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Paediatric Respiratory Exam

Edit this Article | Original article by Tom Leach | Last updated on 4/2/2012 | View Revisions

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General Inspection
How old is the child?
  • You will probably have to adapt the exam accordingly! Generally, you could put the children into three categories depending on their age: 0-6months, 6-24 months and 2 years+

Is the child awake and alert? Are they running around? Do they seem generally ill or distressed? Who is with them? Are they sat on their parents knee?
Are there any medications around?

  • Oxygen – if so, check at the wall how much, and by what method is it being administed (e.g mask, nasal specs)
  • Fluids – what fluids?
  • Inhalers?
  • Cannula
  • Central line (e.g. in F to provide IV antibiotics)

Any audible cough, wheeze, breathing difficulties?

 
Clothes – next it is best to take the child’s clothes off. Be sensible. If they child is under 2, then ask the parents to help. If the child is a bit older, then they are probably able to take their own clothes off. Obviously, with older and adolescent children, you will be able to take a more focussed approach, and be more wary of privacy.
General appearance:
  • Fat/skinny
  • Rashes, scars?
 
Hands
  • Clubbing – sign of CF
  • Tremor – from B2 agonists
  • Check capillary refill
  • Feel temperature of hands / cyanosis
  • Check radial/brachial pulse
    • Radial is often difficult to feel in children
    • Check the respiratory rate at the same time

Face
It is often a good idea to leave ears and throat until last, as these might upset the child, and then you will have trouble doing the rest of the exam!

Nose

  • Snotty / red
  • Nasal polyps (CF)

Ears

  • TAKE TEMPERATURE
  • Always look inside! In an infected ear, it is likely to be red and tender. Check the tympanic membranes. S their a fluid level? Is it damadged? In infection Wax is less likely, as the high temperature often melts it, so if your view is obstructed by wax, it might not be a bad sign

Mouth and Throat

  • Look at the lips and under the tongue for signs of cyanosis
  • Using a torch, look at the back of the throat for signs of infection
  • Using a tongue depressor is down to personal preference. Some practitioners do not recommend it as you could injure the child, particularly the soft palate, and many children don’t like it.
  • Tonsilitis may cause white pus to exude from the tonsils
  • Infections in the larynx and below will generally not have any throat signs. Some textbooks even advise not to look in the throat in croup – as the presence of the tongue depressor can exaggerate the condition.

Neck

Lymph nodes – examine the lymph nodes of the neck in the same way as in an adult.
Trachea

  • Is it central? – in OSCE just say you would check – unpleasant and will upset the child!
  • Tracheal Tug – This is where the trachea is pulled posteriorly and superiorly during inspiration, and results from recruitment of accessory muscles in laboured breathing
 
Chest
Inspection

Any scars – surgery –e.g. Meconium Ileus in CF
Rahses
Hickman line
Recession

  • Subcostal
  • Intercostal
  • Harrison’s Sulcus – two symmetrical sulci, horizontal, at the lower margin of the anterior thorax, at the attachment of the diaphragm. A sign of prolonged respiratory distress in children. Most commonly present in children with asthma who have required an increased respiratory effort over several months. Also present in Rickets where there is insufficient calcium to allow for bone mineralisation, and the soft ribs are distorted by the pull of the diaphragm.
  • Does it look like there is hyper expansion?
  • Check the respiratory rate
 

Palpation

  • Chest Expansion – in young children, only need to check one, usually on the front. In older children, with a larger thorax, you should check 4 times – twice on the front, and twice on the back – at the top, right under the axilla, and at the bottom of the thorax.
  • Measure chest expansion with tape measure – measure at full inspiration and full expiration. (not often performed in practice – but say you would do it)
  • Heart – feel the location of the apex beat, checking for displacement
 

Percussion

  • Difficult and will probably not yield great results in very small children (under 2). Should be performed in older children. Same technique as adult
 

Auscultation

  • Same technique as adult – just make sure you compare sides and listen to all lobes, including under the axilla and to the apices above the clavicle.

Finishing off

Feel for the liver. If the liver is lower than expected, it may be displaced by hyper expanded lungs. Normal liver position:

  • Age 0-6 months – 1-2 fingers below rib cage
  • Age 6-24 months – 0-1 finger below rib cage
  • Age 2+ - usually not palpable (but remember, palpable liver is often still normal)

Do a peak flow test
Check O2 sats
If not already done, you might want to strip off the child to check for rashes (meningitis / septicaemia)
Remember to look in the ears and throat if you missed it out earlier!

Common Findings of Respiratory Exam in children

Condition
Chest Movement
Percussion
Auscultation
Info
Bronchitis
  • Laboured breathing
  • Hyperinflation
  • Recession
Hyper-resonant
Fine crackles +/- wheeze
Most commonly in children aged 1-9 months
Pneumonia
  • Reduced on affected side
  • Rapid, shallow breathing
Dull
Increased vocal fremitus
Crackles
 
Asthma
  • Reduced, but hyperinflated
  • Use of accessory muscles
  • Harrison’s sulcus if prolonged
Hyperresonant
Wheeze
 
CF
  • Hyperinflation
Hyperesonant
Inspiratory crepitations
Expiratory wheeze
Clubbing
Nasal polyps