Pediatrics : Chest and Lungs /

    • Chest and Lungs
      • Chest shape
        • Infants: Shape is almost circular with anteroposterior diameter equaling the transverse or lateral diameter
        • Children and adolescents: The transverse diameter to anteroposterior diameter changes to 2:1
      • Rib and sternum
        • More soft and flexible in infants; symmetric and smooth, with no protrusions or bulges
      • Movement 
        • Symmetric, no retractions
        • Infants: Irregular rhythms are common
        • Children younger than 7 years: More abdominal movement is seen during respirations
      • Breath sounds
        • Inspiration is longer and louder than expiration
        • Vesicular, or soft, swishing sounds, are heard over most of the lungs
      • Breasts
        • Newborn: Breasts can be enlarged during the first few days
        • Children and adolescents: nipples and areolas are darker pigmented and symmetric.
          • Females: Breasts typically develop between 10 to 14 years of age. The breasts should appear asymmetric have no masses and be palpable.
          • Males can develop gynecomastia, which is unilateral or bilateral breast enlargement that occur during puberty
      • Classification of Normal Breath Sounds
        • Vesicular Breath Sounds
          • Heard over the entire surface of the lungs with the exception of the upper intrascapular area and area beneath the manubrium.
          • Inspiration is louder, longer, and higher pitched than expiration.
          • The sound is a soft, swishing noise.
        • Bronchovesicular Breath Sounds
          • Heard over the manubrium and in the upper intrascapular regions where the trachea and bronchi bifurcate.
          • Inspiration is louder and higher pitched than in vesicular breathing.
        • Bronchial Breath Sounds
          • Heard only over trachea near suprasternal notch.
          • The inspiratory phase is short, and the expiratory phase is long.
      • Effective Auscultation
        • Make certain the child is relaxed and not crying, talking, or laughing. Record if the child is crying.
        • Check that the room is comfortable and quiet.
        • Warm the stethoscope before placing it against the child’s skin.
        • Apply firm pressure on the chest piece but not enough to prevent vibrations and transmission of sound.
        • Avoid placing the stethoscope over hair or clothing, moving it against the skin, breathing on the tubing, or sliding fingers over the chest piece, which may cause sounds that falsely resemble pathologic findings.
        • Use a symmetric and orderly approach to compare sounds.
      • Atraumatic Care
        • Encouraging Deep Breaths
          • Ask the child to “blow out” the light on an otoscope or pocket flashlight; discreetly turn off the light on the last try so the child feels successful.
          • Place a cotton ball in the child’s palm; ask the child to blow the ball into the air and have parent catch it.
          • Place a small tissue on the top of a pencil and ask the child to blow the tissue off.
          • Have child blow a pinwheel, a party horn, or bubbles.
      • Various Pattern of Respiration
        • Tachypnea: Increased rate
        • Bradypnea: Decreased rate
        • Dyspnea: Distress during breathing
        • Apnea: Cessation of breathing
        • Hyperpnea: Increased depth
        • Hypoventilation: Decreased depth (shallow) and irregular rhythm
        • Hyperventilation: Increased rate and depth
        • Kussmaul respiration: Hyperventilation, gasping and labored respiration; usually seen in diabetic coma or other states of respiratory acidosis
        • Cheyne-Stokes respiration: Gradually increasing rate and depth with periods of apnea
        • Biot respiration: Periods of hyperpnea alternating with apnea (similar to Cheyne-Stokes except that depth remains constant)
        • Seesaw (paradoxic) respirations: Chest falls on inspiration and rises on expiration
        • Agonal: Last gasping breaths before death
      • Description of selected adventitious sounds and their cause
Type Description Cause
Fine crackles High-pitched, discrete, noncontinuous sound heard at end of inspiration; does not clear with coughing

(Rub pieces of hair together beside your ear to duplicate the sound)

Air passing through watery secretions in the smaller airways (alveoli and bronchioles)
Coarse crackles Loud, lower pitched, more moist or bubbly sound heard during inspiration; does not clear by coughing Air passing through thicker secretions in the airway
Sibilant wheezing Higher pitched, musical, squeaking, or hissing noise usually heard continuously during inspiration or expiration, but generally louder on expiration; does not clear with coughing Air passing through mucus or fluids in a narrowed lower airway (bronchioles) as with asthma
Rhonchi (sonorous wheezing) Coarse, low-pitched sound like a snore, heard during inspiration or expiration; may clear with coughing Air passing through thick secretions that partially obstruct the larger bronchi and trachea
Stridor High-pitched, piercing sound most often heard during inspiration without a stethoscope Whistling sound as air passes through a narrowed trachea and larynx, associated with croup

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