Objective Examination Techniques of a Child"s Chest
INSPECTION Inspection of the lungs involves primarily observation of respiratory movements, which are discussed.
Respirations are evaluated for • Rate (number per minute) • Rhythm (regular, irregular, or periodic) • Depth (deep or shallow) • Quality (effortless, automatic, difficult, or labored) The doctor also notes the character of breath sounds based on inspection without the aid of auscultation, such as noisy, grunting, or snoring.
An average respiratory rate at rest of the child of different ages is; Newborn 40-35 per minute Infant at 6 months 35-30 per minute At 1 year 30 per minute 5 years 25 per minute 10 years 20 per minute 12-18 years 16-20 per minute The respiratory rate is always evaluated in relation to general physical status.
For example, tachypnea is expected with fever, because for every degree Fahrenheit elevation in temperature, the respiratory rate increases 4 breath per minute.
The usual ration of breaths to heartbeats is 1:4.
Disorders of the respiratory rate Tachypnea is the increase of the respiratory rate Bradypnea is the decrease of the respiratory rate Dyspnea is the distress during breathing Apnea is the distress during breathing Apnea is the cessation of breathing Disorders of the respiratory depth Hyperpnea is an increased depth Hypoventilation is a decreased depth and irregular rhythm Hyperventilation is an increased rate and depth Pathological respiration Seesaw (paradoxic) respirations; the chest falls on inspiration and rises on expiration.
It is usually observed in respiratory failure of third degree.
Kussmaul's breathing is hyperventilation, gasping and labored respiration, usua;;y seen in diabetic coma or other states of respiratory acidosis.
PALPATION Another way to achieve this is through palpation.
The main principle of palpation is to check for respiratory movements.
Respiratory movements are felt by placing each hand flat against the back or chest with the thumbs in midline along the lower costal margin of the lungs.
The child should be sitting during this procedure and if cooperative, should take several deep breathes, During respiration the hands will move with the chest wall, The doctor evaluates the amount and speed of respiratory excursion, noting any symmetry of movement, Normally in older children the posterior base of the lungs descends 5 to 6 cm (about 2 inches) during a deep inspiration.
The doctor also palpates for vocal fremitus, the conduction of voice sounds through the respiratory tract.
With the palmar surfaces of each hand on the chest, the doctor can ask the child to repeat words such as ninety nine, one, two, three, thirty three, three hundred and thirty three etc.
The child should speak the words with a voice of Uniform intensity.
Vibrations are felt as the hands move symmetrically on either side or the sternum and vertebral column.
In general, vocal fremitus is the most intense in the regions of the thorax where the trachea and bronchi are the closest to the surface, particularly along the sternum between the first and second ribs and posteriorly between the scapulae, Progressing downward, the sound decreases and is least prominent at the base of the lungs.
Decreased vocal fremitus in the upper airway may indicate • The obstruction of a major bronchus • Pneumo-, hydro-, haemothorax • Emphysema of lungs • Adiposity can also be the cause of decreased vocal fremitus.
The voice of fremitus is increased • In pneumonia • In abscess • In ateletasis • In cavern Absence of fremitus usually indicates obstruction of a major bronchus, which may occur as the result of aspiration of a foreign body.
Decreased or absent fremitus is always recorded and reported for further investigation.
During palpation other vibrations that indicate pathologic conditions are noted.
One is a pleural friction rub, which has a grafting sensation.
It is synchronous with respiratory movements and is the result of opposing surfaces of the inflamed pleural lining rubbing against one another.
Crepitation is felt as a coarse, cracking sensation as the hand presses over the affected area.
It is the result of the escape of air from the lungs into the subcutaneous tissues from an injury or surgical intervention.
Both pleural friction rubs and crepitation can usually be heard as well as felt.
Clinical examination of the child's chest requires skills and technique and hence continuous practice makes this aspect of diagnosis very easy.
Respirations are evaluated for • Rate (number per minute) • Rhythm (regular, irregular, or periodic) • Depth (deep or shallow) • Quality (effortless, automatic, difficult, or labored) The doctor also notes the character of breath sounds based on inspection without the aid of auscultation, such as noisy, grunting, or snoring.
An average respiratory rate at rest of the child of different ages is; Newborn 40-35 per minute Infant at 6 months 35-30 per minute At 1 year 30 per minute 5 years 25 per minute 10 years 20 per minute 12-18 years 16-20 per minute The respiratory rate is always evaluated in relation to general physical status.
For example, tachypnea is expected with fever, because for every degree Fahrenheit elevation in temperature, the respiratory rate increases 4 breath per minute.
The usual ration of breaths to heartbeats is 1:4.
Disorders of the respiratory rate Tachypnea is the increase of the respiratory rate Bradypnea is the decrease of the respiratory rate Dyspnea is the distress during breathing Apnea is the distress during breathing Apnea is the cessation of breathing Disorders of the respiratory depth Hyperpnea is an increased depth Hypoventilation is a decreased depth and irregular rhythm Hyperventilation is an increased rate and depth Pathological respiration Seesaw (paradoxic) respirations; the chest falls on inspiration and rises on expiration.
It is usually observed in respiratory failure of third degree.
Kussmaul's breathing is hyperventilation, gasping and labored respiration, usua;;y seen in diabetic coma or other states of respiratory acidosis.
PALPATION Another way to achieve this is through palpation.
The main principle of palpation is to check for respiratory movements.
Respiratory movements are felt by placing each hand flat against the back or chest with the thumbs in midline along the lower costal margin of the lungs.
The child should be sitting during this procedure and if cooperative, should take several deep breathes, During respiration the hands will move with the chest wall, The doctor evaluates the amount and speed of respiratory excursion, noting any symmetry of movement, Normally in older children the posterior base of the lungs descends 5 to 6 cm (about 2 inches) during a deep inspiration.
The doctor also palpates for vocal fremitus, the conduction of voice sounds through the respiratory tract.
With the palmar surfaces of each hand on the chest, the doctor can ask the child to repeat words such as ninety nine, one, two, three, thirty three, three hundred and thirty three etc.
The child should speak the words with a voice of Uniform intensity.
Vibrations are felt as the hands move symmetrically on either side or the sternum and vertebral column.
In general, vocal fremitus is the most intense in the regions of the thorax where the trachea and bronchi are the closest to the surface, particularly along the sternum between the first and second ribs and posteriorly between the scapulae, Progressing downward, the sound decreases and is least prominent at the base of the lungs.
Decreased vocal fremitus in the upper airway may indicate • The obstruction of a major bronchus • Pneumo-, hydro-, haemothorax • Emphysema of lungs • Adiposity can also be the cause of decreased vocal fremitus.
The voice of fremitus is increased • In pneumonia • In abscess • In ateletasis • In cavern Absence of fremitus usually indicates obstruction of a major bronchus, which may occur as the result of aspiration of a foreign body.
Decreased or absent fremitus is always recorded and reported for further investigation.
During palpation other vibrations that indicate pathologic conditions are noted.
One is a pleural friction rub, which has a grafting sensation.
It is synchronous with respiratory movements and is the result of opposing surfaces of the inflamed pleural lining rubbing against one another.
Crepitation is felt as a coarse, cracking sensation as the hand presses over the affected area.
It is the result of the escape of air from the lungs into the subcutaneous tissues from an injury or surgical intervention.
Both pleural friction rubs and crepitation can usually be heard as well as felt.
Clinical examination of the child's chest requires skills and technique and hence continuous practice makes this aspect of diagnosis very easy.
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