Pediatric Chest Examination

Prof. Malak ShaheenProf. Malak Shaheen

What is new ?

Clinical Examination .. Proper way

Get ready …..

• Sherlock Holmes Model

Use all your senses ……..

Secret ingredient .. Deal with children

Integrated Clinical Practice

Tool kit for a pediatrician ….

Pillars for Clinical Diagnosis

1. Proper History (Sheet)

2. Clinical Examination (General & Local)

3. Investigations (Bedside + others)3. Investigations (Bedside + others)

Chest Exam .. Let us start

When it begins …..

• First look to the child

History Taking

• Common respiratory symptoms

• How to ask?

• How to analyze each symptom?

• Collect data + write down• Collect data + write down

• Example:

• Cough analysis …. (Timing)

• Fever analysis …...

Common symptoms

Cough + sputum production

Haemoptysis

Fever / toxic symptoms

Chest pain (Children different than adults) Chest pain (Children different than adults)

Breathlessness (SOB causes?)

Wheeze (noisy breathing – other examples )

Allergy

Position/Lighting/Exposure

• Position –– Patient should sit upright /Semi-sitting

– The patient's hands should remain at their sides.

• Lighting - adjusted so that it is ideal.• Lighting - adjusted so that it is ideal.

• Exposure - the chest should be fully exposed/ time should be minimized.

General Examination

Rule of “4”

1. A B C D

2. 4 vital data

3. 4 X 2 Skin3. 4 X 2 Skin

4. 4 groups of LN

From Head to Toe

Rest 4 systems (CVS, Neuro, GIT & Uro)

4• Appearance

• Built (weight +

Height)

• Consciousness

• Decubitus

• Respiratory rate

• Pulse

• Blood Pressure

• Temparature

• Decubitus

• Occipital LN

• Cervial LN

• Axillary LN

• Inguinal LN

• 3 colors

• Oedema

• Subcut fat

• Rash

• Elasticity (Turgor)

• Texture

From scalp to toe

Steps of Local Chest Examination

-Inspection

-Palpation

-Percussion-Percussion

-Auscultation

Local Chest Examination

Rule of “3”

• Inspection:

1. Shape

2. Symmetry2. Symmetry

3. Respiratory Movement (diagnosis of

respiratory distress)

Examination of the chest

Inspection

1. Shape of the chestThe normal chest is bilaterally symmetrical and elliptical in cross sectionthe transverse diameter > anter-oposterior diameter (when?)

Comman abnormalities of shapeComman abnormalities of shapekyphosis-forward bending of vertebral columnscoliosis- lateral bending of vertebral columnbarrel shaped chest- increase in anteroposterior diameter flattening

Respiratory Examination

Pectus carinatum Pectus excavatum

Chest wall

May prevent

complete

expiration of air

from the lungs and

thus may restrict

air exchange

considerably.

Base lung

capacity is

decreased

Continue…. Inspection

• 2. Symmetry of chest expansion

chest expansion of a healthy child should be equal on both sides

3. Rate & Rhythm/pattern of respiration

Rate of respiration in health

• Movements of the chest wall (RD)

Age (yrs) Resp Rate (breathes/min)

<1 30-40

2-5 25-30

5-12 20-25

>12 15-20 wall (RD)presence of intercostal recessions or the use of

accessory muscles

>12 15-20

• Respiratory Rate

• Recession

– Mild: sub-costal

– Severe: sternal

• Accessory muscle use

Effort of breathing

• Accessory muscle use

• Grunting

• Alar nasal flare

• Child’s position

• Respiratory noises

– Stridor / wheeze

Effort of breathing: respiratory rate

Age (yrs) Resp Rate (breathes/min)

<1 30-40

2-5 25-30

What are causes

of Resp. Distress?

(Resp & non resp)

2-5 25-30

5-12 20-25

>12 15-20

Rule of “3”

• Palpation:

1. Chest expansion

2. TVF2. TVF

3. Trachea site (Very Very Important)

Palpation

Before making a systemic examination palpate any part of the

chest where the patient complains of pain or where there is a

swelling

• Position of the Apex beat and Trachea

• In normal subjects the trachea is in the midline and can • In normal subjects the trachea is in the midline and can

be palpated in the suprasternal notch

Palpation

• Expansion of the chest

Symmetrical or asymmetrical chest expansion can be assessed by palpation (what is normal?)

• Vocal fremitusVocal fremitus is the vibration detected by palpation with the palm of the hand on the chest, when the patient is asked to repeat “ninety nine” or “44 in arabic” if suitable

In a normal healthy child, the vibrations felt in the corresponding areas on the two sides of the chest are equal in intensity

Rule of “3”

• Percussion (Rt & Lf sides in comparison):

1. Mid clavicular line (light)1. Mid clavicular line (light)

2. Mid axiliary line (light)

3. Scapular line (heavy)

Percussion

The middle finger of the left hand is placed on the chest and middle phalanx is struck with the tip of the middle finger of the right hand

Feel and listen to sound of resonance over a healthy lung has to be learned by practicelearned by practice

Percussion

2nd phalanx over area of

intercostal space

Right middle finger strikes

the 2nd phalanx producing

hammer effecthammer effect

Entire movement comes

from wrist

Reference Lines

• Anterior Chest

– Midsternal line

– Midclavicular line

• Posterior Chest

– Vertebral line – midspinal

– Scapular line

• Lateral Chest

– Anterior Axillary line

– Posterior Axillary line– Posterior Axillary line

– Mid–axillary line

Order of Percussion

Respiratory Examination

• Percussion

– Illicit resonance

– Compare both sides

– Map out abnormal area– Map out abnormal area

Rule of “3”

• Auscultation(Rt & Lf sides in comparison):

1. Air Entary1. Air Entary

2. Breathing sounds

3. Adventitious sounds

Respiratory Examination

• Auscultation technique– Diaphragm of stethoscope

– Mouth open

– Breathing deeply and fairly rapidly– Breathing deeply and fairly rapidly

– Cough

– Compare both sides

Basic Lung Sounds:

http://www.stethographics.com/main/physiology_ls_introduction.html

Auscultation

Diminished

Conduction limited by

– Airflow limitation

e.g. diffusely – asthma, emphysema

Air

Entry

localised – tumour, collapse

– Something separating chest wall from lung

e.g. effusion, fibrosis

Auscultation

• Breath soundsThere are 2 types of breath sounds

- vesicular breath sounds- bronchial breath sounds

Vesicular breath soundsThese originate in the larger airways and are produced by the passage of air in and out of normal lung tissue

In good health, they can be heard all over the chest

-the inspiration is longer than expiration-the inspiration is longer than expiration-the inspiratory sound is intense and louder

than the expiratory sound-it is a low pitched rustling sound-there is no gap between inspiration and expiration

Harsh Vesicular breathing with prolonged expiration

example: airway obstruction (asthma)

Basic Lung Sounds:

http://www.stethographics.com/main/physiology_ls_introduction.html

http://www.cvmbs.colostate.edu/clinsci/callan/breath_sounds.htm

Auscultation

• Bronchial breath soundsThese are produced by the passage of air in the trachea and larger bronchi

In good health, they can be heard only over the trachea

In disease, bronchial breathing may be heard over the area of lung that is affected (lung consolidation, collapse, fibrosis)

-the expiration is long as or longer than inspiration -the pitch and sound of the expiration is loud or

louder than the inspiratory sounds -there is a gap between inspiration and expiration -there is a gap between inspiration and expiration

Respiratory Examination

• Bronchial breathing

Respiratory Examination

• Added sounds

– Wheeze

– Crepitations (crackles)

– Pleural sounds– Pleural sounds

Respiratory ExaminationAbnormal Sound Description Condition

Crackles (rales) Short, discrete, popping or

crackling sounds

Pulmonary oedema

Pneumonia

Atelectasis

Bronchiectasis

Wheezes High pitched, squeaking,

whistling sounds.

Asthma

Bronchospasm

Pleural friction rub Creaking, leathery, loud,

dry, course sounds

Pleurisy

Pleural effusion

Respiratory Examination... more

• Vocal sounds on auscultation

– Vocal resonance

– Increased when voice sounds are louder and more distinct

e.g. consolidation

– Reduced when transmission impeded e.g. effusion,

collapse

D’Espine’s sign

D’Espine’s signImportant sign of a posterior mediastinal mass

At the level of mid-scapula (about T5) – listen over the vertebral spinous process and on either side of the vertebral column. Normally the lateral sounds are louder and more distinct.

When the upper airway sounds are of greater When the upper airway sounds are of greater intensity than the corresponding lateral lung sounds – implies a continuity (a mass) between a mainstem bronchus and vertebra

Special situation:

Critically ill child …. ABC approach

• A = Airway

• B= Breathing

• C= Circulation

• D = Disability (CNS)• D = Disability (CNS)

• E = Exposure

• Respiratory distress

• Air entry

• Pulse oximetry

Efficacy of breathing

A silent chest is a

pre-terminal sign

• Heart rate

• Skin colour

• Level of consciousness

Effects of respiratory inadequacy

Pre-terminal signs:

• Bradycardia

• Central cyonosis

• Unconsciousness

Putting things together ….

Interpretation of findings

Pleural effusion

• Tracheal shift

• stony dull

• reduced air entry

Consolidation

• Trachea central

• reduced expansion

• dull percussion• reduced air entry • dull percussion

• bronchial breathing

• or coarse creps

• increased vocal resonance

Interpretation of findings

Pneumothorax

• deviated trachea

• reduced tactile vocal

fremitus

• hyper-resonance

Consolidation Collapse

• deviated trachea

• reduced tactile vocal

fremitus

• dull percussion• hyper-resonance

• reduced air entry

• reduced vocal resonance

• dull percussion

• reduced air entry

• +/- creps

Alveolar disease …

• Grunting sound

• Fine crepitation

Further Plans ……

• Investigations:

–Bedside: oximeter, peak flow meter–Bedside: oximeter, peak flow meter

–Laboratory: ABG **

–Radiological

–Other

Reaching diagnosis (or D.D.)

• Anatomical diagnosis (where is the

lesion)

• Pathological diagnosis (what is the

lesion)lesion)

• Etiological diagnosis (cause)

• Functional diagnosis

(compensated/decomp.)

• Other complication(s)

Treatment

• Specific ttt (cause)

• Supportive ttt

Chest exam interfaces for you

1. Short case exam

2. Long case exam

3. OSCE

4. Within other pediatrics case (eg. Neuro, 4. Within other pediatrics case (eg. Neuro,

Down, Cardiac,..)

5. Clinical practice …..

OSCE …..

Wash your handsIntroduce yourself

Patient detailsPatient detailsExplain/consent

Scene survey

Further resources … watch & listen

• YouTube

• Assessing lung sounds Part 1

• Assessing lung sounds Part 2

• Lung sounds mix• Lung sounds mix

• The lung & thorax exam

• Learn pediatrics: Respiratory exam

• Examination of lungs and respiratory (Ped)

• Respiratory 1

• Respiratory 2

• How to use stethoscope

• Pediatric respiratory exam: OSCE guide

Further resources … reach & read

1•www.EKB.com

Download resources

2•Register in campus

3•Clinical Key access

Download resources

Prof Malak Shaheen Lectures

Thank You

Drmalak_shaheen@med.asu.edu.eg