruction (e.g., asthma).
Grunting: An expiratory sound that indicates a child is trying to maintain positive end-expiratory pressure (PEEP) to keep their airways open, often a sign of significant respiratory distress.
Respiratory Distress: Look for signs of increased work of breathing.
Nasal flaring: Widening of the nostrils to increase airway diameter.
Subcostal and intercostal recession: Indrawing of the skin between or below the ribs during inspiration.
Tracheal tug: Downward movement of the trachea with inspiration.
Vitals: Record and interpret vital signs.
Respiratory rate: This is the most sensitive vital sign for a child’s health. Normal rates vary significantly with age.
Oxygen saturation (SpO2): Record the SpO2 and note if oxygen is required.
Heart rate: Tachycardia is an early sign of distress.
Systemic Signs: Look for signs of a more systemic problem.
Cyanosis: Assess for a bluish discolouration, especially in the lips and tongue (central cyanosis), indicating poor oxygenation.
Clubbing: Look for clubbing of the fingers, a sign of chronic hypoxia.
Growth: Plot weight and height on a growth chart, as failure to thrive can be associated with chronic respiratory conditions like cystic fibrosis.
Eczema: The presence of eczema can be a sign of atopy, a risk factor for asthma.
Focused Respiratory Examination:
Inspection
Thorax: Ensure good exposure to inspect the chest shape. Look for any deformities like pectus excavatum (sunken chest) or pectus carinatum (pigeon chest).
Symmetry: Observe the chest wall for symmetrical movement during breathing.
Scars: Look for scars from previous surgery, such as a thoracotomy (a lateral scar) or chest drain insertion.
Palpation
Trachea: Gently feel the position of the trachea to ensure it’s central. A deviated trachea can be a sign of a tension pneumothorax or a large pleural effusion.
Chest Wall Movement: Palpate the chest to confirm symmetrical expansion during inspiration in the upper, mid, and lower zones.
Subcutaneous Emphysema: Feel for crackling under the skin, which indicates air has escaped into the subcutaneous tissue.
Percussion
Symmetry: Percuss the chest wall in a ladder pattern, comparing left and right sides.
Sounds: Note any abnormal sounds.
Hyper-resonant: Suggests an area of trapped air, as in a pneumothorax or severe asthma.
Dull: Indicates an area of consolidation (e.g., pneumonia) or fluid (e.g., pleural effusion).
Auscultation
Breath Sounds: Listen with the diaphragm of the stethoscope.
Reduced or Absent: Can indicate a pneumothorax, large pleural effusion, or atelectasis.
Bronchial breath sounds: Harsh breath sounds heard over an area of consolidation (e.g., pneumonia).
Wheeze: A high-pitched, musical sound, often on expiration, indicating narrowing of the small airways.
Crackles: Clicking, bubbling, or rattling sounds. Fine crackles can suggest pneumonia or pulmonary oedema, while coarse crackles can be from secretions in the large airways.
Silent Chest: This is a critical sign in severe asthma where there is no air movement, and it is a medical emergency.