• Inspection: Shape. Movment. Intercostal retraction. Abnormal bulging of

interspaces. Dilated veins. Pigmentation, scars, etc.

Chest Examination

• Palpation: Position. Respiratory movements. TVF. Palpable rhonchi

(Rhonchus fremitus) Points of local tenderness.

Chest Examination

• Percussion.• Auscultation: Air entry. Type of breathing. Vocal resonance. Adventitious sounds.

(Rhonchi, wheezes, crepitations, rub, tranmitted sounds.)

Chest Examination

• 1-Shape of The chest:The newborn’s thorax is nearly round. Gradually the transverse diameter increase until the chest assume the elliptic shape of the adult at about 6 years of age.

Changes in shape:a- Unilateral bulge:pleural effusion or severe pneumothorax.b- Unilateral depression:collapse or fibrosis of the lung.c- Barrel shaped chest:- Increased antero-posterior diameter to become equal to the transverse diameter.- Ribs become more transverse and the intercostal spaces wider.- Posterior kyphosis of the thoracic vertebrae.- Obtuse subcostal angle.- Barrel chest may occur in bronchial asthma.

Inspection

d- Funnel chest(Pectus excavatum):- The lower part of the sternum is indented inward. It may compromise lung expansion.- In infants and children usually congenital anomaly.e- Pigeon-shaped chest:- The antero-posterior diameter is larger than the transverse.- The sternum is protruded forward.- Subcostal angle is acute.- The cross section of the chest in nearly.- Pigeon-shaped chest is seen in severe rickets.f- Rachitic chest may show the following:- Rachitic rosaries: enlargement of costochondral junctions.- Harrison sulcus: a horizontal groove at the costal insertion of the diaphram.- Longitudinal groove devlops lateral to rosaries.- Everted costal margin.- In severe cases: Pigeon shaped deformity.

Inspection

Inspection• 2-Movements:

A. Rate:Respiratory rate:-Obtain respiratory rate by watching, palpating or auscultating the chest.- The infant or child should be calm, count respirations for 1 full minute respirations of infants and young children can be quite irregular.- While counting, note the depth and rhythm of breathing.- Normally the breathing is mainly abdominal toll the age of 7 years.

AgeNormal respiratory rate

At birth 30-80 breaths/minute

Infancy 20-40 breaths/minute

Preschool children20-30 breaths/minute

School children20-25 breaths/minute

At puberty 15-20 breaths/minute

• Notes:- The respiratory rate deceases with age.- Tachypnoea (increased respiratory rate) is considered if the respiratory rate=

- Tachypnoea ocuurs with anxiety, crying, fever and diseases as pneumonia, asthma or heart failure.- Bradypnoea occurs in overdosage of narcotics.- The rhysthm is irregular in young infants with apnoeic spells (usually less than 15 seconds). This is called periodic breathing and is normal in the newborn (apnoeic spells>20 seconds are considered pathologic).

Inspection

In first 2 months>60 cycle/minute

In 2m-1years >50 cycles/minute

More than 1 years>40cycles/minute

Abnormal respiratory patterns: a. Cheyne-stokes breathing:There is a gradual deeping and the diminishing respiratory rate and effort followed by a period of apnoea.It is seen in severe cardiac failure, nacrotic overdosage, and brain damage at the level of both cerebral hemisphere.b. Kussmail breathing:Rapid deep, usually associated with metabolic acidosis. Rapid deep breathing may be seen in exercise and anxity. c. Rapid shallow breathing:In pneumonia, pleuritic chest pain and an elevated diaphragm.

Inspection

d. slow shallow breathing: Alkalosis and nacrotic overdosage. e.Prolonged expiratory phase:Obstructive respiratory problem as asthma.

f. Ataxic breathing (Biot’s respiration):Unpredictable irregular, breaths may be shallow or deep and stop for short periods. Ti is caused by respiratory depression due to brain damage at the medullary level.

Inspection

Inspection

Bradypnea Tachypnea

Cheyne-Stokes respirationRegular

Biot’s respiration(ataxic) Kussmaul’s respiration

Inspection• 2-Movements:

B. Limited movements:- If unilateral pneumonia, effusion, collapse, fibrosis or pneumotharx and foreign body aspiration.- If bilateral e.g. severe asthma.

Inspection• 3-Intercostal retraction(during inspiration):

- Observe the chest for retraction or indrawings, in the supraclavicular ( above clavicle), tracheal (in the sternal notch), substernal (below the sternum) and intercostal (between the ribs).- Retractions are caused by increased negativity of intrapleural pressure.- They are seen in labored breathing in infants and children with asthma, tracheal or laryngeal obstruction.- Intercostal retraction denotes increased lung stiffness or increased work of breathing due to air way obstruction.- They are seen also in large left to right shunts (as VSD), also consolidation, collapse, or fibrosis and paralysis of intercostal muscles.

Inspection

Inspection• 4-Abnormal bulging of the intercostal spaces during

expiration:In asthma or massive pleura effusion, pneumothorax, diaphragm hernia.

• 5-Dilated chest veins:In superior vena cava obstruction.

• 6-Pigmentaion, scars, ulcers, sinuses or local swellings :should be looked for in the skin, subcutaneous emphysema may also be noted.

• 1-Position of the mediastinum:- Position of the trachea indicates the position of upper mediastenum.- Position of the apex indicates the position of the lower mediastenum.- To examine the position of the trachea, the neck is centralized and The distance between the lateral wall of the trachea and the medial border of the sternomastoid on both sides is assessed by alternate feeling by the tip of the index finger.

Causes if shifted mediastinum:a. Pull to the same side if the lesion by fibrosis or collapse of the lung.b. Push to the opposite side of the lesion by: pleural effusion, pneumothorax or mediastinal tumor.

Palpation

• 2-Respiratory movements and expansion of the chest:To assess respiratory movements, place your hands, thumbs together, along the costal margins of the child chest or on the back while the child is sitting.

• 3-Tractile vocal fremitus (TVF):- Palpate for tractile vocal fremitus by using the palmar surfaces of the hands.- Move symmetrically while the child says 44(in Arabic).In the infant, fremitus may be felt as the infant cries.- Increased TVF consolidation in pneumonia.- Decreased TVF pleural effusion, lung collapse, pneumothorax, asthma or foreign body.

Palpation

• 4-Palpable rhonchi (Rhoncus fremitus):In bronchial narowing as in asthma, bronchitis, foreign body or tumor.

• 5-Points of local tenderness:e.g. over the sternum in leukemia.

Palpation

- It is more useful on older children. Percuss over the intercostal spaces moving symmetrically and systematically. The child may sit or lie while the anterior chest in percussed and sit while the posterior chest is percussed.- In infants, you can use direct percussion i.e., percuss directly on the chest wall and not on the midlle finger.

• Types of percussion note:a. Tympanitic: in pneumonthorax.b. Hyper-resonance: in hyper-inflated lung.c. Resonance: in normal lung.d. Impaired note: in collapse or fibrosis.e. Dullness: in consolidation or thick pleura.f. Stony dullness: pleural effusion.

Percussion

• A. Percussion on the front of the chest:By comparison on both sides:- Clavicles are percussed directl.- Sternum and manubrium are also percussed directly.- Percuss the lung along the following lines: Mid-clavicular, anterior, middle and posterior axillary lines.

• B. Percussion of the back of the chest:Along scapular and paravertebral lines.

• C. Tidal percussion(in cooperative children):- It’s used mainly to differentiate supra from infra-diaphragmatic dullness, by percussing the line of dullness while the patient takes deep inspiration and holds his breath and then percuss again on expiration.-If no changes in note the dullness is supradiaphragmatic(pleura or lung).-If the dull note changes the dullness is due to infra-diaphragmatic cause.

Tidal percussion helps also in assessment of diaphragmatic mpvements.

Percussion

Percussion• d. Percussion of the Traube’s area:

- It’s a lozenge shaped area of tympanitiv note overlying the fundus of the stomach:- Traube’s area is bounded by: Right border: Left border of liver. Left border: anterior border of the spleen. Upper border: Lower border of the lung. Lower border: Left costal margin.Causes of dullness in traube’s area:From above: pleural effusion or thickening.From below: - Full stomach or situs inversus. - Ascites. - Subphrenic abscess. - Retroperitoneal tumors.Left border: splenomegaly.Right border: hepatomegaly.

• e. Percussion of Kronig’s isthmus:- It is an area of resonance corresponding to the apex of the lung.- It is bounded by: Anterior border : Medial 2/3 of the clavicle. Posterior border: Medial 1/3 of the spine of the scapula. Medial border: A line connecting the sternoclavicular joint in front with 7th cevical spine behind. Lateral border: A line joins the anterior point (junction of the medial 2/3 and lateral 1/3 of the clavicle) with the posterior point (junction of the medial 1/3 and lateral 2/3 of the spine of the scapula).The causes of impaired note over Kronig’s istmus:-Consolidaion, collapse or fibrosis of apical segment of the upper lobe.-Apical pleural thickening.

Percussion

Percussion

Anterior view of the external relations of the abdominal thoracic organs

• e. Percussion of Kronig’s isthmus:- It is an area of resonance corresponding to the apex of the lung.- It is bounded by: Anterior border : Medial 2/3 of the clavicle. Posterior border: Medial 1/3 of the spine of the scapula. Medial border: A line connecting the sternoclavicular joint in front with 7th cevical spine behind. Lateral border: A line joins the anterior point (junction of the medial 2/3 and lateral 1/3 of the clavicle) with the posterior point (junction of the medial 1/3 and lateral 2/3 of the spine of the scapula).The causes of impaired note over Kronig’s istmus:-Consolidaion, collapse or fibrosis of apical segment of the upper lobe.-Apical pleural thickening.

Percussion

• Important notes on percussion:A. In hyper-inflated lungs: there is encroachment on both cardiac and hepatic dullness.B.Shifting dullness help in D.D. between pleural effusion and hydropneumothorax.- In hydropneumothorax: there is change in note of upper part affected side with change in position (thypanitic on sitting and impaired on lying down).C. Do not forget the general rules of percussion:- Movement must be from the wrist joint.-Percussed finger must be in close contact with percussed surface.- Percussed finger must be parallel to the border to be percussed.-Percussion must be from resonance to dullness.-Light percussion is done for the lungs while heavy percussion is done for deeper organs e.g. liver.-The percussion finger must be kept at right angles to the percussed finger as it falls.-The percussed finger must be away from other fingers of the hand (fanning of fingers).

Percussion

• 1-Air entry:- It is decreased on the affected lung e.g. in obstruction of bronchial tree or pneumothorax.

• 2-Types of breathing:a. Vesicular breathing: -Normal breath sounds. -Inspiration > expiration. - No pause between inspiration and expiration.b. Harsh vesicular (or pertile breathing): - Normal in infants and young children. - It’s vesicular breathing but is louder and harsher due to thin chest wallc. Vesicular breathing with prolonged expiration: -It’s heared in the bronchial narrowing as bronchial asthma.

Auscultation

d. Bronchial breathing: - Hollow in character. - Inspiration = expiration. - A pause is present between inspiration and expiration. - Bronchial breathing is usually accompanied by increased vocal resonance and bronchophony. - It is heard in consolidation (usually pneumonia), neoplasm or abscess. - It is normally heard on the trachea.

• 3-Vocal resonance:- like TVF. It is examined for by ascking the patient to repeat 44(in Arabic) while listening to chest in the same areas as auscultation- In infants, crying is used instead of asying44.- Increased vocal resonance: in consolidation.- Decreased vocal resonance: pleural effusion, lung collapse, pneumothorax, asthma or foreign body.

Auscultation

• Special abnormalities in vocal resonance:A. Bronchophony: - Voice sounds are louder and clearer than usual (i.e. increased vocal resonance with increased clarity of sound). -It’s present in consolidation (usually pneumonia). B. Whispering pectoriloquy: - Whispered sounds are louder and clear because of enhanced transmission in the consolidated clear.C. Aegophony: - Nasal quality of voice sounds, usually heard at the upper border of pleural effusion.

Auscultation

• 4- Adventitious sounds:A. Rhonchi: 1. Sonorous: - continuous, snoring, low pitched, heard througout respiratory cycle. Clear with coughing. Indicative of involvement of large bronchi and trachea. - It’s heard in bronchitis. 2. Sibilant (wheezes) : - continuous, musical, high pitched. - Heard in mid to late expiration. - Indicative of edema and obstruction in smaller airways. - May be audible without a stehoscope. - It is heard in asthma.

Auscultation

• 4- Adventitious sounds:B. Crepitations (Rales or crackles): I. Fine: Indicative of fluid in alveoli, heard late in inspiration. - Cause: Congestive heart failure and pneumonia. . II. Medium sized : - Intermitted, bubbling, medium pitched sound. - Heard in early or mid-inspiration. - Clear with cough, indicative of fluid in bronchioles and bronchi. They me be:Consonating:If there is surrounding conolidation e.g. bronchopneumonia.Non consonating:If there is surrounding normal lung tissue e.g. in bronchitis, bronchial asthma, or pulmonary congestion and edema secondary to left ventricular failure.

Auscultation

• 4- Adventitious sounds:B. Crepitations (Rales or crackles): III. Coarse : - Air bubbling through fluid in larger bronchi. - Heard on expiration. - Clear with coughing. - Heard in bronchiectasis.C. Pleural rub: - This is superficial friction sound occurring to and fro during both inspiration and expiration, and is not changed by coufh. It is usually associated with pain and is exaggerated by deep breathing and pressure by the stethoscope.- It is indicative of dry pleurisy.

Auscultation

D. Transmitted sounds: - Sounds may be referred from the upper respiratory tract if a child has mucus in the nose or throat. - To determine id sounds are referred, place the diaphragm of the stethoscope near the child’s mouth. - Referred sounds are loudest near their origin.

Auscultation