Respiratory Exam
Tip; From the outset of your exam, esp general inspection, start considering the unifying diagnosis. Your
findings must be coherent & make sense.
(eg. If in resp distress, expect findings for the rest of exam – eg wheeze/ crackles on auscultation; if inhalers by the bed
– make sure you don’t miss signs such as barrel chest or harrison’s sulcus, hyper-resonance, wheeze etc.; if chest drain
in situ, don’t miss stony dullness; if IV antibiotics hanging, be vigilant about picking up ↓ air entry / crackles etc.)
The patient may not have these text-book signs & may have indeed normal findings, but let the clues you
gather early in the exam aid your precision for the rest of it. As best as possible, have your findings consistent
with each other.
O/E;
1) Inspection
i)
General (while washing hands
& ask expose chest)
C H A N D L E R
Listen for sounds audible from end of bed
Infant; Ask mum to expose child’s chest & abdomen
Leave infant in mum’s arms
Older child; expose child to waist (except adolescent girl)
ii)
Signs of respiratory distress;
Tachypnoea
Dysponea (?difficulty speaking)
Recession
(supraclavic, inter- & sub-costal)
Tracheal tug
Nasal Flaring
Accessory muscles,
Abdominal breathing
Grunting
Resp-specific
Hands – clubbing, (stages? causes?), anaemia, BCG scar
Pulse
Head & Neck – cyanosis (under tongue) tracheal tug
Coryza/secretions, Petechiae (from coughing)
Defer further ENT until the end.
iii)
Tip;
Take advantage of whatever
position the child is in –
eg. If infant happy clinging to
mum while back exposed,
examine the back first – but say
you’re doing this to the examiner.
You can decide to examine
anteriorly first & then move to the
back, or if child sitting up you can
inspect front & back, palpate front
& back, & so on if it suits. Again,
let the examiner know what
you’re doing, & take charge!
Chest
Resp rate; count for 10 secs & multiply x6
*abdominal breathers until 3-4 years*
nb. any signs of Resp Distress
Shape; Pectus carinatum / excavatum
harrison’s sulcus
hyperinflation (barrel chest)
Symmetry & Movement; compare sides
Scars
Axilla – inspect ? drains / scars / swellings
Spine; scoliosis (formal test later if indicated)
CO2 retention; v rare Paeds
Signs are;
Sweaty/clammy hands
Tremor/asterixis
Dialated veins (bk hand)
Bounding pulse
± papilloedema
Scars & surgery;
Thoracotomy; lobectomy
Left; CoA, BT shunt
Right; BT, Oesophageal
Sternotomy; usually cardiac
Chest drains; site;
5th i/c space mid-ax. line
2) Palpation –
Neck; Lymph nodes, (best done from behind)
↑ VF; consolidation
neck swellings
↓ VF; pneumothorax,
tracheal deviation,
th
th
effusion, collapse
Apex beat – MCL 5 intercostal space (4 in < 3 yrs)
Chest expansion [if > 4-5 years; normally 3-5 cm]
Vocal fremitus [not useful < 3-4 yrs];
place one hand each side & ‘say “99”’; vibratory sensation
+/- liver palpation if hyperinflation/wheeze, esp in infant! (do at the end)
3) Percussion – Not very useful < 3yrs, but know how to do it
explain to the child, “play knock knock / like a drum”
start at clavicle – to guage normal sound- get used to sounds
side to side to compare sides
include axillae
↑ resonance; hyperinfln
pneumothorax
↓ resonance; collapse,
consol., organs,
effusion; stony
dull
4) Auscultation
Bell of stethoscope – warm it up first
6 positions front & back, compare sides
(+ supraclavicular/apex in older child ie. 8)
don’t forget axilla
full inspiration & expiration at each site
Comment on;
 Air Entry; ?equal bilateral or reduced?
 Breathing type; Vesicular vs. bronchial

ie. Listen insp/exp phases? duration of each? gap?
Any extra sounds; Creps / wheeze,
+/- other; eg. pleural rub
Vocal Fremitus – (not necessary if tactile vocal fremitus done)
Say “99” – listen in same areas as for regular auscultation
Sounds louder over areas of consolidaton
REPEAT AT THE BACK NOW;(sit child forward)
Inspect – scars, scoliosis
Palpate – expansion, tactile vocal fremitus
Percuss – (as above) – [ask child to stretch arms in front to expose under scapula]
Auscultate – (as above)
5) At end;
a. ENT (offer to do this, but only at end; upsetting for young children)
b. PEFR (over 6 years)
c. Examine sputum
Breath sounds;
Reduced/absent; collapse / effusion / pneumothorax / obstruction
(ie. ↑ gap between lung & chest wall/ you listening, so can’t hear as much)
Vesicular breathing; (normal) insp:exp 3:1, no gap, exp. fades
Bronchial breathing; insp & exp same duration, no pause between, doesn’t fade (listen over your trachea)
Patent bronchi but alveoli full/blocked ; ie. Consolidation / fibrosis
Prolonged expiration; (often with wheeze); obstructive disease eg, asthma
Wheeze (exp) = Rhonci; Asthma / bronchiolitis / viral induced / foreign body
(high-pitched, due to partial obstruction of bronchioles)
[can occur in inspiration (stridor) if obstruction severe]
Creps/crackles; consolidation / fibrosis
Fine (ie more high-pitched – indicate alveoli > bronchioles)
Coarse (ie variable pitch - indicate bronchioles > alveoli)
Transmitted sounds; from upper airways
Exercise 1 – go over the above exam structure & select out the parts of it that are
relevant to the examination of the infant.
Exercise 2 – consider what pattern of clinical findings you’d expect to find in the
following conditions;
Auscultation
Condition
Consolidation
Collapse
Effusion
Pneumothorax
Obstructive dx
(asthma)
Chronic dx CF
Foreign body
Inspection
Movement
Mediastin
al shift
Percussion Vocal
resonance
Air
Entry
. extra
Breathing
sounds