Assessment of the respiratory

System in the child

R.RAGUPATHY M.SC(N)
NURSING TUTOR, GOVT. VELLORE MEDICAL COLLEGE, VELLORE

Anatomy
Bronchopulmonary segment is a wedge of the lung tissue, supplied by a single
bronchus and corresponding pulmonary artery and vein
Rt Lung 3 Lobes
Lt Lung 2 Lobes & Lingula
Major Fissure (Oblique fissure)
A curved line from 2nd thoracic spine in the back to the 6th costocondral junction in the
front

Minor Fissure (Transverse Fissure)

A line from Sternum at the level of 4th costal cartilage, joining the oblique fissure at the
Midaxillary line

Main functions of the Respiratory system

in children
Breathing and gas exchange
Defense function
Metabolic function
Deposited function
Filtrated function
Endocrine function

Basic steps for examination

1. History taking
2. Inspection
3. Palpation
4. Percussion
5. Auscultation

Child may have any one of the following

symptoms
Breathlessness

Cough

Haemoptysis

Sputum

Nasal discharge

Catarrh

Chest pain

Respiration Rate or Rhythm

disorder

Fever
Cyanosis

Non-specific complaints.

Present History
Origin
Duration
Progress
Aggravating factors
Relieving factors
Any treatment taken

Past history
Attack or disease similar to the present one
Allergic disorders: eczema, urticaria, angioedema and hay fever.

Admission in any hospital before and why?

Chest injuries and operations.
Other Surgical Procedures.
Coma , convulsions.may predispose to aspiration lung abscess
Cardiac diseases and history of Rheumatic fever.
Any high altitude visits It is important to identify any exercise or sleep related symptoms
Diabetes Mellitus ,Hypertension. (Cough may result from ACE inhibitors)
T.B and history of admission to a chest hospital for treatment of T.B. medicines, duration of the
treatment and the adherence to it.

Previous radiological examination: comparison with the current radiograph

Family & Social History

Similar condition in the family.

History of T.B.
History of allergy as eczema and hay fever.
History of DM
Any smoker in close contact with the child? (R/O passive
smoking)

Birth History
Antenatal, Natal & Postnatal History

Any illness did mother suffer?

Did she take any medication/alcohol during pregnancy?
Any H/o fetal distress?

Was the baby born at term?

Birth weight? Type of delivery?
Any breathing problems/fits?
Immunization taken?

Before Examination, Remove your assets if any.

Always ensure that your hands have been washed properly till the elbow and
dried prior to the examination of any patient.
Introduce yourself to pt/family, Make a good rapport explain what going to do.

Position of pt for Best examination method by age:

Neonates, very young infants: on examining table
Up to preschool: lying / sitting on mothers lap

Adolescent: without family presence.

Inspection of the chest

Major Points
Shape of the chest
Tracheal position
Apical position
Respiratory movement

Additional Points
Spine
Shape & contour of chest
Pulsations
Veins
Respiratory sounds like cough,
wheeze, stridor, grunt

Shape of Chest
Bilaterally symmetrical
Normal elliptical
Normal ratio 5:7
ABNORMAL SHAPE
1)Barrel Shape Ant & Post diameter >Lateral diameter
2)Pectus excavatum -Depression in the Sternum
3)Pectus Carinatum Prominence of the sternum

Inspection Contd..
TRACHEAL POSITION
Noting the position -Shift of mediastinum can be detected
APICAL POSITION
Can be shifted to same side (pull) shifted to opposite side (push)
RESPIRATORY M0VEMENT
Rate, Rhythm, Character, Equality, Accessory muscles of respiration,
Intercostal retraction

Rate
<1 year
- 60
14
- 35
48
- 25
8 12
- 20
Inspect movement whether bilaterally symmetrical
The side moves less will be the abnormal side

RHYTHM
Normal respiration has regular rhythm with inspiration longer than expiration.
Abnormal/ irregular rhythm-Pathological

Inspection Contd..
SPINE Scoliosis, Kyphosis, Lordosis

Chest wall - Bulging / Depression /Shoulder drooping

Pulsation - Visible & pulsating vessels Anastomotic circulation
Distended chest veins

Palpation
Major Points

Tracheal position
Position of Apex
Vocal Fremitus
Movements of Chest wall

Additional points
Intercostal tenderness
Pulsation
Spine
Palpable rhonchi, rub,
crepitations
Subcutaneous
emphysema

Tracheal Position
Valuable information about position of mediastinum
4 to 5 cm is felt in the neck

Sit or Stand
Head in midline
Neck slightly extended
Fix the head in midline with Lt hand
Tip of the rt index finger in the suprasternal notch and slide

Apex
Is the lower most and outermost point in the precordium where a
definite cardiac impluse is felt
Normally felt to 1cm inside Lt midclavicular line in the 5th space

Palm of the hand to feel the apex

Localisation done with single digit
APEX BEAT is obscured in 1) Obesity 2)Emphysema 3)Pericardial
effusion 4) apex come under rib

Vocal Fremitus
Palpation of vibration of chest wall produced by asking the patient to
say one-one-one
In small this can be done during crying
Medial side of the hand is used
Check either side
Proceed systematically from upward
Intensity of the fremitus tends to parallel breath sound intensity
Intensity varies considerably from front (strong) to back and from apex
(strong) to the lung base in normal person

Abnormal VF
Increased - Consolidation
Decreased - Pneumothorax, Pleural effusion, collapse,
Fibrosis, Bronchial obstruction

Movement Of Chest Wall

Comparative palpation of the two sides of the chest in an orderly manner
from above downward is the best important method for the evaluation of
the degree and symmetry of expansion with respiration
Infraclavicular & infra mammary from front
Supraclavicular,upper inter scapular lower scapular fron back

Percussion
Major points
Lung field percussion
Liver dullness
Tidal percussion
Cardiac dullness

Additional
Shifting dullness
S shaped curve of Ellis
Traubes area
Splenic dullness

Types of Percussion Notes

Normal percussion note of the chest is due to the underlying lung tissue,
containing a normal amount of air in the air vesicles, air sacs and air
passages
Abnormal

Tympany: Over the stomach

Hyperresonant: Pneumothorax
Impaired note: Consolidation
Dull note: Consolidation
Stony dullness: Pleural effusion

Auscultation
Provide important clues to the condition of the lung and pleura
Breath sounds are produced by the flow of the air through the respiratory tree. They
are characterised by PITCH,INTENSITY & QUALITY and the relative duration of their
inspiratory and expiratory phase
Normal breath
VESICULAR
Bronchial larynx, trachea, lower cervical spine
Bronchovesicular over major bronchus

Breath Sounds
VESICULAR sounds are low pitched , low intensity sounds heard over the
healthy lung tissue
This is characterised by active inspiration due to inflow of the air into
bronchi and alveoli, followed by shorter expiration due to elastic recoil of
the alveoli without a pause between inspiration and expiration
BRONCHIAL BREATH The inspiration is low in intensity while the
expiration is high pitched, loud and prolonged the duration of
inspiration . There will be a pause in between

Pleural Rub
Due to the rubbing of the two inflamed and roughened
surfaces of the pleura
Low pitched ,heard both inspiration & Expiration
Common site - lower part of axilla
Superficial, scratchy sound
Associated with pleural pain
Intensified by pressing stethoscope over chest
Does not alter with cough