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Chest and Lungs. Adapted from Mosby’s Guide to Physical Examination, 6 th Ed. Ch. 13. Newborns. Obligate Nose Breathers Only open their mouth to breathe if in respiratory distress Rely primarily on the diaphragm for respiratory effort Commonly use abdominal muscles

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Chest and lungs

Chest and Lungs

Adapted from Mosby’s Guide to Physical Examination, 6th Ed.

Ch. 13


Newborns
Newborns

  • Obligate Nose Breathers

    • Only open their mouth to breathe if in respiratory distress

  • Rely primarily on the diaphragm for respiratory effort

    • Commonly use abdominal muscles

    • Gradually adding intercostal muscles


Newborns1
Newborns

  • Coughing

    • Rare

    • Should be considered a problem

  • Sneezing

    • Frequent and expected

    • Clears the nose


Newborn
Newborn

  • Chest is generally round

    • A-P diameter approximately the same as the transverse

  • Chest circumference is approximately the same as the head circumference

    • Until ~2 years of age

      *With growth, the lateral diameter will eventually exceed the A-P diameter (adult)


Infant and young child
Infant and Young Child

  • Bony structure is more prominent than the adult

    • Relatively thin chest wall

  • More cartilaginous and yielding

  • Xiphoid process is often more prominent and a bit more moveable


Newborn apgar scoring

NewbornAPGAR Scoring


Apgar score
APGAR SCORE

  • Developed by Dr. Virginia Apgar (1953)

  • Subjective qualitative evaluation

    • done at 1 and 5 minutes

    • determine “survivability” of the newborn by observing the level of function of 5 components

      • Heart rate

      • Respiratory rate

      • Muscle tone

      • Reflex irritability

      • Color

A ctivity

P ulse

G rimace

A ppearance

R espirations



A newborn whose respirations are inadequate but who is otherwise normal…

  • may initially score 1 (or even 0) on

    • heart rate

    • muscle tone

    • irritability

    • color


Depressed respiration
Depressed Respiration

Origins:

  • Maternal environment during labor

    • Sedatives

    • Compromised blood supply to the child

  • Mechanical obstruction by mucus

    What about…

    Neurological damage (birth trauma)?


Infant chest lung exam
Infant Chest & Lung Exam

  • Similar to the adult exam

    • Inspecting without disturbing the baby is key

    • Percussion is usually unreliable

      • Examiner’s fingers may be too large


  • Inspect thoracic cage

    • Size

    • Shape

  • Measure chest circumference

    • Full-term infant: 30-36 cm

    • Sometimes 2-3 cm smaller than head circumference

      • Increases with prematurity


Intrauterine growth retardation

  • Smaller chest circumference compared to the head

    Poorly controlled diabetes

  • Relatively larger chest circumference


Breast development in a newborn -d/t hormonal influences


Respiratory rate
Respiratory Rate

  • Count for 1 minute

    • Average: 40-60 rpm

      • though 80 rpm is not uncommon

  • If room temp is very warm or cool, variation in the rate occurs

    • Most often tachypnea

    • Sometimes bradypnea


Rhythm
Rhythm

  • Note regularity of respiration

  • Premature infants are more likely to have irregular respiratory patterns

    • Periodic breathing

      • sequence of relatively vigorous respiratory efforts followed by apnea of as long as 10-15 seconds


Periodic breathing
Periodic Breathing

Cause for concern if …

  • Apneic episodes tend to be prolonged

  • Baby becomes centrally cyanotic

    • In the term infant periodic breathing should wane a few hours after birth

    • Persistence in preterm infants is relative to gestational age

      • Apneic periods should diminish in frequency as they approach term status


Clinical note
CLINICAL NOTE

Newborn

  • Pattern of respirations will vary with room temperature, feeding and sleep

    • During the first few hours… respiratory effort may be depressed by passive transfer of drugs given to the mother before delivery


If chest expansion is asymmetric

suspect inability to fill one of the lungs

  • Pneumothorax

    • Presence of air/gas in the pleural cavity

  • Diaphragmatic hernia


Palpate
Palpate

  • Rib cage and sternum

    • Loss of symmetry

    • Unusual masses

    • Crepitus

      • Fractured clavicle (birth trauma)

        • May show no evidence of pain

  • Xiphoid

    • Mobile and prominent

      • Sharp inferior tip; move back and forth under your finger


Auscultation

Auscultation

Wait for quiet!


Auscultation1
Auscultation

  • Localization of breath sounds is difficult

  • Difficult to detect absence of breath sounds in any given area

    • Breath sounds are easily transmitted from one segment to another


  • Movement

  • Mucus in the upper airway

  • Gurgling (intestinal tract)

    …may contribute to adventitious sounds making evaluation difficult

  • If GI gurgling sounds are persistently hears in the chest

    • Suspect diaphragmatic hernia


  • Crackles and ronchi
    Crackles and Ronchi

    • Not uncommon immediately after birth

      • Fluid has not completely cleared

    • If asymmetric…

      • a problem should be suspected

        • aspiration of meconium


    Stridor
    Stridor

    • High pitched, piercing sound

      • Most often heard during inspiration

    • Obstruction high in the respiratory tree

      *Cannot be dismissed as inconsequential

      • Especially when inspiration is longer than expiration


    If accompanied by cough, hoarseness or retraction you must consider a serious problem in trachea or larynx…

    Differentials include:

    • Floppy epiglottis

    • Congenital defects

    • Croup

    • Edematous response

      • Infection

      • Allergen

      • Smoke

      • Chemicals

      • Aspirated foreign body


    Respiratory grunting
    Respiratory Grunting consider a serious problem in trachea or larynx…

    • Infant tries to expel trapped air or fetal lung fluid while trying to retain air and increase oxygen levels

      If persistent, cause for concern.


    Increased respiratory effort
    Increased Respiratory Effort consider a serious problem in trachea or larynx…

    • Retraction at the supraclavicular notch

    • Contraction of the SCM’s

    • Flaring of the nostrils (alae nasi)

      *Should be considered significant.

    See-saw respirations



    Assessing respiratory distress
    Assessing Respiratory Distress age 6 or 7

    • Does a loss of synchrony between L and R occur during the respiratory effort? Is there a lag in movement of the chest on one side? Atelectasis? Diaphragmatic hernia?

    • Is there stridor? Croup? Epiglottitis?

    • Is there retraction at the suprasternal notch, intercostally, or at the xiphoid process?

    • Do the nares dilate and flare with respiratory effort? Is pneumonia present?

    • Is there an audible expiratory grunt? Is it audible with the stethoscope only or without? Is there lower airway obstruction? Focal atelectasis?

    • Is there paradoxic breathing?



    Crying child seize the opportunity
    Crying Child… age 6 or 7 Seize the opportunity!

    • A sob is frequently followed by a deep breath

    • Allows the evaluation of vocal resonance

    • Feel for tactile fremitus

      • Whole hand, palm and fingers


    5 years old
    <5 years old age 6 or 7

    • May not be able to give enough of an expiration to satisfy you

      • Especially with subtle wheezing

      • Ask them to “blow out” your penlight or to blow away a bit of tissue in your hand

      • Listen after they run up and down the hallway


    • Chest wall is thinner and more resonant than adult’s age 6 or 7

      • Intrathoracic sounds are easier to hear

      • Hyperresonance is common

    • Easy to miss the dullness of underlying consolidation (percussion)

      If you sense some loss of resonance, give it as much importance as you would give frank dullness in the adult.


    Child
    Child age 6 or 7

    Because the chest wall is thinner…

    • Breath sounds may sound louder, harsher, and more bronchial

      Bronchovesicular sounds may be heard throughout the chest.


    Persistence of barrel chest
    Persistence of “Barrel Chest” age 6 or 7

    • If the “roundness” of a child’s chest persists past the 2nd year

      • Possible chronic obstructive pulmonary problem

        • Cystic fibrosis


    Common conditions

    Common Conditions age 6 or 7


    Asthma
    Asthma age 6 or 7

    • Chronic obstructive pulmonary disease (COPD) characterized by airway inflammation

      • Hyperreactivity to:

        • Allergens

        • Anxiety

        • URTI

        • Smoke

        • Exercise

        • Cold air


    Results in: age 6 or 7

    • mucosal edema

    • increased secretions

    • bronchoconstriction

      Airway resistance increases and respiratory flow is impeded.


    Episodes are characterized by: age 6 or 7

    • Paroxysmal dyspnea

    • Tachypnea

    • Cough

    • Wheezing (expiration & inspiration)

    • Prolonged expiration

    • Chest pain/tightness



    Asthma1
    Asthma prolonged over days


    Note… prolonged over days

    A wheezing patient withgeneralized pulmonary findingsmay haveasthma or a viral infection, but rarely, if ever, a bacterial infection.


    Atelectasis
    Atelectasis prolonged over days

    Lung is airless…

    • Incomplete expansion of the lung at birth OR

    • Collapse of the lung at any age

      • Compression from outside

        • Exudates, tumors

      • Resorption of gas from the alveoli with complete internal obstruction


    Atelectasis1
    Atelectasis prolonged over days


    Bronchiolitis
    Bronchiolitis prolonged over days

    Viral; respiratory syncytial virus (RSV)

    Most common: <6 months

    • Expiration becomes difficult

      • Hyperinflation of lungs

        • Increased A-P diameter of thoracic cage

        • Hyperresonant percussion


    • Infant appears anxious prolonged over days

    • Tachypnea

      • Rapid and short breaths; expiratory phase prolonged

    • Generalized retraction

    • Perioral cyanosis

    • Abdomen appears distended (swallowed air)

    • Possible wheezing and crackles


    Bronchitis
    Bronchitis prolonged over days

    Initial stimulus = irritation

    (Internal or external)

    • Inflammation of the mucus membranes of the bronchial tubes


    • Acute bronchitis prolonged over days

      • Fever and chest pain

      • May be more or less severe than chronic

    • Chronic bronchitis

      • Variety of causes and physical manifestations

        • Excessive secretion of mucus in the bronchial tree

    • Both can show varying degrees of involvement

      • Possible obstruction and even atelectasis

      • Most often quite mild


    Bronchitis1
    Bronchitis prolonged over days


    Cystic fibrosis
    Cystic Fibrosis prolonged over days

    • Autosomal recessive disorder of exocrine glands

      • Lungs

      • Pancreas

      • Sweat glands

    • Scottish and English populations


    • Salt loss in sweat prolonged over days

      • Parent may report that the child’s skin is unusually salty

    • Frequent and progressive pulmonary infections

      • Heavy secretions of thick mucus clog bronchi and bronchioles

        As dysfunction progresses…

      • Tolerance for exercise decreases

      • Pulmonary hypertension and cor pulmonale


    Croup
    Croup prolonged over days

    • Viral, particulary parainfluenza viruses

      Who gets it?

      • Very young children

        • 1 ½ to 3 years old

      • Boys > girls

      • Some are prone to recurrent episodes




    Epiglottitis
    Epiglottitis sleep

    • Haemophilus influenzae type B

      • Incidence appears to have reduced

        • ? vaccine

    • Acute, life-threatening

      • Begins suddenly and progresses rapidly

        • Full obstruction of the airway

    • Most common: 3-7 years old



    • Treat this as a forwardmedical emergency

      • No one should examine the child’s mouth until intubation equipment is available

    • Inserting tongue blade may be deadly!

      • may result in complete airway obstruction


    Influenza
    Influenza forward

    • Generalized febrile illness (viral)

      • Cough

      • Fever

      • Malaise

      • Headache

      • Coryza

      • Mild sore throat

    • In mild cases, it may seem like a cold BUT

      the very young are at higher risk


    • Respiratory tract may be over-whelmed forward

      • interstitial inflammation and necrosis throughout the bronchiolar and alveolar tissue

        Signs & symptoms:

      • crackles, rhonchi, tachypnea, cough (nonproductive) and substernal pain


    Pneumonia
    Pneumonia forward

    • Inflammatory response of the bronchioles and alveolar space to an infective agent

      • Bacterial

      • Fungal

      • Viral

    • Exudates lead to lung consolidation

      • Dyspnea, tachypnea, and crackles

      • Diminished breath sounds; dullness to percussion


    Pneumonia1
    Pneumonia forward


    Tracheomalacia
    Tracheomalacia forward

    • Floppiness of the trachea or airway

      • Lack of rigidity; trachea changes in response to varying pressures of inspiration and expiration

    • “Noisy breathing” in infancy

      • Wheezing, inspiratory stridor

        *Generally benign and self-limiting with age


    dDx forward

    • Vascular lesion

    • Tracheal stenoisis

    • Foreign body

      Also note…

      Laryngomalacia

      • Floppiness of the larynx

        Laryngotracheomalacia

      • Entire large airway is involved


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