What are the structural components, signs, and interpretations of a chest examination in pediatric patients?

From the Guidelines

Chest examination in pediatric patients requires a structured approach that includes inspection, palpation, percussion, and auscultation, with adaptations for pediatric patients, and should be guided by the most recent evidence, such as the 2011 clinical practice guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America 1.

Key Components of Chest Examination

The examination should begin with establishing rapport with the child through play or distraction while observing their general appearance, respiratory rate, work of breathing, and any visible abnormalities like chest wall deformities or retractions.

• Inspection: observe the child's general appearance, respiratory rate, and work of breathing
• Palpation: assess for tactile fremitus, chest expansion, and any areas of tenderness
• Percussion: performed gently, comparing resonance between sides to identify areas of consolidation or effusion
• Auscultation: requires a systematic approach using the diaphragm of the stethoscope, listening for breath sounds, adventitious sounds like crackles or wheezes, and vocal resonance

Normal and Abnormal Findings

Normal findings in children include a respiratory rate that varies by age (30-60 breaths/minute in infants, decreasing to 12-20 in adolescents), symmetrical chest expansion, and clear vesicular breath sounds.

• Common abnormal findings include:
  • Wheezing (suggesting bronchospasm in asthma or bronchiolitis)
  • Crackles (indicating fluid in airways as in pneumonia)
  • Decreased breath sounds (suggesting effusion or pneumothorax)
  • Bronchophony or egophony (indicating consolidation)

Age-Specific Considerations

When interpreting findings, consider the child's age, as infants and young children have more compliant chest walls, predominantly diaphragmatic breathing, and transmitted upper airway sounds, as noted in a study on chest indrawing in children less than 2 years of age 1.

• Infants and young children tend to have more severe pneumonia with a greater need for hospitalization and a higher risk of respiratory failure, as highlighted in the 2003 clinical policy for children younger than three years presenting to the emergency department with fever 1.

Modifications for Pediatric Patients

The examination should be modified by using distraction techniques, examining from least to most invasive steps, and involving caregivers to comfort the child, which improves cooperation and accuracy of findings.

• The presence of significant comorbid conditions, such as reactive airway disease or genetic syndromes, is also a risk factor for the development of pneumonia and should be considered during the examination, as noted in the 2011 guidelines 1.

From the Research

Structural Components of a Chest Examination

• The respiratory system develops relatively late in the embryo and continues after birth until the age of seven to eight years 2
• The developing anatomy of the respiratory system in infants and children means that certain conditions may occur, and precautions are required when assessing them 2

Signs of a Chest Examination

• Respiratory auscultation involves listening to and interpreting sounds from within the chest 3
• In children with structurally normal, healthy lungs and a regular breathing pattern, the respiratory sound should be relatively quiet, with regular movement of air along the trachea and bronchioles, in and out of the lungs 3
• Any breath sounds heard in unexpected areas require further investigation, while a complete absence of breath sounds must be treated as a clinical emergency 3
• Clinical signs such as respiratory rate, chest in-drawing, ability to feed normally, cyanosis, and level of consciousness are used to diagnose pneumonia and determine its severity 4

Interpretations of a Chest Examination

• Respiratory auscultation is an essential procedure for informing differential diagnoses and assessing the trajectory of a child's illness and response to treatment 3
• Chest radiography is widely used in acute lower respiratory infection in children, but its benefits are unknown, and there is no evidence that it improves outcome in ambulatory children with acute lower respiratory infection 5
• The assessment of children with recurrent chest infections requires close attention to history and examination, and in selected cases, extensive investigations 6
• Early and accurate diagnosis is essential to ensure that optimal treatment is given and to minimize the risk of progressive or irreversible lung damage 6