RESPIRATORY ASSESSMENT AND DISTRESS Version 2012

RESPIRATORY EXAM Consider upper vs lower

adapted from Dieckmann R, ed. Pediatric Education for Prehospital Professionals.
2nd ed. Sudbury, MA: Jones & Bartlett Publishers, American Academy of Pediatrics; 2006.

RESPIRATORY EXAM
ORGANIZATION

SOUND

1. VITAL SIGNS
a. RR & SpO2

STRIDOR

UPPER

Croup, Foreign Body Aspiration (lodged in the

upper airway), Retropharyngeal Abscess,
Anaphylaxis (upper airway swelling), Vascular
Ring/Sling, Laryngo/tracheomalacia, Subglottic
stenosis, Vocal cord paralysis, Tumor

STERTOR
(Lower-pitched, snoring sound that
comes from obstructions mainly in the
oronasopharynx)

UPPER

Nasopharyngeal secretions, Tracheostomy noises

(when needing suctioning), Upper airway mucous,
Snoring, Obstructive sleep apnea

2. AUDIO/VISUAL SIGNS (appearance)

a. Comfortable
b. Comfortably tachypneic
c. Tachypneic with suprasternal
retractions (in mild distress)
d. Tachypneic, flaring, headbobbing, and severely
retracting (in mod-severe
distress)
e. Could include audible stridor
or grunting - as these are
heard without a stethoscope!
3. AERATION
a. Good (hearing the volume of
breath sounds you expect)
b. Fair (lower than expected)
c. Poor (far lower than expected)
4. BREATH SOUNDS
a. Description + Location
i. Ex: Wheezing throughout
ii. Ex: Crackles in the LLL

UPPER
vs
LOWER

(High-pitched sound made by turbulent

airflow through a partially obstructed
large, extrathoracic airway, generated
around the level of the glottis)

DIMINISHED/ABSENT BREATH
SOUNDS

UPPER or
LOWER

EXAMPLES

Completely obstructing FBA, SEVERE asthma,

Pleural effusion, Pneumonia

WHEEZING

LOWER

Asthma, Foreign Body Aspiration (to a lower

airway), Bronchiolitis, Anaphylaxis (lower airway
swelling), Cystic Fibrosis, Pneumonitis (inhalation
injury), Aspiration (via GER or other)

CRACKLES

LOWER

Pneumonia, Bronchiolitis, Fluid/mucous/blood in

lower airways, Heart Failure

(High-pitched whistling sound made

from partial obstruction of the lower
airways, usually occurs on exhalation.)

HEAR Stridor with your EAR.

Auscultate Wheezing with a Stethoscope

Respiratory Assessment

Respiratory distress is a common presenting complaint in

young children. In assessing this, it is important to take an
organized approach. We recommend beginning with the vital
& audio-visual signs (outside) and working inward to the
quality of aeration and breath sounds (see above).
Vital Signs. It is tough to interpret a single vital sign in
isolation. For example, what diagnoses could explain an SpO2
of 75%? Pneumonia...FBA...? What about - SpO2 75% &
RR 2? Now, I bet youre thinking more along the lines of
overdose or a neurologic cause! So in reviewing vital signs,
remember to obtain and report all the ones that pertain to the
area you are assessing, whether it be respiratory (RR/O2),
cardiovascular (HR/BP), or all five (Temp, RR/O2, HR/BP).
Audio Signs. The audio signs of respiratory distress are
the the sounds you hear without a stethoscope. Stridor, the
sound of upper airway turbulent airflow, can be heard with
your ear alone (and sometimes from across the room!).
Additionally, you may hear sonorous respiratory sounds that
are nasopharyngeal in origin (e.g. congestion, snorting, or
stertor) when patients are stuffy or sleeping soundly.
Visual Signs. The visual signs of respiration can be hard
to describe and vary by age. Young children, when distressed,
usually breathe faster, harder, and louder. The best place to see
these visual signs are in the face (nasal flaring), neck (tracheal
tugging), and chest (suprasternal, intercostal, subcostal
retractions). Additionally, you might find that some older
children purse their lips a little as they breathe to auto-PEEP

their expiratory phase. In this case, their breathing could be

described as deliberate, as breathing this way takes a great deal of
concentration!
Aeration. Aeration is meant to describe the loudness,
location, and quality of breaths heard when auscultating the
chest. Think of aeration as a comparison between what youd
expect to hear with what you actually hear. For people with
thicker chest walls, you may expect to hear softer breath
sounds. However, if it is hard to auscultate breaths on a thin
toddler, thats a problem! Ask yourself, is this softer/louder
than I expected? Are breath sounds missing in areas? Do they
sound qualitatively different?
Breath Sounds. When describing the pulmonary exam
on a patient, try to close with the auscultatory exam. Be
definitive in describing the location (e.g. diffusely, throughout,
left/right, L lower lobe, bilateral bases, right apex, anteriorly,
posteriorly...etc) and quality of the sound (e.g. wheezing, coarse
wheezes, crackles, wet/coarse crackles, fine crackles...etc).
Here are a couple examples:
Moderate bronchiolitis (lower airway infection):
...breathing 54, satting 90%, tachypneic with suprasternal retractions
and nasal flaring, mostly fair aeration, poor at the bases, with coarse wet
breath sounds and occasional end-expiratory wheezes...
Foreign body aspiration (upper airway process):
...breathing 42, satting 86%, loud biphasic stridor, anxious and
tachypneic with nasal flaring and deep subcostal retractions, poor aeration,
with transmitted upper airway sounds...