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 flexible when examining a child, adjusting your approach whilst taking into consideration the patient’s age, personality and how unwell they are.

Be opportunistic in your examination – i.e. taking advantage of periods of quiet to listen to the chest, 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!

Check out our paediatric respiratory examination mark scheme here.


Introduction

  • Wash your hands
  • Introduce yourself to both the parents and the child
  • Explain what the respiratory examination will involve
  • Gain consent from the parents/carers and/or child before proceeding.

Today I’d like to perform a respiratory examination, which will involve observing your child, feeling their pulse and listening to their breathing with my stethoscope.

Are you happy for me to carry out the examination?


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:

  • How alert is the child?
  • How active is the child?
  • Do they look ‘well’ or ‘sick’? (see this useful resource)
  • Do they appear to be a normal colour? (e.g. pallor, cyanosis)
  • Do they have an obvious rash?
  • Do they appear a healthy weight?

 

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

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

Observe for any equipment in the patient’s immediate surroundings and consider why this might be relevant to the respiratory system:

  • Mobility aids – a neuromuscular disorder
  • Feeding tubes (NG/NJ/Gastrostomy) – ex-premature infant, cystic fibrosis
  • 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 patient’s room and consider what underlying diagnoses they may indicate:

  • Antibiotics – pneumonia, bronchiectasis, cystic fibrosis
  • Inhalers – asthma
  • Pancreatic enzymes – cystic fibrosis

Hands

Inspect the hands

  • Peripheral cyanosis – hypoxia, hypothermia
  • Finger clubbing – bronchiectasis, cystic fibrosis, primary ciliary dyskinesia
  • Eczema – increased likelihood of asthma and hayfever (atopy)
  • Tremor – beta 2 agonist use (e.g. salbutamol)

Pulses

  • Radial pulse (femoral pulse in babies) – assess rate and rhythm

Face

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

General

  • Nasal flaring/grunting – increased work of breathing
  • Micrognathia (undersized jaw) – associated with a wide range of genetic syndromes (e.g. Pierre Robin, Noonan, Marfan)

Eyes

  • Conjunctival pallor – anaemia

Ears

  • Hearing aids – primary ciliary dyskinesia

Mouth

  • Central cyanosis – bluish discolouration of the lips and/or the tongue – persistent pulmonary hypertension, bronchospasm, lower respiratory tract infection
  • Cleft palate
  • Tip: Ask the child to see how long their tongue is or how big their mouth is.

Nose

  • Deviated nasal septum
  • Nasal polyps – atopy, cystic fibrosis

Throat

  • 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 – recurrent tonsillitis, airway obstruction

Neck

  • Inspect tracheal position
  • Palpate the cervical lymph nodes
  • Lymphadenopathy may indicate infection (most commonly) or malignancy

Expose 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.

Respiratory rate

 

  • Count the respiratory rate whilst observing the child.
  • The range of a normal respiratory rate varies significantly depending on the age of the child, so make sure to take this into account.
Newborn40-60 breaths/minute
1 week to 3 months30-50 breaths/minute
3 months to 2 years30-40 breaths/minute
2 to 10 years14-24 breaths/minute
>10 years12-20 breaths/minute

 

Work of breathing

Assess for signs of increased work of breathing.

General signs of increased work of breathing

  • Difficulty speaking (or feeding)
  • Expiratory grunting (increasing positive end-expiratory pressure)

Recession

  • Tracheal tug
  • Supraclavicular recession
  • Intercostal recession
  • Subcostal recession

Use of accessory muscles

  • Nasal flaring
  • Abdominal breathing
  • Head bobbing (secondary to sternocleidomastoid contractions)

Chest wall shape

Observe the shape of the child’s chest, looking for any abnormalities:

  • Asymmetry of chest wall movement – pneumothorax, consolidation
  • Harrison’s sulcus (indrawing of the chest wall from long term diaphragmatic tug) poorly controlled asthma
  • Chest hyper-expansion (barrel chest) – asthma, chronic respiratory obstruction
  • Pectus excavatum (hollow chest) and pectus carniatum (Pigeon chest) Marfan syndrome, Noonan syndrome, Osteogenesis imperfecta

Examine the Chest

Palpation

Assess chest expansion

  • Place your hands on the child’s chest, inferior to the nipples
  • Gently wrap your fingers around either side of the chest
  • Bring your thumbs together in the midline, so that they touch
  • Observe the movement of your thumbs, they should move apart equally
  • If one of your thumbs moves less, this suggests reduced expansion on that side
  • Reduced expansion can be caused by lung collapse, pneumonia and restrictive lung disease

Palpate the apex beat

Palpate the cardiac apex, noting its position:

  • Normal position – 5th intercostal space, midclavicular line
  • Left displacement – cardiomegaly
  • Right displacement – dextrocardia, diaphragmatic hernia

Percussion

  • 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 chest wall

2. Your middle finger should overlie the area you want to percuss (between ribs)

3. With your dominant hand’s middle finger, strike the middle phalanx of your non-dominant hand’s middle finger

4. The striking finger should be removed quickly, otherwise, you may muffle resulting percussion note

Types of percussion note

  • Resonant – this is a normal finding
  • Dullness – this suggests increased tissue density – consolidation, fluid, tumour, collapse
  • Stony dullness – this suggests the presence of a pleural effusion
  • Hyper-resonance – the opposite of dullness, suggestive of decreased tissue density – pneumothorax

Auscultation

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.

Auscultate the chest in a systematic manner:

  • Ask the child to take ‘big breaths’ – some abnormal sounds may be inaudible if taking shallow breaths
  • Auscultate each side of the chest in a symmetrical pattern, comparing side to side
  • Pay attention to the inspiratory and expiratory sounds at each placement
  • Note the quality and volume of breath sounds
  • Note any additional sounds
  • Repeat auscultation on the posterior aspect of the chest

Vesicular breath sounds

  • Low frequency, non-musical sound, barely audible at rest
  • A normal finding
  • 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.

Bronchial breath sounds

  • Higher pitched, harsh breath sounds
  • Normal to be heard over the trachea
  • If heard elsewhere, they are suggestive of consolidation
  • Length of inspiration and expiration is equal

Crackles

  • Coarse crackles – consolidation, pulmonary oedema
  • Fine crackles – pulmonary fibrosis

Wheeze

  • High pitched expiratory sound
  • Distal airway obstruction
  • Polyphonic – asthma
  • Monophonic – foreign body

Vocal resonance

  • Increased – consolidation
  • Reduced – effusion

Stridor

  • Harsh, low pitched inspiratory noise from upper airway obstruction

Pleural rub

  • Inflamed pleura secondary to pneumonia or pulmonary embolism

Reduced air entry

  • Pneumothorax
  • Consolidation
  • Asthma – severe
  • Pleural effusion
Where to auscultate a child's chest

Diagram of areas to percuss and auscultate on the anterior chest (repeat on the posterior chest)


To Complete the Examination…

  • Ensure the child is re-dressed after the examination
  • Thank the child and/or parents
  • Explain your findings to the parents and/or child
  • Ask if the parents and/or child have any questions
  • Wash your hands

Further clinical assessments to consider

Further investigations


Syndromes that may impact the respiratory system

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.

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.  
Hearing loss
Cleft palate
Micrognathia
Hypoplastic malar

Recurrent chest infections

Laryngotracheoesophageal anomalies

Feeding/breathing difficulties
Down’s Syndrome
A genetic disorder caused by the presence of all or part of a third copy of chromosome 21.



Epicanthic folds
Brushfield spots
Protruding tongue
Low set ears

Recurrent chest infections

Persistent pulmonary hypertension
Fetal Alcohol Spectrum Disorder
A range of effects that can occur in an individual who was prenatally exposed to alcohol.
Macrocephaly
IUGR
Smooth philtrum
Joint abnormality

Lung hypoplasia

Altered surfactant production
Marfan Sydnrome
An autosomal dominant connective tissue disorder.

Hypermobility
Arachnodactyly
Marfanoid habitus (tall, long limbs)

Pneumothorax

Chest wall deformities

Pierre Robin Sequence
Most cases are thought to result from hypoplasia of the mandible that occurs before the ninth week of development.

Cleft palate

Micrognathia

Glossoptosis

Stickler Syndrome
An inherited disorder of connective tissue.
Flat face
Upturned nose
Prominent eyes
Mid-facial hypoplasia
Hypotonia
Hypermobility
Eye disorders

Feeding/breathing difficulties

Scoliosis
Treacher Collins Syndrome
An autosomal-dominant disorder of craniofacial development with a variable degree of penetrance.
Malar hypoplasia
Down slanting palpebral fissures
Lower lip defect
External ear abnormality
Eye disorders
Cleft palate

Underdevelopment of the facial bones and airway can lead to airway obstruction.

Reviewer

Dr Sunil Bhopal 

Senior Paediatric Registrar


References

  • RCPCH. Spotting the sick child [LINK]
  • Lissauer, T., Clayden, G., & Craft, A (2012). Illustrated textbook of paediatrics. Edinburgh: Mosby.
  • Robertson (2017). Paediatric Respiratory History and Examination. Royal Children’s Hospital Melbourne.[LINK] (Accessed 4 Mar 19)
  • Tasker, R. C., McClure, R. J. & Acerini, C. L. (2013). Oxford handbook of paediatrics. Oxford: Oxford University Press.
  • Taylor, Gfeller, & Ring (date unknown). Respiratory Examination. Learnpediatrics.com Narration. The University of British Columbia. [LINK](Accessed 4 Mar 2019)
  • Whitehouse & Ng (2019). Respiratory Examination Guide. MRCPCH Clinical Revision. Trainees Committee, London School of Paediatrics.[LINK] (Accessed 4 Mar 2019)

Photo credits

  • Rijksmuseum (2019). Portret van Johannes Kojo, en face. Adapted by Geeky Medics – Available at:[LINK] [Accessed 25 Mar. 2019].

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