11/13/24, 7\:07 PM Guide | Paediatric respiratory exam

Paediatric respiratory exam

Table of contents

Background

Paediatrics is full of respiratory presentations and thus, respiratory examinations. This guide provides an overview of how to
perform a paediatric respiratory examination in an OSCE setting.
It is important to be
personality and how unwell they are.
Be opportunistic in your examination - taking advantage of periods of quiet to listen to the chest and open mouth yawns or
cries to look at the throat. Remember, parents and carers can also be a great asset - helping to explain the next step in the
examination and position the child as you need them. Work as a team!

Introduction

Wash your hands and don PPE if appropriate.
Introduce yourself to the parents and the child, including your name and role.
Con
Brie
" T o d a y I' d l i k e t o p e r f o r m a r e s p i r a t o r y
e x a m i n a t i o n , w h i c h w i l l i n v o l v e o b s e r v i n g y o u r c h i l d , f e e l i n g t h e i r p u l s e a n d l i s t e n i n g t o t h e i r b r e a t h i n g w i t h m y s t e t h o s c o p e .
"
Gain consent from the parents/carers and/or child before proceeding\: " A r e y o u h a p p y f o r m e t o c a r r y o u t t h e e x a m i n a t i o n ?"

General inspection

Appearance and behaviour

Observe the child in their environment (e.g. waiting room, hospital bed) and take note of their appearance and behaviour\:
Activity/alertness\: note if the child appears alert and engaged, or quiet and listless.
Cyanosis\: bluish discolouration of the skin due to poor circulation (e.g. peripheral vasoconstriction secondary to
hypovolaemia) or inadequate oxygenation of the blood (e.g. right-to-left cardiac shunting).
Shortness of breath\: may indicate underlying cardiovascular (e.g. congenital heart disease) or respiratory disease (e.g.
asthma).
Pallor\: a pale colour of the skin that can suggest underlying anaemia (e.g. blood dyscrasia, chronic disease) or poor
perfusion (e.g. congestive cardiac failure).
Weight\: note if the child appears a healthy weight for their age and height.
Syndromic features
Pay attention to features that may indicate the presence of an underlying genetic condition\:
Stature (e.g. tall/short)
Syndromic facial features
See the end of this guide for a non-exhaustive list of clinical syndromes which can be associated with respiratory system
pathology.

Sounds

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Note any audible sounds as you observe the child and consider what underlying pathology they may indicate\:
Cough with wheeze\: asthma, viral-induced wheeze
Productive cough\: lower respiratory tract infection
Barking cough\: croup, laryngomalacia
Dry cough\: allergies, tuberculosis
Hoarse voice\: laryngitis
Hot potato voice\: peritonsillar abscess
Acute stridor\: croup, foreign body, bacterial tracheitis, epiglottitis
Chronic stridor\: laryngomalacia, subglottic stenosis

Equipment

system\:
Observe for any equipment in the child's immediate surroundings and consider why this might be relevant to the respiratory
Mobility aids\: neuromuscular disorder
Feeding tubes (NG/NJ/gastrostomy)\: ex-premature infant, cystic
Oxygen saturation monitor or oxygen cylinder\: chronic lung disease
Tracheostomy\: upper airway obstruction - each child in the UK should have a box of emergency tracheostomy equipment
(often blue/red in colour). See our tracheostomy overview guide.

Medications

Note any medications by the bedside or in the child's room and consider what underlying diagnoses they may indicate\:
Antibiotics\: pneumonia, bronchiectasis, cystic
Inhalers\: asthma
Pancreatic enzymes\: cystic
Cyanosis [1]

Hands

The hands can provide lots of clinically relevant information and therefore a focused, structured assessment is essential.

Inspect the hands

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General observations
Inspect the hands for clinical signs relevant to the cardiovascular system\:
Colour\: pallor suggests poor peripheral perfusion (e.g. congestive heart failure) and cyanosis may indicate underlying
hypoxaemia.
Tremor\: may be caused by beta 2 agonist use (e.g. salbutamol).
Eczema\: increased likelihood of asthma and hayfever (atopy).
Finger clubbing
Finger clubbing involves uniform soft tissue swelling of the terminal phalanx of a digit with subsequent loss of the normal
angle between the nail and the nail bed. Finger clubbing is associated with several underlying disease processes, but those
most likely to appear in a respiratory OSCE station include bronchiectasis, cystic
To assess for
Ask the child to copy you in placing the nails of their index
In a healthy individual, you should be able to observe a small diamond-shaped window (known as Schamroth’s window).
When
If the child is too young for this to be possible, you can simply inspect the
terminal phalanx of the digits.
Finger clubbing [2]

Pulse

Radial pulse
Palpate the child's radial pulse, located at the radial side of the wrist, with the tips of your index and middle
longitudinally over the course of the artery.
Once you have located the radial pulse, assess the rate and rhythm.
In babies, assess the femoral pulse instead.
Heart rate
Assessing heart rate\:
You can calculate the heart rate in a number of ways, including measuring for 60 seconds, measuring for 30 seconds and
multiplying by 2 or measuring for 15 seconds and multiplying by 4.
For irregular rhythms, you should measure the pulse for a full 60 seconds to improve accuracy.
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Palpate the radial pulse

Face

Observe the child's facial complexion and features, including their eyes, ears, nose, mouth and throat.

General appearance

Inspect the general appearance of the child's face for signs relevant to the respiratory system\:
Nasal
Micrognathia (undersized jaw)\: associated with a wide range of genetic syndromes (e.g. Pierre Robin, Noonan, Marfan).

Eyes

Inspect the eyes for signs relevant to the respiratory system\:
Conjunctival pallor\: suggestive of underlying anaemia. Gently pull down their lower eyelid to inspect the conjunctiva.

Ears

Inspect the ears for signs relevant to the respiratory system\:
Tympanic membrane\: may be in
respiratory tract infections.
Hearing aids\: hearing loss is associated with primary ciliary dyskinesia.

Nose

Inspect the nose for signs relevant to the respiratory system\:
Deviated nasal septum\: may contribute to breathing di
Nasal polyps\: associated with atopy and cystic

Mouth

their mouth is)\:
Inspect the mouth for signs relevant to the respiratory system (tip - ask the child to see how long their tongue is or how big
Central cyanosis\: bluish discolouration of the lips and/or the tongue associated with hypoxaemia (e.g. persistent pulmonary
hypertension, bronchospasm, lower respiratory tract infection).
Cleft palate\: the full palate should be examined by visual inspection.
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Throat

Inspect the throat for signs relevant to the respiratory system\:
Inspect the throat using a pen torch and tongue depressor (this is often best left until the end of the examination of young
children, as it is likely to upset them).
Tonsillar hypertrophy\: may indicate a history of recurrent tonsillitis and airway obstruction.
Conjunctival pallor

Tracheal position

Inspect the position of the trachea, which should be central in healthy children.
Causes of tracheal deviation
The trachea deviates away from pneumothorax and large pleural e
The trachea deviates towards lobar collapse and pneumonectomy.

Close inspection of the chest

Ask the parent or child (if appropriate) to expose the child's chest.
Observe the chest, paying particular attention to the respiratory rate and work of breathing.

Closely inspect the anterior chest

Look for clinical signs that may provide clues as to the child's past medical/surgical history\:
Scars suggestive of previous thoracic surgery\: see the thoracic scars section below.
Pectus excavatum\: a caved-in or sunken appearance of the chest (e.g. Marfan syndrome).
Pectus carinatum\: protrusion of the sternum and ribs (e.g. Noonan syndrome).
Asymmetry of chest wall movement\: may indicate underlying pneumothorax or consolidation.
Harrison's sulcus (indrawing of the chest wall from long term diaphragmatic tug)\: associated with poorly controlled asthma.
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Chest hyper-expansion (barrel chest)\: can be associated with asthma and chronic respiratory obstruction.
Pectus carinatum [5]

Respiratory rate

Assess the child's respiratory rate for 60 seconds to calculate the number of breaths per minute\:
Note any asymmetries in the expiratory and inspiratory phases of respiration (e.g. the expiratory phase is often prolonged
in asthma exacerbations).
The range of a normal respiratory rate varies signi
account.
Age Respiratory rate
Newborn 40-60 breaths/minute
1 week to 3 months 30-50 breaths/minute
3 months to 2 years 30-40 breaths/minute
2 to 10 years 14-24 breaths/minute
>10 years 12-20 breaths/minute

Work of breathing

Assess for signs of increased work of breathing.
General signs of increased work of breathing\:
Di
Expiratory grunting (increasing positive end-expiratory pressure)
Recession\:
Tracheal tug
Supraclavicular recession
Intercostal recession
Subcostal recession
Use of accessory muscles\:
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Nasal
Abdominal breathing
Head bobbing (secondary to sternocleidomastoid contractions)
Intercostal recession [7]
Thoracic scars
Median sternotomy scar\: located in the midline of the thorax. This surgical approach is used for cardiac valve
replacement and pulmonary artery banding.
Right thoracotomy scar\: located between the lateral border of the sternum and the mid-axillary line at the 4 th th
or 5
intercostal space on the right. This surgical approach is used to perform pulmonary artery banding and a Blalock–
Taussig shunt.
Left thoracotomy scar\: located between the lateral border of the sternum and the mid-axillary line at the 4 th th
or 5
intercostal space on the left. This surgical approach is used to perform pulmonary artery banding, patent ductus
arteriosus ligation, a Blalock–Taussig shunt and coarctation of the aorta repair.
Infraclavicular scar\: located in the infraclavicular region (on either side). This surgical approach is used for pacemaker
insertion.
Left mid-axillary scar\: this surgical approach is used for the insertion of a subcutaneous implantable cardioverter-
de
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Subclavicular incision

Palpation of the chest

Palpate the apex beat

Palpate the apex beat with your
In healthy individuals, it is typically located in the 5th intercostal space in the midclavicular line.
Causes of a displaced apex beat
Leftward displacement\: cardiomegaly, right pleural e
pneumothorax Rightward displacement\: dextrocardia, diaphragmatic hernia, left pleural e
pneumothorax

Assess chest expansion

1. Place your hands on the child's chest, inferior to the nipples.
2. Wrap your
3. Bring your thumbs together in the midline, so that they touch.
4. Observe the movement of your thumbs (in healthy individuals they should move symmetrically upwards/outwards during
inspiration and symmetrically downwards/inwards during expiration).
Reduced movement of one of your thumbs indicates reduced chest expansion on that side.
Causes of reduced chest expansion
Reduced chest expansion can be caused by lung collapse, pneumonia and restrictive lung disease.
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Palpate the apex beat

Percussion of the chest

Percussion of the chest involves listening to the volume and pitch of percussion notes across the chest to identify underlying
pathology. Correct technique is essential to generating e
Warn the child before beginning percussion –
‘I’m going to play your chest like a drum!’
Perform percussion gently, comparing one side to the other.
Percussion is often not performed on younger children.

Percussion technique

1. Place your non-dominant hand on the child's chest wall.
2. Position your middle
3. With your dominant hand's middle
swinging movement of the wrist.
4. The striking
Areas to percuss
Percuss the following areas of the chest, comparing side to side as you progress (see image example below)\:
Supraclavicular region\: lung apices
Infraclavicular region
Chest wall\: percuss over 3-4 locations bilaterally
Axilla
Types of percussion note
Resonant\: a normal
Dullness\: suggests increased tissue density (e.g. cardiac dullness, consolidation, tumour, lobar collapse).
Stony dullness\: typically caused by an underlying pleural e
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Hyper-resonance\: the opposite of dullness, suggestive of decreased tissue density (e.g. pneumothorax).
Percuss the lung

Auscultation of the chest

Start by showing the child your stethoscope and demonstrate it on your own chest and/or on one of their toys to familiarise
them with this piece of equipment.
Suggest listening to their chest, making sure the stethoscope diaphragm isn't cold prior to it making contact with the child.
When auscultating the chest, it is important that you have a systematic approach that allows you to compare each area on
both the left and the right as you progress.

Technique

1. Ask the child to take ‘big breaths’
– some abnormal sounds may be inaudible if taking shallow breaths.
2. Position the diaphragm of the stethoscope over each of the relevant locations on the chest wall to ensure all lung regions
have been assessed and listen to the breathing sounds during inspiration and expiration. Assess the quality and volume of
breath sounds and note any added sounds.
3. Auscultate each side of the chest at each location to allow for direct comparison and increased sensitivity at detecting local
abnormalities.
Quality of breath sounds
Vesicular\: the normal quality of breath sounds in healthy individuals.
Bronchial\: harsh-sounding (similar to auscultating over the trachea), inspiration and expiration are equal and there is a
pause between. This type of breath sound is associated with consolidation. Be aware that harsh breath sounds from
the upper airway are readily transmitted to the upper chest in infants, which can be misinterpreted as abnormal added
sounds.
Volume of breath sounds
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Quiet breath sounds\: suggest reduced air entry into that region of the lung (e.g. pleural e
When presenting your
, rather than 'reduced air entry'
.
Added sounds
Wheeze\: a continuous, coarse, whistling sound produced in the respiratory airways during breathing. Wheeze is often
associated with asthma and bronchiectasis.
Stridor\: a high-pitched extra-thoracic breath sound resulting from turbulent air
Stridor has a wide range of causes, including foreign body inhalation (acute) and subglottic stenosis (chronic).
Coarse crackles\: discontinuous, brief, popping lung sounds typically associated with pneumonia, bronchiectasis and
pulmonary oedema.
Fine end-inspiratory crackles\: often described as sounding similar to the noise generated when separating velcro.
Fine end-inspiratory crackles are associated with pulmonary

Assess vocal resonance

Assessing vocal resonance in an adult involves auscultating over di
word or number consistently. The presence of increased tissue density or
speech is transmitted to the diaphragm of the stethoscope.
Vocal resonance may be di
context. We have included further details on how to assess and interpret vocal resonance below.
Technique
1. Ask the child to say “99” or some other word every time you listen to their chest.
2. Auscultate all major regions of the anterior chest wall, comparing each side at each location.
Abnormal vocal resonance
Increased volume over an area suggests increased tissue density (e.g. consolidation, tumour, lobar collapse).
Decreased volume over an area suggests the presence of
pneumothorax).
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Areas to auscultate the lungs on the anterior chest wall

Lymph nodes

Inspect for any evidence of obvious lymphadenopathy a
Palpate the lymph nodes
1. Position yourself behind the child and use both hands to start palpating the neck.
2. Use the pads of the second, third and fourth
the various characteristics of the lymph nodes. By using both hands (one for each side) you can note any asymmetry in size,
consistency and mobility of lymph nodes.
3. Start in the submental area and progress through the various lymph node chains. Any order of examination can be used, but
a systematic approach will ensure no areas are missed\:
Submental
Submandibular
Pre-auricular
Post-auricular
Super
Deep cervical
Posterior cervical
Supraclavicular
Take caution when examining the anterior cervical chain that you do not compromise cerebral blood
compression). It may be best to examine one side at a time here.
A common mistake is a “piano-playing” or “spider’s legs” technique with the
the pads of the second, third and fourth
Causes of lymphadenopathy
Lymphadenopathy may indicate infection (most commonly) or malignancy.
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Palpate the lymph nodes

Posterior chest assessment

Assess the posterior chest including inspection, chest expansion, percussion, vocal resonance and auscultation.
Allocate adequate time to assessing the posterior aspect of the chest as this is where you are most likely to identify clinical
signs.
Posterolateral thoracotomy scar
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Final steps

Assess for evidence of oedema\:
Ask the parents if the child looks pu
Inspect the limbs, sacral area and face\: a
Pedal oedema [8]

To complete the examination...

Explain to the child and parents that the examination is now
Ensure the child is re-dressed after the examination.
Thank the child and parents for their time.
Explain your
Ask if the parents and child (if appropriate) have any questions.
Dispose of PPE appropriately and wash your hands.
Summarise your

Further assessments and investigations

Suggest further assessments and investigations to the examiner\:
Cardiovascular examination\: if concerned about cardiac pathology (e.g. heart failure with secondary pulmonary oedema).
Inhaler technique assessment\: if asthmatic and concerned about long term management.
Record a full set of vital signs
Assess peak expiratory \: if asthmatic to assess response to treatment.
Send a sputum sample for culture\: if concerned about possible pneumonia.
Plot the height and weight of the child on a growth chart
Venous blood gas\: if concerned about respiratory failure.
Chest X-ray\: if concerned about consolidation or pneumothorax.
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Relevant syndromes

Below is a non-exhaustive list of clinical syndromes which can be associated with respiratory system pathology. The features
of the syndrome relevant to the respiratory system are shown in bold.
Syndrome Clinical features
Hearing loss
Cleft palate
Micrognathia
Hypoplastic malar
DiGeorge syndrome
A constellation of signs and symptoms associated with defective
development of the pharyngeal pouch system. Most cases are caused
by a heterozygous chromosomal deletion at 22q11.2.
Recurrent chest infections
Laryngotracheoesophageal anomalies
Down's syndrome
A genetic disorder caused by the presence of all or part of a third copy of
chromosome 21.
Feeding/breathing di
Epicanthic folds
Brush
Protruding tongue
Low set ears
Recurrent chest infections
Fetal alcohol spectrum disorder
A range of e
exposed to alcohol.
Marfan syndrome
An autosomal dominant connective tissue disorder.
Pierre Robin sequence
Most cases are thought to result from hypoplasia of the mandible that
occurs before the ninth week of development.
Stickler syndrome
An inherited disorder of connective tissue.
Persistent pulmonary hypertension
Microcephaly
Intrauterine growth restriction (IUGR)
Smooth philtrum
Joint abnormality
Lung hypoplasia
Altered surfactant production
Hypermobility
Arachnodactyly
Marfanoid habitus (tall, long limbs)
Pneumothorax
Chest wall deformities
Cleft palate
Micrognathia
Glossoptosis
Flat face
Upturned nose
Prominent eyes
Mid-facial hypoplasia
Hypotonia
Hypermobility
Eye disorders
Feeding/breathing di
Scoliosis
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Treacher Collins syndrome
An autosomal-dominant disorder of craniofacial development with a
variable degree of penetrance.
Malar hypoplasia
Down slanting palpebral
Lower lip defect
External ear abnormality
Eye disorders
Cleft palate
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