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 childrenBreathing 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 symptomsBreathlessness

Haemoptysis

Nasal discharge

Chest pain

Fever

Cyanosis

Cough

Sputum

Catarrh

Respiration Rate or Rhythm disorder

Non-specific complaints.

Present HistoryOrigin

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 HistorySimilar 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

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