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Pediatric Respiratory System Pediatric Respiratory System in Brief
Prof Malak ShaheenProf. Malak Shaheen
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Prof Malak ShaheenLecturesProf Malak ShaheenLectures
Clinical Reasoning .. Properway
Integrated ClinicalPractice
Get ready …..
• Sherlock Holmes Model
Use all your senses …… ..
Secret ingredient .. Deal with children
Tool kit for a pediatrician….
Pillars for ClinicalDiagnosis
1 P Hi t (Sh t)1. Proper History (Sheet)2. Clinical Examination (General & Local)( )3. Investigations (Bedside +others)
Chest Exam .. Let us start
When it begins…..
• First look to thechild
History Taking
• Common respiratory symptoms• How to ask?
How to analyze eachsymptom?• How to analyze eachsymptom?• Collect data + write down
E l• Example:• Cough analysis ….(Timing)g y ( g)• Fever analysis …...
Common symptomsCough +sputum production HaemoptysisFever / toxicsymptomsFever / toxicsymptomsChest pain (Children different than adults) Breathlessness (SOBcauses?)Wheeze (noisy breathing – other examples)Wheeze (noisy breathing – other examples) Allergy
Position/Lighting/Exposure• Position –
Patient should sit upright/Semi-sitting– Patient should sit upright/Semi-sitting– The patient's hands should remain at theirsides.
• Lighting - adjusted so that it is ideal.
• Exposure - the chest should be fully exposed/ time should be minimized.
General Examination R l f “4”Rule of “4”
1 ABC D1. ABC D2. 4 vital data3. 4 X 2Skin4. 4 groups of LN
From Head to Toe
R 4 (CVS N GIT & U )Rest 4 systems (CVS, Neuro, GIT & Uro)
4• Appearance • Respiratory rate• Built (weight+
Height)• Pulse• Blood PressureHeight)
• Consciousness• Blood Pressure• Temparature
• Decubitus• 3 colors
• Occipital LN
3 colors• Oedema
• Cervial LN• Axillary LN
• Subcut fat• Rash• Axillary LN
• Inguinal LN
Rash• Elasticity (Turgor)• Texture
From scalp to toe
Steps of Local ChestExamination
I ti-Inspection-Palpationp-PercussionA l i-Auscultation
Local Chest Examination R l f “3”Rule of “3”
I ti• Inspection:1 Shape1. Shape2. Symmetry3. Respiratory Movement (diagnosis of
respiratory distress)respiratory distress)
Examination of the chestExamination of the chestInspection
1. Shape of thechestThe normal chest is bilaterally symmetrical and elliptical in cross section the trans erse diameter >anter oposterior diameter ( hen?)the transverse diameter > anter-oposterior diameter (when?)
Comman abnormalities of shapekyphosis-forward bending of vertebralcolumn scoliosis- lateral bending of vertebralcolumnbarrel shaped chest- increase in anteroposteriordiameterflatteningg
Respiratory Examination
Chest wall
Pectusexcavatum
Chest wall
Pectus carinatum
May prevent complete
fexpiration of air from the lungs and
thus may restrict i h
Base lungcapacity isdecreasedair exchange
considerably.decreased
Continue…. Inspection• 2. Symmetry of chestexpansion
h i f h l h hild h ldbchest expansion of a healthy child shouldbe equal on both sides
3 Rate& Rhythm/patternAge (yrs) Resp Rate
(breathes/min) 3. Rate & Rhythm/pattern of respiration
Rate of respiration inhealth<1 30-40
2-5 25-302-5 25-30
5-12 20-25• Movements of thechest
wall (RD (presence of intercostal recessions or theuse of
accessorymuscles>12 15-20
Eff t f b thiEffort of breathing
• Respiratory Rate• Recession
– Mild: sub-costalS l– Severe: sternal
• Accessory muscle use• Grunting• Alar nasal flare• Child’s position• Respiratory noisesp y
– Stridor / wheeze
Effort of breathing:Effort of breathing:respiratory rate
Age (yrs) Resp Rate (b th / i )
<1(breathes/min)
30-40What are causesof Resp. Distress?(Resp& non resp)
2-5 25-30(Resp& non resp)
5 12 20 255-12 20-25
>12 15-20
Rule of “3”
P l ti• Palpation:1 Chest expansion1. Chest expansion2. TVF3. Trachea site (Very Very Important)
PalpationPalpationBefore making a systemic examination palpate any part of the
chest where the patient complains of pain or where there is achest where the patient complains of pain or where there is a swelling
• Position of the Apex beat andTrachea
• In normal subjects the trachea is in the midline and can be palpated in the suprasternalnotchp p p
PalpationPalpation
• Expansion of thechest
Symmetrical or asymmetrical chest expansion can be assessed by palpation (what isnormal?)
• Vocal fremitusVocal fremitus is the vibration detected by palpation withthe palm of the hand on the chest, when the patient is asked to repeat “ninety nine” or “44 in arabic” if suitable
In a normal healthy child, the vibrations felt in the corresponding areas on the two sides of the chest are equal in intensity
Rule of “3”
P i (Rt & Lf id i• Percussion (Rt & Lf sidesin comparison):p )
1. Mid clavicular line (light)2 Mid ili li (li ht)2. Mid axiliary line (light)3. Scapular line (heavy)
Percussion
The middle finger of the left hand is placed on the chest andmiddle phalanx is struck with the tip of the middle finger of theright handright hand
Feel and listen to sound of resonance over ahealthy lung has tobeFeel and listen to sound of resonance over a healthy lung has tobe learned by practice
Percussion2nd phalanx over area of intercostal spaceintercostal space
Right middle finger strikesthe 2nd phalanx producinghammer effectEntire movement comesEntire movement comes from wrist
Reference Lines
• Anterior Chest– Midsternal line– Midclavicular lineMidclavicular line
• Posterior Chest– Vertebral line –midspinalp– Scapular line
L t l Ch t• Lateral Chest– Anterior Axillary liney– Posterior Axillary line– Mid–axillary line– Mid–axillary line
Order of PercussionOrder of Percussion
Respiratory Examination
• Percussion– Illicit resonance– Compare both sides– Map out abnormalarea
Rule of “3”
A lt ti (Rt & Lf id i• Auscultation(Rt & Lf sidesin comparison):p )
1. Air Entary2 B thi d2. Breathing sounds3. Adventitious sounds
Respiratory Examination
• Auscultation technique– Diaphragm of stethoscope– Mouth openp– Breathing deeply and fairly rapidly– CoughCough– Compare both sides
Basic Lung Sounds:http://www stethographics com/main/physiology ls introduction htmlhttp://www.stethographics.com/main/physiology_ls_introduction.html
AuscultationAuscultation
Air EntryDiminished
C d i li i d bConduction limited by– Airflow limitation
e.g. diffusely – asthma,emphysema localised – tumour, collapse
– Something separating chest wall from lungSomething separating chest wall from lunge.g. effusion, fibrosis
Auscultation
• Breath soundsThere are 2types of breathsounds
vesicular breath sounds- vesicular breath sounds- bronchial breath sounds
Vesicular breath soundsescua b eat sou dsThese originate in the larger airways and are producedby the passage of air in and out of normal lung tissue
In good health they can be heard all over the chestIn good health, they can be heard all over the chest -the inspiration is longer thanexpiration -the inspiratory sound isintense and louder
th th i t dthan the expiratorysound -it is a lowpitched rustling sound -there is no gap between inspiration and expiration
Harsh Vesicular breathing with prolonged expiration example: airway obstruction (asthma)example: airway obstruction (asthma)
Basic Lung Sounds: http://www stethographics com/main/physiology ls introduction htmlhttp://www.stethographics.com/main/physiology_ls_introduction.html http://www.cvmbs.colostate.edu/clinsci/callan/breath_sounds.htm
A lt tiAuscultation
• Bronchial breath soundsThese are produced by the passage of air in the trachea and larger bronchiThese are produced by the passage of air in the trachea and larger bronchi
In good health, they can be heard only over the trachea
I di b hi l b hi b h d h f l h iIn disease, bronchial breathing may be heard over the area of lung that is affected (lung consolidation, collapse, fibrosis)
-the expiration is long as or longer than inspirationth it h d d f th i ti i l d -the pitch and sound of the expiration is loud or
louder than the inspiratorysounds-there is a gap between inspiration and expiration
Respiratory Examination• Bronchial breathing
Respiratory Examination
• Added sounds– Wheeze– Crepitations (crackles)– Pleural sounds
Respiratory ExaminationAb l S d D i ti C ditiAbnormal Sound Description Condition
Crackles (rales) Short, discrete, popping or Pulmonary oedema crackling sounds Pneumonia
Atelectasis Bronchiectasis
Wheezes High pitched, squeaking, hi li d
Asthma hwhistling sounds. Bronchospasm
Pleural friction rub Creaking, leathery, loud, Pleurisy g ydry, course sounds
yPleural effusion
Respiratory Examination... more
• Vocal sounds on auscultation– Vocal resonance– Increased when voice sounds are louder and moredistinct
e.g. consolidation– Reduced when transmission impeded e.g. effusion,
collapse
D’Espine’s signD’Espine’s sign
D’Espine’s signD’Espine’s signImportant sign of a posterior mediastinalmass At the level of mid-scapula (about T5) –listenover the vertebral spinous process and on o e e e eb a sp ous p ocess a d oeither side of the vertebral column. Normally the lateral sounds are louder and moredistinct.the lateral sounds are louder and moredistinct.When the upper airway sounds are of greater intensity than the corresponding lateral lungintensity than the corresponding lateral lung sounds – implies a continuity (a mass) between amainstem bronchus and vertebraa mainstem bronchus and vertebra
Special situation:Special situation: Critically ill child ABCapproachCritically ill child …. ABCapproach
• A =Airway• B=Breathing
C=Circulation• C=Circulation• D = Disability (CNS)y ( )• E = Exposure
Effi f b thiEfficacy of breathing
• Respiratory distress• Air entry• Pulse oximetryPulse oximetry
A silent chest is aA silent chest is a pre-terminal sign
Eff t f i t i dEffects of respiratory inadequacy
• Heart rate• Skin colour• Level of consciousnessLevel of consciousness
Pre terminal signs:Pre-terminal signs:• Bradycardia• Central cyonosis• UnconsciousnessUnconsciousness
Putting things together ….
Interpretation of findingsInterpretation of findings
Pleural effusion• Tracheal shift• stony dull
Consolidation• Tracheacentral• reducedexpansion• stony dull
reduced air entry• reducedexpansion
dull percussion• bronchial breathingbronchial breathing• or coarsecreps• increased vocal resonance
Interpretation of findingsPneumothorax Consolidation Collapse• deviated trachea• reduced tactile vocal
f it
• deviated trachea• reduced tactile vocal
f itfremitus• hyper-resonance
d d i t
fremitus• dull percussion
d d i t• reduced air entry• reduced vocal resonance
• reduced air entry• +/- creps
Alveolar disease…
• Grunting sound• Fine crepitation
Further Plans ……
• Investigations:g
–Bedside: oximeter, peak flow meter–Laboratory: ABG**Radiological–Radiological
–Other
Reaching diagnosis (or D.D.)• Anatomical diagnosis (where is the
)lesion)• Pathological diagnosis (what is thePathological diagnosis (what is the
lesion)Eti l i l di i ( )• Etiological diagnosis (cause)
• Functional diagnosis g(compensated/decomp.)
• Other complication(s)• Other complication(s)
Treatment
• Specific ttt (cause)• Supportive ttt
Chest exam interfaces for you
1. Short caseexam2. Long case exam3 OSCE3. OSCE4. Within other pediatrics case (eg.Neuro, p ( g
Down, Cardiac,..)5 Clinical practice5. Clinical practice …..
OSCEOSCE …..
Wash your hands Wash your hands Introduce yourselfy
Patient details Explain/consent
SScenesurvey
Further resources …watch & listen
• YouTube• Assessing lung sounds Part 1• Assessing lung sounds Part 2• Lung sounds mix• The lung & thoraxexamg• Learn pediatrics: Respiratoryexam• Examination of lungs and respiratory(Ped)g p y( )• Respiratory1• Respiratory2p y• How to usestethoscope• Pediatric respiratory exam: OSCEguidePediatric respiratory exam: OSCEguide
Further resources …reach & read
Download resources
1 • www.EKB.com
• Official e-mail2 Official e mail
3 • Clinical Keyaccess
Test yourselfTest yourself
Diagnosis??Diagnosis??
History6 hild k i h h• 6 years child –Recurrent attacks night cough –
• wheezy chest
General Exam• N/A
Local exam• Respiratory distress ‐ Central Trachea• Wheezy chest
Diagnosis??Diagnosis??
History• 10 years child Persistent cough purulent expectoration• 10 years child –Persistent cough – purulent expectoration• Duration: 2 years
General ExamSh t t t F il t th i P l l bbi• Short stature – Failure to thrive – Pale clubbing
Local exami di h hif d id• Respiratory distress – Trachea shifted to one side
• Same side is full of fine creptations
Diagnosis??Diagnosis??
History2 hild F d h f 2 d d ti• 2 years child –Fever and cough of 2 days duration –
• Difficulty of breathing (Tachypnea)
General Exam• Fever: 39 ° C• Child weight: 9 Kg
Local exam• Respiratory distress ‐ Central Trachea• Chest: bronchial breathing in Rt lung lower lobe (back)
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Prof Malak ShaheenLecturesProf Malak ShaheenLectures
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