Chest and lungs
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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


Apgar score1

APGAR SCORE


Chest and lungs

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


Chest and lungs

  • 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


Chest and lungs

Intrauterine growth retardation

  • Smaller chest circumference compared to the head

    Poorly controlled diabetes

  • Relatively larger chest circumference


Chest and lungs

  • Measure distance between the nipples

    • ¼ chest circumference

  • Note:

    • Symmetry in size

    • Supernumerary

    • Swelling

    • Discharge

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


Chest and lungs

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


Chest and lungs

  • 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


    Chest and lungs

    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

    • 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

    • Retraction at the supraclavicular notch

    • Contraction of the SCM’s

    • Flaring of the nostrils (alae nasi)

      *Should be considered significant.

    See-saw respirations


    Chest and lungs

    • Use thoracic (intercostal) musculature for respiration by age 6 or 7

      • Obvious intercostal exertion (retractions) suggests a problem

    • Respiratory rates that exceed the indicated limits also suggest difficulty


    Assessing respiratory distress

    Assessing Respiratory Distress

    • 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?


    Child chest and lung exam

    Child Chest and Lung Exam


    Crying child seize the opportunity

    Crying Child… 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

    • 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 and lungs

    • Chest wall is thinner and more resonant than adult’s

      • 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

    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”

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

      • Possible chronic obstructive pulmonary problem

        • Cystic fibrosis


    Common conditions

    Common Conditions


    Asthma

    Asthma

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

      • Hyperreactivity to:

        • Allergens

        • Anxiety

        • URTI

        • Smoke

        • Exercise

        • Cold air


    Chest and lungs

    Results in:

    • mucosal edema

    • increased secretions

    • bronchoconstriction

      Airway resistance increases and respiratory flow is impeded.


    Chest and lungs

    Episodes are characterized by:

    • Paroxysmal dyspnea

    • Tachypnea

    • Cough

    • Wheezing (expiration & inspiration)

    • Prolonged expiration

    • Chest pain/tightness


    Chest and lungs

    • Episodes may last for just minutes or hours, or they may be prolonged over days

    • ANXIETY

    • Can be life threatening though usually reversible

      • spontaneously or in response to therapy

    • Between episodes, the patient my be completely asymptomatic


    Asthma1

    Asthma


    Chest and lungs

    Note…

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


    Atelectasis

    Atelectasis

    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


    Bronchiolitis

    Bronchiolitis

    Viral; respiratory syncytial virus (RSV)

    Most common: <6 months

    • Expiration becomes difficult

      • Hyperinflation of lungs

        • Increased A-P diameter of thoracic cage

        • Hyperresonant percussion


    Chest and lungs

    • Infant appears anxious

    • Tachypnea

      • Rapid and short breaths; expiratory phase prolonged

    • Generalized retraction

    • Perioral cyanosis

    • Abdomen appears distended (swallowed air)

    • Possible wheezing and crackles


    Bronchitis

    Bronchitis

    Initial stimulus = irritation

    (Internal or external)

    • Inflammation of the mucus membranes of the bronchial tubes


    Chest and lungs

    • Acute bronchitis

      • 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


    Cystic fibrosis

    Cystic Fibrosis

    • Autosomal recessive disorder of exocrine glands

      • Lungs

      • Pancreas

      • Sweat glands

    • Scottish and English populations


    Chest and lungs

    • Salt loss in sweat

      • 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

    • Viral, particulary parainfluenza viruses

      Who gets it?

      • Very young children

        • 1 ½ to 3 years old

      • Boys > girls

      • Some are prone to recurrent episodes


    Chest and lungs

    • Inflammation is subglottic; may involve areas beyond the larynx

    • dDx

    • Epiglottitis

      • Toxic, drooling facies

    • Aspirated foreign body


    Chest and lungs

    • Often begins in the evening after the child has gone to sleep

      • Awakens suddenly, frightened

        Signs & symptoms:

      • Harsh stridorous cough

        • Bark of a seal

      • Labored breathing

      • Retraction

      • Inspiratory stridor

      • NOT always fever


    Epiglottitis

    Epiglottitis

    • 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


    Chest and lungs

    • Child sits straight up with neck extended, head held forward

    • Appears very anxious and ill

    • Unable to swallow

    • Drooling from the open mouth

    • Cough is NOT common


    Chest and lungs

    • Treat this as a medical 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

    • 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


    Chest and lungs

    • Respiratory tract may be over-whelmed

      • interstitial inflammation and necrosis throughout the bronchiolar and alveolar tissue

        Signs & symptoms:

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


    Pneumonia

    Pneumonia

    • 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


    Tracheomalacia

    Tracheomalacia

    • 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


    Chest and lungs

    dDx

    • Vascular lesion

    • Tracheal stenoisis

    • Foreign body

      Also note…

      Laryngomalacia

      • Floppiness of the larynx

        Laryngotracheomalacia

      • Entire large airway is involved


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