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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
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