Respiratory system examination in children

1. Morpho-functional peculiarity of
respiratory system in children
Methods of clinical and paraclinical
investigation
Semiology of diseases
Nursing of sick children

2. Content
 Morpho-functional peculiarity of
respiratory system
 Methods of clinical investigation
 Methods of paraclinical investigation
 Semiology of diseases
 Nursing of sick children

3. The Function of Respiratory System
 I. Respiratory -
to deliver the air to organism for gas
exchange, to get the oxygen and to
excrete the carbon dioxide.
 II. Nonrespiratory

4. The Nonrespiratory Function of
Respiratory System
 Production and regulation of hormone’s and biological active substance’s
activities
 production of prostaglandins E, F2-alpha
 angiotensin II (arterial blood pressure)
 regulation of aldosteron secretion (water and electrolytes metabolism)
 inactivation of noradrenalin (sympatric nerves system)
 Regulation of blood rheology
 Water metabolism
 Thermoregulation
 Influence the concentration of biologically active substances and drugs
used in medicine in arterial blood
 Filter out small blood clots formed in veins
 Filter out gas micro-bubbles occurring in the venous blood stream during
diving decompression
 Protection for the heart

5. Major elements of the respiratory system
 Chest wall
 Airways
 Alveolar-capillary
units (Lungs)
 Pleura
 Pulmonary and
bronchial
circulations
 Nerves
 Lymphatics

6. upper
respiratory
tract
middle
respiratory
tract

7. middle
respiratory
tract
lower
respiratory
tract

8. Lung Embryogenesis
Postnatal development
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compartments. Capillary volume increases more rapidly than air space volume, and this,
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structures - alveolar septation.
the airways), originate from the mesenchyme.
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f.However,
the final size of the lungs dependences on many other factors such as the subject's level
gestation.

9. Respiratory Distress Syndrome(Pathophysiology)
 At birth the pressure needed to expand the lungs requires high
inspiratory pressure.
 Normal surfactant - lungs retain 40% of the residual volume
after exhale
Deficiency of surfactant - lungs collapse between breaths, it
makes each inhale as hard as the first breath.
 On further - the pulmonary capillary membranes become more
permeable, letting in fibrin, fluid accumulates between the
alveolar spaces - a hyaline membrane is formed - barrier for
gas exchange, caused hypoxemia and carbon dioxide retention

10. Anatomophysiological peculiarities
of respiratory system in children
The nose is relatively small and short
The nasal passage is narrow
In the newborn the lower nasal passage
is absent, it is formed only on the age of
four years.
The nasal mucous is very delicate and
intensively vascularized.
The cavernous portion of the submucosa
of the nasal cavity is under differentiated,
developing only by the age of 8-9 years,
and particularly during puberty.

11. Anatomophysiological
peculiarities
of paranasal sinuses
in children
The frontal sinus is absent in babies younger than 1-year, it
appears after 2 yr, attaining its full development by 12-15 yr
The maxillare sinuses are present at birth, but they are very
small, it enlarges gradually to reach its maximum dimensions
about the 21 year (eruption of the upper wisdom tooth)
The ethmoid sinus is present in newborn, but its cells are very
weakly differentiated
The sphenoid sinus occupies the body of the sphenoid bone,
and may be absent or present at birth as a small indentation of
nasal mucosa

12. Anatomophysiological
peculiarities
of upper respiratory tract
in children
The lymphatic ring surrounding the pharynx is not clearly defined
Tonsils are not visible before the end of the first year of life
The lymphatic ring attain its maximum development between 4-10 years
A process of resorption occurs from 14-15 years
Chronic inflammations of the tonsils
and adenoiditis are typical pathology for children

13. Anatomophysiological
peculiarities
of middle respiratory tract in
children
The larynx passage is narrow, its cartilages are soft,
vascularization is intensive larynx stenosis
(croup)
The trachea bifurcates - at the level of the 3rd thoracic
vertebra in the newborn, descending by adolescence to
the level of the 5th .

14. Stridor
is an inspiratory musical wheeze heard
loudest over the trachea during inspiration.
Stridor suggests an obstructed trachea or
larynx.

15. Anatomophysiological peculiarities
of middle respiratory tract in children
(bronchi)
 The bronchial passage is narrower than in
adults
 The elastic fibres are less defined
 The cartilages are soft
 The mucous is extensively vascularized
The bronchial lumens become constricted
more easily than in adults

16. Anatomophysiological peculiarities
of lower respiratory tract in children
 The lungs are not formed
completely at the moment of
birth, it’s development and
differentiation continues up to
puberty period
 The interstitial pulmonary tissue
is better developed and more
vascularized than in adults
 Capillaries and lymphatic
sinuses are wider
 The lungs of infants are poor in
elastic tissue, particularly in
vicinity of the alveoli

17. The clinical methods of examination
 Interrogation
 Observation
 Palpation
 Percussion
 Auscultation

18. The common complains:
 Cough
 Dyspnea
 Voice change
 Hemoptysis (the coughing with blood)
 Chest pain
 Wheezing, Stridor, and Snoring - audible
sounds that can be heard without a stethoscope

19. Cough description
 Dry or Moist
 Onset- acute or slow
 Frequency –seldom or often
 Regularity –irregular is the most common, regular
(pertussis, chronic diseses)
 Pitch/loudness- loud/quiet, high or low pitch
 Postural
 Quality- hoarse with croup, inspiratory whoop with
pertussis

20. Dyspnea
Inspiratory / expiratory types

21. Chest Pain
Describe onset, frequency, location, severity, associated symptoms
Specific diagnosis
 Pulmonary - Pneumonia, Pleurisy, Pneumothorax
 Heart diseases - Coronary insufficiency, Myocarditis, Pericarditis
 Hiatal hernia
 Gastric Ulcer, Reflux
 Esophageal spasm
 Cholecystitis
 Pancreatitis
 Cervical radiculopathy
 Osteochondritis
 Shoulder disorder

22. Observation / Inspection of the respiratory system
 Physical development
 Cyanosis
 Position (hands on the knees)
 Rate and pattern of breathing
 Visible abnormalities of the thoracic cage
 Depth and symmetry of lung expansion
 Direction of abdominal wall movement
 Using of accessory muscles of respiration
 Ability to speak
 Voice
 Digital clubbing
 Smell of breath

23. The pattern of breathing
= respiratory rate + rhythm+ depth of breathing+ relative amount
of time spent in inspiration and expiration
 Respiratory rate
- Normal
 newborn
 1-2 years
 5-6 years
 10 years
 adults
40-60 per min
30-35
up to 25
18-20
14-16
- Tachypnea / bradypnea
 Tidal volume – 5 ml/kg
 Ratio of inspiratory to expiratory time - 2:3

24. ABNORMAL BREATHING PATTERNS
APNEA - CARDIAC ARREST
BIOTS – INCREASED INTRACRANIAL PRESSURE –
DRUGS
CHEYNE STOKES – CONGESTIVE HEART FAILURE –
DRUGS – CEREBRAL
KUSSMAULS – METABOLIC ACIDOSIS

25. Normal chests of children and adults
Movement of the chest wall is minima and symmetrical.
Expansion of chest and abdomen
Use of accessory muscles (intercostal, stenocleidomastoid)
indicates pulmonary impairment
Chest’s observation

26. Digital clubbing -
PAINLESS – FINGERNAILS CURVED AND ENLARGEMENT OF THE CONNECTIVE TISSUES
IN THE TERMINAL PHALANGES OF THE FINGERS >TOES

27. Clubbing

28. Smell the breath
Fruity – ketoacidosis
Fishy – uremia
Putrid - sinusitis, cancer, lung abscess
Cinnamon - pulmonary tuberculoses

29. Palpation of Thorax
 Feel for pulsations
 Areas of induration, bulges, depressions, unusual
movements
 Crepitus-crackly or crinkly sensation
 Tactile fremitus

30. Tactile fremitus
Condition Tactile
fremitus
Consolidation or atelectasis
(with patent airway)
Increased
Consolidation or atelectasis
(with blocked airway)
Decreased
Asthma Normal
Interstitial lung disease Normal
Emphysema Decreased
Pneumothorax Decreased
Pleural effusion Decreased

31. PERCUSSION SOUNDS (norma)
Relative
Intensity
Relative
Pitch
Relative
Duration
Example Location
Flatness Soft High Short Thigh
Dullness Medium Medium Medium Liver
Resonance Loud Low Long Normal lung
Hyperresonance Very loud Lower Longer None normally
Tympanic Loud High Gastric air bubble
or puffed-out
cheek

32. TOPOGRAPHIC PERCUSSION

33. Boundaries of the lungs
Front
 Right lung: the V rib on
the mammilary line.
 the IX rib on the axillary
line
 Left lung: at the IX rib on
the axillary line
Back
Both lungs:
at the level of the spinous
process of the X – XI thoracic
vertebrae.

34. TOPOGRAPHIC PERCUSSION
DIAPHRAGMATIC EXCURSION
•Patient takes a deep breath
and holds
•Percuss on scapular line until
dullness is heard
• Mark this point
• Allow patient to breath
normally
•Repeat deep breath then
exhale and hold
• Percuss up from the mark until
resonance is heard
• Mark the area
•Diaphragmatic excursion is the
distance between these two
points
NORMAL 3 – 6 CM

35. Comparative Percussion
 Compare bilaterally
Use one side as control for the other
Move systematically side to side at intervals
of several centimeters

36. Typical Chest Percussion Sound
in Selected Clinical Conditions
Condition Percussion
Normal Resonant
Consolidation or atelectasis Dull
Asthma Hyperresonant
Interstitial lung disease Resonant
Emphysema Hyperresonant
Pneumothorax Hyperresonant
Pleural effusion Dull

37. Lung Auscultation

38. LUNG SOUNDS
BREATH SOUNDS ADVENTITIOUS
TRACHEAL
BRONCHIAL
VESICULAR
WHEEZE
RHONCHI
CRACKLE
PLEURAL RUB
Lung Auscultation

39. BREATH SOUNDS
CHARACTERISTIC TRACHEAL BRONCHIAL BV VESICULAR
INTENSITY VERY LOUD LOUD MODERATE LOW
I:E RATIO 1:1 1:3 1:1 3:1

40. Abnormal Breath Sounds
ADVENTITIOUS SOUNDS
 To determine:
Loudness, pitch/ and duration (summarized
as fine or coarse)
Number (few to many)
Timing in the respiratory cycle
Location on the chest wall
Persistence of their pattern from breath to
breath
Any change after a cough or a change in the
patient's position

41. Abnormal Breath Sounds
ADVENTITIOUS SOUNDS
 Crackles (crepitation) - heard during middle
or end of inspiration, not cleared by cough
 Rhonchi - loud, low, coarse, coughing may
clear
 Wheeze - musical-louder during inspiration
A more significant finding is heard in expiration
 Pleural Friction rub- dry rubbing

42. VOCAL FREMITUS
 THE PATIENTS VOICE IS HEARD
THROUGH A STETHOSCOPE PLACED
ON THE PATIENTS CHEST –
NORMALLY THE SOUNDS ARE
INDISTINCT
 ABNORMALITIES – SOUND MUCH
LOUDER THAN NORMAL -
BRONCHOPHONY

43. The main methods of paraclinical
examination
 examination of secretions
 pulmonary function testing
 sweat testing
 microbiology
 blood gas analysis
 chest roentgenograms
 computer tomography and magnetic resonance imaging
 laryngoscopy, bronchoscopy with bronchoalveolar
lavage, thoracoscopy
 contrast studies - bronchograms, pulmonary
arteriograms
 percutaneous lung tap, lung biopsy

44. Spirography

45. Pickflowmetry

46. Rentgenography

47. Pulse-oxymetry

48. Bronchoscopy

49. Bronchography

50. The main pathological syndromes
of respiratory diseases
 Respiratory insufficiency
 Obstructive
 Croup
 Restrictive
 Respiratory Distress Syndrome

51. Respiratory insufficiency syndrome
 Dyspnea
 Cyanosis
 Tachycardia
 Changes in correlation of pulse/respiratory rate
 Trend to increased BP
 Acidosis, decreased pO2 (80-60 mm Hg),
increased pCO2 (60-80 mm Hg).

52. Obstructive syndrome
Cough
Expiratory dyspnea
Hyperresonanse
Percussion sound
Wheeze

53. Obstructive syndrome

54. Restrictive syndrome
 occurs if the lungs are limited in the capability to
broadening
 Reasons:
 pneumosclerosis
 abundant effusion in exudative pleurisy
 limited motility due to rib affection (osteomyelitis, fracture
of ribs) or muscle affections (myopathy, paresis and
paralysis of intercostal nerves)

55. Croup syndrome
 Voice change
 Dry backing cough
 Inspiratory dyspnea
It can occur in virus laryngotracheitis,
diphtheritic laryngotracheitis, and measles.

56. PNEUMONIA
INSPECTION – cough, dyspnea, respiratory
failure
PALPATION – INCREASED FREMITUS
PERCUSSION – DULL
AUSCULTATION – BRONCHIAL BREATH
SOUNDS, CRACKLES, EGOPHONY,
PECTORILOQUY, RHONCHI
ENDOBRONCHIAL OBSTRUCTION
MAY MASK THE USUAL PHYSICAL
FINDINGS OF PNEUMONIA
PNEUMONIA

57. PNEUMOTHORAX
INSPECTION – LAG AFFECTED SIDE
PALPATION – ABSENT FREMITUS
PERCUSSION – TYMPANIC
AUSCULTATION – ABSENT BREATH SOUNDS
PNEUMOTHORAX

58. Care for children with respiratory diseases
 hygienic regime: temperature regime,
fresh air, cleanliness
 accurate nutrition
 cleaning of airways
 various methods of oxygenation (oxygen
mask, incubator, oxygen supply through
nasal, tracheal tube, AVL)
 treatment according to the etiology and
pathogenesis of the disease