Pediatric Respiratory System Pediatric Respiratory System in Brief

Prof Malak ShaheenProf. Malak Shaheen

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Prof Malak ShaheenLecturesProf Malak ShaheenLectures

Clinical Reasoning .. Properway

Integrated ClinicalPractice

Get ready …..

• Sherlock Holmes Model

Use all your senses …… ..

Secret ingredient .. Deal with children

Tool kit for a pediatrician….

Pillars for ClinicalDiagnosis

1 P Hi t (Sh t)1. Proper History (Sheet)2. Clinical Examination (General & Local)( )3. Investigations (Bedside +others)

Chest Exam .. Let us start

When it begins…..

• First look to thechild

History Taking

• Common respiratory symptoms• How to ask?

How to analyze eachsymptom?• How to analyze eachsymptom?• Collect data + write down

E l• Example:• Cough analysis ….(Timing)g y ( g)• Fever analysis …...

Common symptomsCough +sputum production HaemoptysisFever / toxicsymptomsFever / toxicsymptomsChest pain (Children different than adults) Breathlessness (SOBcauses?)Wheeze (noisy breathing – other examples)Wheeze (noisy breathing – other examples) Allergy

Position/Lighting/Exposure• Position –

Patient should sit upright/Semi-sitting– Patient should sit upright/Semi-sitting– The patient's hands should remain at theirsides.

• Lighting - adjusted so that it is ideal.

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

General Examination R l f “4”Rule of “4”

1 ABC D1. ABC D2. 4 vital data3. 4 X 2Skin4. 4 groups of LN

From Head to Toe

R 4 (CVS N GIT & U )Rest 4 systems (CVS, Neuro, GIT & Uro)

4• Appearance • Respiratory rate• Built (weight+

Height)• Pulse• Blood PressureHeight)

• Consciousness• Blood Pressure• Temparature

• Decubitus• 3 colors

• Occipital LN

3 colors• Oedema

• Cervial LN• Axillary LN

• Subcut fat• Rash• Axillary LN

• Inguinal LN

Rash• Elasticity (Turgor)• Texture

From scalp to toe

Steps of Local ChestExamination

I ti-Inspection-Palpationp-PercussionA l i-Auscultation

Local Chest Examination R l f “3”Rule of “3”

I ti• Inspection:1 Shape1. Shape2. Symmetry3. Respiratory Movement (diagnosis of

respiratory distress)respiratory distress)

Examination of the chestExamination of the chestInspection

1. Shape of thechestThe normal chest is bilaterally symmetrical and elliptical in cross section the trans erse diameter >anter oposterior diameter ( hen?)the transverse diameter > anter-oposterior diameter (when?)

Comman abnormalities of shapekyphosis-forward bending of vertebralcolumn scoliosis- lateral bending of vertebralcolumnbarrel shaped chest- increase in anteroposteriordiameterflatteningg

Respiratory Examination

Chest wall

Pectusexcavatum

Chest wall

Pectus carinatum

May prevent complete

fexpiration of air from the lungs and

thus may restrict i h

Base lungcapacity isdecreasedair exchange

considerably.decreased

Continue…. Inspection• 2. Symmetry of chestexpansion

h i f h l h hild h ldbchest expansion of a healthy child shouldbe equal on both sides

3 Rate& Rhythm/patternAge (yrs) Resp Rate

(breathes/min) 3. Rate & Rhythm/pattern of respiration

Rate of respiration inhealth<1 30-40

2-5 25-302-5 25-30

5-12 20-25• Movements of thechest

wall (RD (presence of intercostal recessions or theuse of

accessorymuscles>12 15-20

Eff t f b thiEffort of breathing

• Respiratory Rate• Recession

– Mild: sub-costalS l– Severe: sternal

• Accessory muscle use• Grunting• Alar nasal flare• Child’s position• Respiratory noisesp y

– Stridor / wheeze

Effort of breathing:Effort of breathing:respiratory rate

Age (yrs) Resp Rate (b th / i )

<1(breathes/min)

30-40What are causesof Resp. Distress?(Resp& non resp)

2-5 25-30(Resp& non resp)

5 12 20 255-12 20-25

>12 15-20

Rule of “3”

P l ti• Palpation:1 Chest expansion1. Chest expansion2. TVF3. Trachea site (Very Very Important)

PalpationPalpationBefore making a systemic examination palpate any part of the

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

• Position of the Apex beat andTrachea

• In normal subjects the trachea is in the midline and can be palpated in the suprasternalnotchp p p

PalpationPalpation

• Expansion of thechest

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

• Vocal fremitusVocal fremitus is the vibration detected by palpation withthe 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”

P i (Rt & Lf id i• Percussion (Rt & Lf sidesin comparison):p )

1. Mid clavicular line (light)2 Mid ili li (li ht)2. Mid axiliary line (light)3. Scapular line (heavy)

Percussion

The middle finger of the left hand is placed on the chest andmiddle phalanx is struck with the tip of the middle finger of theright handright hand

Feel and listen to sound of resonance over ahealthy lung has tobeFeel and listen to sound of resonance over a healthy lung has tobe learned by practice

Percussion2nd phalanx over area of intercostal spaceintercostal space

Right middle finger strikesthe 2nd phalanx producinghammer effectEntire movement comesEntire movement comes from wrist

Reference Lines

• Anterior Chest– Midsternal line– Midclavicular lineMidclavicular line

• Posterior Chest– Vertebral line –midspinalp– Scapular line

L t l Ch t• Lateral Chest– Anterior Axillary liney– Posterior Axillary line– Mid–axillary line– Mid–axillary line

Order of PercussionOrder of Percussion

Respiratory Examination

• Percussion– Illicit resonance– Compare both sides– Map out abnormalarea

Rule of “3”

A lt ti (Rt & Lf id i• Auscultation(Rt & Lf sidesin comparison):p )

1. Air Entary2 B thi d2. Breathing sounds3. Adventitious sounds

Respiratory Examination

• Auscultation technique– Diaphragm of stethoscope– Mouth openp– Breathing deeply and fairly rapidly– CoughCough– Compare both sides

Basic Lung Sounds:http://www stethographics com/main/physiology ls introduction htmlhttp://www.stethographics.com/main/physiology_ls_introduction.html

AuscultationAuscultation

Air EntryDiminished

C d i li i d bConduction limited by– Airflow limitation

e.g. diffusely – asthma,emphysema localised – tumour, collapse

– Something separating chest wall from lungSomething separating chest wall from lunge.g. effusion, fibrosis

Auscultation

• Breath soundsThere are 2types of breathsounds

vesicular breath sounds- vesicular breath sounds- bronchial breath sounds

Vesicular breath soundsescua b eat sou dsThese originate in the larger airways and are producedby the passage of air in and out of normal lung tissue

In good health they can be heard all over the chestIn good health, they can be heard all over the chest -the inspiration is longer thanexpiration -the inspiratory sound isintense and louder

th th i t dthan the expiratorysound -it is a lowpitched rustling sound -there is no gap between inspiration and expiration

Harsh Vesicular breathing with prolonged expiration example: airway obstruction (asthma)example: airway obstruction (asthma)

Basic Lung Sounds: http://www stethographics com/main/physiology ls introduction htmlhttp://www.stethographics.com/main/physiology_ls_introduction.html http://www.cvmbs.colostate.edu/clinsci/callan/breath_sounds.htm

A lt tiAuscultation

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

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

I di b hi l b hi b h d h f l h iIn 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 inspirationth it h d d f th i ti i l d -the pitch and sound of the expiration is loud or

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

Respiratory Examination• Bronchial breathing

Respiratory Examination

• Added sounds– Wheeze– Crepitations (crackles)– Pleural sounds

Respiratory ExaminationAb l S d D i ti C ditiAbnormal Sound Description Condition

Crackles (rales) Short, discrete, popping or Pulmonary oedema crackling sounds Pneumonia

Atelectasis Bronchiectasis

Wheezes High pitched, squeaking, hi li d

Asthma hwhistling sounds. Bronchospasm

Pleural friction rub Creaking, leathery, loud, Pleurisy g ydry, course sounds

yPleural effusion

Respiratory Examination... more

• Vocal sounds on auscultation– Vocal resonance– Increased when voice sounds are louder and moredistinct

e.g. consolidation– Reduced when transmission impeded e.g. effusion,

collapse

D’Espine’s signD’Espine’s sign

D’Espine’s signD’Espine’s signImportant sign of a posterior mediastinalmass At the level of mid-scapula (about T5) –listenover the vertebral spinous process and on o e e e eb a sp ous p ocess a d oeither side of the vertebral column. Normally the lateral sounds are louder and moredistinct.the lateral sounds are louder and moredistinct.When the upper airway sounds are of greater intensity than the corresponding lateral lungintensity than the corresponding lateral lung sounds – implies a continuity (a mass) between amainstem bronchus and vertebraa mainstem bronchus and vertebra

Special situation:Special situation: Critically ill child ABCapproachCritically ill child …. ABCapproach

• A =Airway• B=Breathing

C=Circulation• C=Circulation• D = Disability (CNS)y ( )• E = Exposure

Effi f b thiEfficacy of breathing

• Respiratory distress• Air entry• Pulse oximetryPulse oximetry

A silent chest is aA silent chest is a pre-terminal sign

Eff t f i t i dEffects of respiratory inadequacy

• Heart rate• Skin colour• Level of consciousnessLevel of consciousness

Pre terminal signs:Pre-terminal signs:• Bradycardia• Central cyonosis• UnconsciousnessUnconsciousness

Putting things together ….

Interpretation of findingsInterpretation of findings

Pleural effusion• Tracheal shift• stony dull

Consolidation• Tracheacentral• reducedexpansion• stony dull

reduced air entry• reducedexpansion

dull percussion• bronchial breathingbronchial breathing• or coarsecreps• increased vocal resonance

Interpretation of findingsPneumothorax Consolidation Collapse• deviated trachea• reduced tactile vocal

f it

• deviated trachea• reduced tactile vocal

f itfremitus• hyper-resonance

d d i t

fremitus• dull percussion

d d i t• reduced air entry• reduced vocal resonance

• reduced air entry• +/- creps

Alveolar disease…

• Grunting sound• Fine crepitation

Further Plans ……

• Investigations:g

–Bedside: oximeter, peak flow meter–Laboratory: ABG**Radiological–Radiological

–Other

Reaching diagnosis (or D.D.)• Anatomical diagnosis (where is the

)lesion)• Pathological diagnosis (what is thePathological diagnosis (what is the

lesion)Eti l i l di i ( )• Etiological diagnosis (cause)

• Functional diagnosis g(compensated/decomp.)

• Other complication(s)• Other complication(s)

Treatment

• Specific ttt (cause)• Supportive ttt

Chest exam interfaces for you

1. Short caseexam2. Long case exam3 OSCE3. OSCE4. Within other pediatrics case (eg.Neuro, p ( g

Down, Cardiac,..)5 Clinical practice5. Clinical practice …..

OSCEOSCE …..

Wash your hands Wash your hands Introduce yourselfy

Patient details Explain/consent

SScenesurvey

Further resources …watch & listen

• YouTube• Assessing lung sounds Part 1• Assessing lung sounds Part 2• Lung sounds mix• The lung & thoraxexamg• Learn pediatrics: Respiratoryexam• Examination of lungs and respiratory(Ped)g p y( )• Respiratory1• Respiratory2p y• How to usestethoscope• Pediatric respiratory exam: OSCEguidePediatric respiratory exam: OSCEguide

Further resources …reach & read

Download resources

1 • www.EKB.com

• Official e-mail2 Official e mail

3 • Clinical Keyaccess

Test yourselfTest yourself

Diagnosis??Diagnosis??

History6 hild k i h h• 6 years child –Recurrent attacks night cough –

• wheezy chest

General Exam• N/A

Local exam• Respiratory distress ‐ Central Trachea• Wheezy chest

Diagnosis??Diagnosis??

History• 10 years child Persistent cough purulent expectoration• 10 years child –Persistent cough – purulent expectoration• Duration: 2 years

General ExamSh t t t F il t th i P l l bbi• Short stature – Failure to thrive – Pale clubbing

Local exami di h hif d id• Respiratory distress – Trachea shifted to one side

• Same side is full of fine creptations

Diagnosis??Diagnosis??

History2 hild F d h f 2 d d ti• 2 years child –Fever and cough of 2 days  duration –

• Difficulty of breathing (Tachypnea)

General Exam• Fever: 39 ° C• Child weight: 9 Kg

Local exam• Respiratory distress ‐ Central Trachea• Chest: bronchial breathing in Rt lung lower lobe (back)

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Prof Malak ShaheenLecturesProf Malak ShaheenLectures

ThankYouThank You

Drmalak_shaheen@med.asu.edu.eg