Chest _ Lungs _c fw06_ by wanghonghx

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									    Chest and Lungs

 Adapted from Mosby’s Guide
to Physical Examination, 6th 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
  – Gradually adding intercostal muscles
             Newborns
• Coughing
  – Rare
  – Should be considered a problem


• Sneezing
  – Frequent and expected
  – Clears the nose
                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
• 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
           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
                                     A ctivity
    1) Heart rate
                                     P ulse
    2) Respiratory rate
    3) Muscle tone                   G rimace
    4) Reflex irritability           A ppearance
    5) Color
                                     R espirations
               APGAR SCORE
                       0              1                2
Heart rate       Absent        <100             >100
Respiratory                                     Easy; Good
                 Absent        Slow/irregular
effort                                          crying
                                Some flexion Active
Muscle tone         Limp
                                of extremities motion
                                Grimace,
Reflex irritability No response                Lusty cry
                                slow
Color            Blue/pale     Acrocyanosis Pink
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
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
• 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
• Measure distance between the
  nipples
  – ¼ chest circumference

• Note:
  –   Symmetry in size
  –   Supernumerary
  –   Swelling
                            Breast development
  –   Discharge             in a newborn
                            -d/t hormonal influences
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

• 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
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
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
• 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
      Wait for quiet!
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
• Not uncommon immediately after birth
  – Fluid has not completely cleared


• If asymmetric…
  – a problem should be suspected
    • aspiration of meconium
                   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
• 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
Retraction at the supraclavicular notch
Contraction of the SCM’s
Flaring of the nostrils (alae nasi)
   *Should be considered significant.




   See-saw respirations
• 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
Age        Rate per minute
Newborn    30-80
1 year     20-40
3 years    20-30
6 years    16-22
10 years   16-20
17 years   12-20
  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
        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
• 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
  – 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
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”
• If the “roundness” of a child’s chest
  persists past the 2nd year
  – Possible chronic obstructive pulmonary
    problem
    • Cystic fibrosis
Common Conditions
                  Asthma
• Chronic obstructive pulmonary
  disease (COPD) characterized by
  airway inflammation
  – Hyperreactivity to:
    • Allergens
    • Anxiety
    • URTI
    • Smoke
    • Exercise
    • Cold air
Results in:
  –   mucosal edema
  –   increased secretions
  –   bronchoconstriction



       Airway resistance increases and
          respiratory flow is impeded.
Episodes are characterized by:
  – Paroxysmal dyspnea
  – Tachypnea
  – Cough
  – Wheezing (expiration & inspiration)
  – Prolonged expiration
  – Chest pain/tightness
• 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
                             Asthma
INSPECTION   Tachypnea
             Dyspnea
PALPATION    Tachycardia
             Diminished fremitus
PERCUSSION   Hyper-resonance
             Limited diaphragmatic
             descent; lower diaphragmatic
             level
AUSCULTATION Prolonged expiration
             Wheezes
             Diminished lung sounds
             Note…

A wheezing patient with generalized
pulmonary findings may have
asthma or a viral infection, but
rarely, if ever, a bacterial infection.
             Atelectasis
Lung is airless…
  1. Incomplete expansion of the
     lung at birth OR
  2. Collapse of the lung at any age
    • Compression from outside
       – Exudates, tumors
    • Resorption of gas from the alveoli
      with complete internal obstruction
                               Atelectasis
INSPECTION      Delayed/diminished chest wall
                movement, narrow intercostal spaces
                Tachypnea
PALPATION       Diminished fremitus
                Apical pulse & trachea deviated
                ipsilaterally
PERCUSSION      Dullness over affected lung

AUSCULTATION Upper lobe: bronchial breathing,
                egophony, whispered pectoriloquy
                Lower lobe: diminished or absent
                breath sounds
                Wheezes, rhonchi, and crackles in
                varying amounts
              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
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
       Initial stimulus = irritation
         (Internal or external)
• Inflammation of the mucus
  membranes of the bronchial tubes
• 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
                            Bronchitis
INSPECTION    Occasional tachypnea
              Occasional shallow breathing
              Often no deviation from
              expected findings
PALPATION     Tactile fremitus undiminished
PERCUSSION    Resonance
AUSCULTATION Breath sounds may be
             prolonged
             Occasional crackles
             Occasional expiratory wheezes
Cystic Fibrosis
• Autosomal recessive disorder of
  exocrine glands

  – Lungs
  – Pancreas
  – Sweat glands



• Scottish and English populations
 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
• Viral, particulary parainfluenza viruses


Who gets it?
  – Very young children
     • 1 ½ to 3 years old
  – Boys > girls
  – Some are prone to recurrent episodes
• Inflammation is subglottic; may involve
  areas beyond the larynx




• dDx
• Epiglottitis
  – Toxic, drooling facies
• Aspirated foreign body
• 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
• 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
– 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
• 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
• 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
  – interstitial inflammation
    and necrosis throughout
    the bronchiolar and
    alveolar tissue


Signs & symptoms:
  – crackles, rhonchi, tachypnea, cough
    (nonproductive) and substernal pain
            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
                             Pneumonia
INSPECTION      Tachypnea
                Shallow breathing
                Flaring of nostrils
                Occasional cyanosis
                Limited movement; splinting
PALPATION       Increased fremitus (consolidation)
PERCUSSION   Dullness (consolidation)
AUSCULTATION Variety of crackles
                Occasional rhochi
                Bronchial breath sounds
                Egophony, bronchophony,
                whispered pectoriloquy
      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
dDx
• Vascular lesion
• Tracheal stenoisis
• Foreign body

               Also note…
Laryngomalacia
  – Floppiness of the larynx
Laryngotracheomalacia
  – Entire large airway is involved

								
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