Chest and Respiratory System

Development
- Lung development in utero begins approx 4 weeks gestation
- Forms from a sac on the ventral wall of the alimentary canal
- Branchings of the lung bud form the trachea, bronchi and bronchioles at 16-17 weeeks
- 17 weeks primitive alveoli is formed
- 24-28 weeks capable of gas exchange
- 24-26 weeks alveolar cells begin to secrete surfactant
- 30-36 weeks maturation and expansion of the alveoli
- 1st 4 years of life peak of alveolar replication and growth
- Breathing movements occur in utero, irregular, ranging from 30-70 breaths per min, becoming
more rapid as gestation advances
- Gas exchange is via the placenta
- Movement of fluid in and out of the potential air sacs conditions the respiratory muscles and
stimulates lung development
- At birth, the lungs fill with air for the first time and take on the role of ventilation and
oxygenation
- The fluid in the lungs move into the tissues surrounding the alveoli and is absorbed into the
lymphatic system; gas exchange occurs via diffusion across the alveolar-pulmonary capillary
membranes

Physiological Variations of the Chest and Lungs

age Developmental stage
Preterm infant * Respiratory muscles are weak, poorly adapted for extrauterine life; periodic
breathing occurs that is similar to fetal breathing; become easily hypoxic and apnea
occurs
Newborn* Diaphragm is flatter, more compliant; paradoxical breathing occurs in neonate with
inward movement of chest during inspiration; predominantly nose breathers until 4
weeks of age; chest circumference very close in size to head circumference at birth
Infant Smaller airways with increased resistance to airflow; rapid RR; minimal nasal mucus
causes mild to moderate upper airway obstruction
Toddler and Rapid growth and maturation of alveoli improve ventilation; respiratory rate
preschooler decreases dramatically from the newborn period
School-age child Alveoli continue to increase in number; lung development is complete by 5-6 years of
age
adolescent Alveolar size matures to adult capacity
* Hypotonia in preterm and term infants impacts the chest wall muscles and compromises
normal ventilation

Anatomy and Physiology

THORAX
- Bony cartilage that surrounds the heart and lungs
- Composed of: manubrium, sternum and xiphoid process
o Sternum: flat, narrow bone composed of highly vascular tissues enclosed by dense bone
o Manubrium: roughly triangular and attaches to the first and second ribs; provides a
place of attachment for the sternocleidomastoid and pectoralis major muscles
 o Xiphoid process: small,thin, cartilaginous end of the sternum, varies greatly in size and
prominence in infants and children because of heredity, nutrition and intrauterine
development
- PECTUS CARIINATUM
o Pigeon breat
o Abnormal protrusion of the xiphoid process and sternum
- PECTUS EXCAVATUM
o Funnel chest
o Abnormal depression of the sternum
- The chest cavity is dvided with the middle portion known as the MEDIASTINUM
- 12 pairs of ribs
o 1-7 pairs attach anteriorly via their corresponding costal cartilages to the sternum
o 8, 9, 10 attach to the costal cartilage on the rib above them
o 11 and 12 do not attach anteriorly
o All attach posteriorly to the thoracic vertebrae
o 11 intercostal muscles anteriorly and posteriorly; 8 thoracic muscles that help increase
the volume of the rib cage with inspiration and decrease the thoracic volume with
expiration
- LANDMARKS used in describing the location of physical findings in the chest
o MSL (midsternal line) runs down the middle of the manubrium
o MCL (midclavicular line) located on the R and L sides of the chest runs parallel to the
MSL and through the middle of the clavicles bilaterally
o AAL (anterior axillary line) begins at the anterior axillary folds
o MAL (midaxillary line) begins at the middle of the axilla
o PAL (posterior axillary line) begins at the posterior axillary folds
o Vertebral line posteriorly runs down the middle of the spine
o Scapular line runs down the inferior angle of each scapula

RESPIRATORY TRACT
1. Upper Respiratory tract nasal cavity, pharynx and larynx
2. Lower respiratory tract- lungs, trachea, bronchi, bronchioles, alveolar ducts and sacs and alveoli
o Trachea is the tube that lies anteriorly to the esophagus
o Distally the trachea splits into the right and left mainstem bronchi
bifurcation is at the level of T# in infancy and childhood
adult at T4 or T5
right mainstem bronchus is shorter and more vertical than the left; more
susceptible to aspiration of foreign bodies in young children
o Bronchioles: 3 branches on the R and 2 branches on the L; each branch supplies one of
the lung lobes
o Divide further into segmental smaller bronchi called respiratory bronchioles to supply
each segment of the lungs
o Terminates with the alveolar ducts, alveolar sacs and alveoli
o Bronchial arteries branch from the aorta and supply blood to lung parenchyma
o Blood supply is returned primarily by the pulmonary veins

LUNGS
- Positioned on the lateral aspects of the thorax, separated by the heart and mediastinal
structures
 - Right lung with 3 lobes (upper, middle and lower)
- Left lung with 2 lobes (upper and lower)
- Apex is the top portion of the upper lobes, which extend above the clavicle
- Right: minor or horizontal fissure, located at the 4th rib, divides the right upper lobe (RUL) from
the right middle lobe (RML)
- Left: Lingula- tongue-shaped projection that extends from the left upper lobe (LUL)
- Laterally: right lower lobe (RLL) and left lower lobe (LLL) occupy most of the lower lateral chest
area
- Only a small of the RML extends to the midaxillary line, and it does not go beyond that point
- Posteriorly: the vertebral column helps in identifying the underlying lung lobes
o T3 and T4 mark the inferior portion of the upper lobes and the superior portion of the
lower lobes
o T10 or T12 (depending on the phase of respiration) marks the base or the bottom
portion of the lower lobes
- Principal function of the lungs: maintain an acid-base balance by supplying ooxygen to organs
and tissue and eliminating carbon dioxide

SYSTEM-SPECIFIC HISTORY
- Questions should be open-ended and age-specific to allow the parent or caregiver an
opportunity to give a full explanation of past and present concerns
- Always obtain information directly from the older child or adolescent during the visit

INFORMATION GATHERING FOR CHEST/LUNG ASSESSMENT AT KEY DEVELOPMENTAL STAGES

AGE Questions to ask
Preterm infant How many weeks gestation?
Any episode of apnea, tachypnea?
Need for oxygen?
Admitted to the neonatal ICU? Length of stay? Need for ventilation? For how
long? Infant discharged home on any medications?
Any maternal substance abuse?
newborn Birth weight? How many weeks gestation? Any birth complications? Meconium
aspiration? Breathing problems at birth? Any episode of apnea or tachypnea?
infant History of respiratory infections as infant(respiratory syncytial virus [RSV],
rhinovirus,etc? Frequent upper respiratory infections (URI)? History of wheezing?
Hospitalizations? History of intubations? History of eczema/skin allergies? In
daycare? Immunization status? Frequent vomiting after feeds/choking
episodes? Arches back after feeding?
Toddler Does childs speech have nasal or congested resonance? Multiple URIs or
symptoms of respiratory allergies? In daycare? History of apnea/breath-holding
spells? Does child suck a finger/pacifier? Still use bottle for milk/juice?
Frequently puts objects in mouth/nose?
Preschooler History of nasal congestion, chronic rhinorrhea, tonsillitis? Exposure to Group A
strep infection? Does child snore at night? Injuries to mouth/nose? Concerns
about speech? In preschool? Exposure to ill contacts? Foreign travel/recent
immigrant?
School-age child History of nasal congestion, chronic rhinorrhea, tonsillitis? Exposure to Group A
strep infection? Does child snore at night? History of asthma? Exposure to ill
 contacts? Foreign travel/recent immigrant?
Adolescent History of chronic URIs, allergic rhinitis/asthma, recurrent tonsillitis? History of
oral sex? Tobacco use? How many cigarettes per day? Marijuana use? Any oral
piercing?
Environmental risks Location of home? Number of people in home? Anyone smoke in home? Pets in
home? Wood-burning stove? Mold? Carpets? Drapes? Mice or roaches?
Presence of chemicals/fumes?

PRESENTING RESPIRATORY SYMPTOMS

SYMPTOM Questions to ask
Cough Onset of cough symptoms? Coughing for how long? Is cough worsening or
changing character? Was onset sudden or gradual? Is cough wet, dry, hacking,
barking, whooping?
Pattern: occasional, regular, paroxysmal, or coughing spasms? Worse during day
or night? Worse with feeding, sleeping, running? Shortness of breath, chest pain,
tightness of cough? Choking episodes?
History of aspiration (small toy, food, etc.)? Rhinorrhea or nasal congestion?
In older child/adolescent: Is cough productive with sputum or nonproductive?
Wheeze Onset of wheezing? Onset sudden or gradually worsening?
Pattern: occasional, regular, increase with exercise?
History of aspiration of small toy or food?
Other symptoms: cough, shortness of breath, chest pain/tightness?
Shortness of breath Is it difficult to get air in, out or both? History of aspiration of small toy, food?
Chest excursion asymmetrical? Accompanying symptoms of cough, wheezing?
History of breath-holding spells, seizures?
Chest pain Is it difficult to get air in, out or both? Chest pain occurs with movement or rest?
Type of pain (sharp, dull)? Ask verbal child to point to area of pain. History of
trauma or recent sports injury or weight lifting>
? accompanying symptoms of cough, wheezing, shortness of breath?

PHYSICAL ASSESSMENT
Equipment
- Stethoscope
Size is important
i. Stethoscopes with a smaller bell and diaphragm should be used in infants and
toddlers
ii. Isolating cardiac and respiratory sounds is difficult in small children with too
large a diaphragm
iii. Using a diaphragm that is too small on adolescents and children who are
obese/overweight may miss findings of cardiac and respiratory sounds on
auscultation

Positioning
- Young children: more relaxed on parents lap
- Role playing: allow them to listen to their parent, doll or stuffed animal
- School-age children are very curious and respond well to games
 - Explain what you will be doing
- Pictures of the lungs may be helpful with older children, explain what you are looking for and
listening to

Chest
- Include anterior and posterior chest
- Usually best performed first
- Also include exam of upper airways and the extremities
- Upper airways: nasal passages are examined for the presence of rhinitis, any nasal secretions,
polyps or nasal obstruction. When looking at the nasopharynx, note the presence of postnasal
drip and tonsillar size
- Extremities for signs of digital clubbing (may be hereditary, result of cardiac or respiratory
disease or severe malnutrition)

INSPECTION
Infant and child
- Undress from the waist up
- Observe RR, breathing pattern, respiratory effort, inspiratory to expiratory ratio (I:E ratio), skin
color, presence of noisy breathing, chest symmetry and shape
- Wait till the patient is calm and relaxed on the parents lap
- If the child is irritable and resists auscultation, it is most helpful to just observe the respiratory
pattern and rate
- Assess the shape of the chest and note abnormalities
o Normal AP to transverse ratio is 1:2
o Infant chest is round with a diameter roughly equal to the head circumference and
AP/transverse ratio of 1:1 giving a barresl chest appearance
o At 6yo, the ratio is 1:1.36
o Barrel chest is seen in chronic air trapping such as in advanced stages of cystic fibrosis
o Decreased lung expansion may be seen in pectus carinatum, excavatum or scoliosis

ASSESSMENT OF RESPIRATIONS
- The childs rhythm of breathing should be regular
- The childs R should not be evaluated in isolation of other respiratory parameters and should be
correlated with the other physical findings
- Periodic breathing
o rapid breathing followed by periods of apnea
o normal for the first few hours of life in healthy full-term newborns
o more likely to persist in preterm infants
- Apnea
o Prolonged cessation of breathing >15 sec, accompanied by central cyanosis or
bradycardia
o Abnormal and requires immediate further evaluation
- Paradoxical breathing
o Seesaw breathing
o Often sen in newborns and infants because they use abdominal muscles more than
intercostals
- Cheyne-Stokes breathing
o Cycles of increasing and decreasing tidal volume separated by apnea
 o Occurs in CHF and increased ICP
- NOISY Breathing: stridor, grunting, snoring
o Stridor
is a high-pitched, loud, inspiratory sound produced by upper airway obstruction:
edema status post intubation, subglottic stenosis, laryngotracheobronchitis,
foreign body aspiration
o grunting
a low-pitched expiratory sound caused by a partial closure of the glottis
o Snoring
a rough, snorting sound that can be present on inspiration and expiration
may be present during sleep in healthy children who have an upper respiratory
infection, in children experiencing respiratory distress, or with chest pain
often heard in the presence of nasal polyps, sdenoidal and tonsillar hypertrophy
or congenital anomalies that involve the upper airway or facies
- NASAL FLARING or USE OF ACCCESSORY MUSCLES
o Mild nasal flaring can be seen in newborns being preferential nose breathers in the first
month of life
o Increased nasal flaring is a sign of labored breathing
o Other signs of increased effort and respiratory distress include retractions, bulging of
intercostals muscles, head bobbing
Mild retractions may be seen in some healthy young children
Increased retractions can be a sign of airway obstruction
The chest wall of newborns and infants is more compliant than that of older
children making them more prone to retractions
Bulging of the intercostals spaces also may be seen with airway obstruction as a
consequence of increased expiratory effort.
Head bobbing, the forward movement of the infants head is a sign of
respiratory distress due to the contraction of the scalene and
sternocleidomastoid muscles
- INSPIRATORY TO EXPIRATORY (I:E) RATIO
o Additional sign of respiratory distress
o Normal I:E ratio in infants is 1:2 seconds except in the newborn when it is variable
o Obstructive diseases (cystic fibrosis or asthma) can increase the expiratory time
o Restrictive diseases can give ratio of 1:1
o acute upper airway obstruction can produce a ratio of 2:2 to 4:2
- ASSESS FOR CYANOSIS
o Acrocyanosis of the hands and feet is normal in the newborn and can persist for days in
the infant placed in a cool environment
o Central cyanosis occurs in the conjunctiva, lips, mucous membrane, and tongue is an
abnormal finding at any age and warrants immediate investigation
o In the anemic child, it may be difficult to detect cyanosis early on because the arterial
oxygen saturation at which cyanosis becomes apparent varies with the total hemoglobin
level

AUSCULTATION
- Best performed at the beginning of the exam while the infant is cooperative and attentive
- Diaphragm of the stethoscope is placed firmly on the chest
- Chest is bare because clothing can change the quality of the breath sounds
 - Breath sounds tend to be louder because of the thinness of the chest wall
- Breath sounds can be identified by their intensity, pitch and duration
- Auscultate moving from side to side across the chest for comparison and linger at each location
for one full breath

NORMAL BREATH SOUNDS

sound description Duration of inspiration Sound diagram
and expiration
Vesicular Soft sound heard over entire Inspiration>expiration
surface of lungs; inspiration louder,
longer, higher-pitched than
expiration
Bronchovesicular Loud, high-pitched sounds heard Inspiration=expiration
over intrascapular area; inspiration 1:1
and expiration are equal
Bronchial Very loud over trachea near Inspiration<expiration
(tubular) suprasternal notch; inspiration is 1:2
shorter tan expiration

- Transmitted sounds or an infants cry can be assessed with a stethoscope

- Voice sounds are typically muffled on auscultation
- If any of these signs are positive, it is evidence of a consolidation
o If you hear the voice sound or cry loud and clear, it is termed bronchophony
o If the verbal child speaks the sound ee and it sounds like ay it is called egophony
o If the child whispers nd it is heard loudly, it is called whispered pectoriloquy

ABNORMAL LUNG SOUNDS (ADVENTITIOUS)

- superimposed on the normal breath sounds
Sound Description
Crackles or Discontinuous sounds, heard primarily on inspiration, do not clear with cough;
rales associated with pneumonia, bronchopulmonary dysplasia, cystic fibrosis
- fine cracles higher in pitch, generally indicative of fluid in smaller airways in
infants, children
- coarse crackles lower in pitch, usu signify fluid in larger airways
Wheezes Continuous, high-pitched musical sounds heard primarily on expiration; assoc with
partial obstruction of one or more bronchi caused by narrowing of airways due to
inflammatory response; as with asthma and aspiration of foreign body
Rhonchi Continuous low-pitched sounds; clears with coughing; caused by secretions/mucus in
larger airways as in bronchitis and lower respiratory tract infections

PALPATION
- Performed to identify anatomical landmarks, respiratory symmetry and areas of tenderness or
abnormalities
- Begin with counting the ribs, locate the sterna angle, the angle of Louis and move your fingers
laterally to feel the second rib and corresponding costal cartilage. Directly below this rib is the
second intercostals space, the important landmark for cardiac examination. From here, count
downward to other ribs and their respective intercostals spaces
 - To assess chest excursion, place your hands along the lateral rib cage and squeeze the thumbs
toward each other so that you gather a small amount of skin in between your thumbs
- Note symmetry of chest excursion, anteriorly and posteriorly
- Asymmetry is an abnormal finding
o Newborn: diaphragmatic hernia
o Newborn or later: pneumothorax, mass, foreign body, or abnormal chest wall shape
- Palpation of the trachea to assess mediastinal shift
o A shift in the trachea occurs when there is a difference in volume or pressure between
the two sides of the chest as in pneumothorax or pleural effusion
- Assess for tactile fremitus
o Use your palm, the ulnar surface of your hand or fingers depending on the size of the
chest wall, and ask the verbal child to say 1-2-3
o If uncooperative, this is performed when the child is crying
o Do this on the R/L, A/P
o Increased or decreased: pneumothorax or consolidation

PERCUSSION
- Used to determine the sounds of the underlying organs and tissues to distinguish whether the
tissue is air-filled, fluid filled or solid
- Five sounds produced: resonance, hyperresonance, dull, flat and tympany
- Infants and toddlers: the sound is more resonant because the chest wall is thinner
- Hyperextend the middle finger of your non-dominant hand and press the distal interphalangel
joint firmly on the chest. With the middle finger of your dominant hand, strike down on the
hyperextended interphalangel joint. The movement must be sharp and quick, strike each area 2-
3x and then move to the opposite side for comparison
- Percussion is sometimes deferred in infants and children
tone intensity pitch Quality
Tympanic Loud High Drumlike
Resonant Loud Low Hollow
Dull Moderate Medium to high Dull thud
Flat soft high Very dull

ABNORMAL CONDITIONS
CONDITION DESCRIPTION
Acute bronchiolitis Inflammatory obstruction of small airways caused by edema, mucus
plugging; occurs during first 2 years of life with peak incidence at 6 mos of
age
Etiology: viral etiology common with >50% caused by respiratory syncytial
virus (RSV)
Acute epiglottitis Obstructive inflammatory process of airway that is supraglottic; abrupt onset
of high fever, sore throat, drooling, dysphagia, dyspnea, increasing airway
obstruction; occurs between 2 and 7 years of age
Etiology: bacterial with marked decrease in incidence because of widespread
use of H. influenza vaccine
Asthma or reactive Inflammatory process initiated by irritability/hyperreactivity of airway to
airway disease variety of stimuli, obstruction/brnchoconstriction; inflammation plays key
role in factors leading to cough, wheezing, tachypnea, dyspnea with
 prolonged expiration
Croup or Acute upper airway obstruction; inflammation, edema of airway leads to
laryngotracheobronchitis hoarse, barking cough, intermittent stridor; respiratory distress occurs in
some cases, which is worse at night; most common between 3 mos and 5
years of age
Etiology: ~75% parainfluenza virus
Cystic fibrosis An inherited autosomal recessive trait causing multisystem disorder in
children; characterized by obstruction, infection of airways caused by
dysfunction of epithelial surface leading to thick, retained secretions
Overall incidence:1:4 births, most common occurrence in whites
Foreign body aspiration Lodging of object in larynx, trachea, bronchi with degree of obstruction
dependent on size/location of object in respiratory tract; hotdogs, bread are
most common causes of fatal aspiration; possibility of foreign body must be
considered in infants, young children with respiratory distress regardless of
history
Gastroesophageal reflux A passive transfer/reflux of gastric contents across lower sophageal
sphincter, which may lead to tissue damage causing gastroesophageal reflux
disease (GERD); GERD may be assoc with respiratory conditions such as
bronchospasm, pneumonia
Laryngomalacia or A congenital deformity of larynx or trachea oftern termed floppy airway;
tracheomalacia manifests as harsh noise/stridor on inspiration caused by airway collapse;
onset in early neonatal period; diagnosed by laryngoscopy
Pneumonia Inflammation of parenchyma of lungs; may be primary condition or
manifestation of another illness
Etiology: mostly caused by viral microorganisms- RSV, parainfluenza,
adenovirus; bacterial pneumonia is less common, but Mycoplasma
pneumonia accounts for ~70% of all pneumonia in 9-to 15-year olds;
noninfectious causes such as foreign body should be considered
Respiratory distress A condition related to developmental delay of maturation of lungs; deficient
syndrome production of surfactant, a phospholipid secreted by alveolar epithelium, in
preterm infant produces severe respiratory compromise, inadequate
pulmonary perfusion and ventilation develop resulting in long-term
respiratory complications