Respiratory diseases cause a high proportion of childhood illness and acute paediatrics admissions, thus being able to recognise certain signs early is vital for the prevention of further deterioration or respiratory arrest.

As with any examination, you should start from the end of the bed and then proceed with inspection, palpation, and auscultation.

Below is a useful format to follow when performing a respiratory examination with common potential findings. This is helpful for day to day work in paediatrics and also for exams!

Peripheral examination

General observation

After introducing yourself to the child and parents start off the respiratory examination by observing the child’s appearance and behaviour at the end of the bed:

Nutritional status:

• Does the child have healthy weight and height centiles appropriate for their age? A wasted habitus can be suggestive of chronic malnutrition as seen in cystic fibrosis (CF) and bronchiectasis.
• In a child with short stature (and dysmorphic features) it may be worth considering certain syndromes. [see Figure 2]

Colour:

• Observe for any cyanosis, pallor, or mottling
• Cyanosis is when there is a blue discolouration of the skin and mucous membranes either due to poor circulation or poor oxygenation of the blood. Cyanosis can be peripheral, central or both and it can be seen in cases of shock and cyanotic congenital heart disease.
• Peri-oral cyanosis can be observed when oxygen saturations fall < 85%.  

Fig 1: A baby with central cyanosis (dusky/purple lips and tongue)

• Pallor is when the skin and mucous membranes appear pale, most commonly it suggests an underlying anaemia.

• Mottled skin is when the skin colour changes from pink to pale-blue lace like appearance. whilst it can be common in infants, it could also be a sign of infection, respiratory failure, and circulatory collapse.

Dysmorphic features:

Certain syndromes are associated with respiratory problems, to note are Down’s syndrome (trisomy 21), Pierre robin sequence, Di George syndrome, foetal alcohol syndrome, Marfan syndrome, Stickler syndrome and Treacher Collins syndrome. Characteristic features of each can be found below., although these are just a few of many syndromes assosciated with respiratory problems.

Fig 3: An example of intercostal recessions seen in a neonate with bronchiolitis

Sourced from: Almost a doctor – Bronchiolitis

Respiratory distress:

• Does the child have increased work of breathing or shortness of breath?
• Increased WOB is evidenced by nasal flaring, tracheal tug, recessions- supraclavicular, intercostal, subcostal, and use of accessory muscles, abdominal breathing, head bobbing and grunting. Presence of any of these signs is an indicator of respiratory distress.

Audible sounds:

Note any sounds that can be heard without a stethoscope from the child at rest which can be suggestive of the underlying disease process, such sounds to listen out for are:

• Cough with wheeze: asthma, viral induced wheeze
• Wet cough: CF, bronchiectasis, pneumonia, primary ciliary dyskinesia (PCD)
• Dry cough: atopy
• Barking cough: croup
• Hoarse voice: laryngitis
• Stridor: croup, epiglottitis, foreign body inhalation, bacterial tracheitis

As well as observing the child, it is helpful to take a note of any equipment around them that can be suggestive of respiratory disease, such as:

• Inhalers, spacers, peak flow meters: suggestive of asthma, CF, or bronchiectasis
• Sputum pots: they could be useful in most respiratory conditions but usually seen at the bedside of children with CF

Fig 4: A: Inhaler with spacer; B: nebuliser, Sourced from PharmEasy

• Feeding tubes: ex-premature infants with bronchopulmonary dysplasia (BPD), CF, underlying syndrome e.g. T21
• Oxygen masks/ low flow oxygen and oxygen monitors: may be suggestive of chronic hypoxia
• Mobility aids: e.g. a child with cerebral palsy and BPD because of being an ex-preterm may be in a wheelchair
• Cough assist devices: may be seen at the bedside of children with CF or PCD

Medications:

• Creon^® – a type of pancreatic enzyme replacement therapy which is given in children with CF.
• Antibiotics: lower respiratory tract infections
• Nebulisers: seen at the bedside of children with asthma, CF or bronchiectasis

Hands

Looking at the hands can provide a lot of clues to respiratory problems so an organised approach is imperative

Colour:

Is there peripheral cyanosis or pallor? In the presence of cyanosis, it may be useful to consider pulse oximetry to monitor oxygen saturations, and to start thinking of differentials like obstructive lung diseases or infection.

Clubbing:

To assess for finger clubbing ask the child to place their fingers back-to-back, and look out for the small diamond shaped window (Schamroth window). The easiest way to explain this is to ask the child to point up to the sky with their index fingers, then point down to the ground, and put the backs of their fingers together. The absence of this window is known as Schamroth sign, aka clubbing. Clubbing is seen in diseases causing chronic hypoxia, such as CF, PCD, bronchiectasis. Non- respiratory causes of clubbing are congenital cardiac defects and IBD.

Fig 5: Finger clubbing

Sourced from: Clubbed fingers- an early sign of disease

Tremor:

Ask the child to extend their arms in front of them and note for any tremor. A resting tremor may be noted in children who frequently use beta agonists.

Pulse:

Assess the rhythm, character, and symmetry by palpating the radial pulse. In infants, it is best to assess the pulse when they are settled as crying will cause an increase in heart rate.

Nail changes:

Koilonychia is a nail abnormality characterised by a central depression and raised edges, it’s also known as spoon-shaped nails. In infants, physiologic koilonychia is common because of the crawling motion and it disappears with walking. However, a common cause of koilonychia is iron deficiency anaemia, which is common in ex preterms and children with chronic lung diseases.

Fig 7: Koilonychia

Sourced from: Primary care dermatology society

Leukonychia is when there is a white discolouration of the nail plate. This can take the form of white spots (leukonychia punctata) or lines (longitudinal leukonychia). It’s most likely caused by trauma to the nail bed as seen in nail biting, though is assosciated with systemic disease and chronic illness.

Fig 8: Punctate leukonychia in an 8-year-old boy

Sourced from: ResearchGate- onychomycosis in children

Cannulation scars

In children who have BPD (ex-preterms), old cannula scars may be seen on the back of the hands. You would likely also see old cannulation scars in many children with chronic disease, e.g. CF / PCD

Eczema:

May be suggestive of atopy (allergic rhinitis, allergic dermatitis, allergic asthma)

Face

Conjunctiva:

Gently pull down the lower eyelid to assess for pallor. Pale conjunctival membranes are another sign of anaemia.

Ears:

Assess the position of the ears- low set ears are seen in Down’s syndrome, and malformed ears may be seen in Pierre Robin syndrome. It is also good practice to look at the tympanic membranes of both ears with an otoscope and note the presence of any discharge. Inflamed tympanic membranes, perforation of membranes and serous or purulent discharge from them are highly suggestive of otitis media.

Recurrent ear infections and nasal congestion should raise suspicion of primary ciliary dyskinesia.

Nose:

Are there any visible polyps? (could suggest atopy or possibly CF)

Throat:

To inspect the throat, you’ll need a pen torch and a tongue depressor. Look out for cleft palate and tonsillar hypertrophy. Presence of hypertrophy may indicate recent infection such as tonsillitis. The best time to examine the throat is at the end of the examination because chances are that it will make the child cry, and they won’t be your friend anymore!

In a child with suspected croup of epiglottitis (evidenced by stridor), do not examine the throat as it will upset them and could potentially worsen their airway obstruction.

Neck:

Assess the position of the trachea and for any lymphadenopathy.

In pneumothorax, the trachea is deviated away from the pneumothorax whereas in collapse the trachea is deviated towards the side of the lesion. A helpful way to remember this would be to think about the free air in pneumothorax pushing away the trachea to the opposite direction, whereas in atelectasis the collapsed lung is pulling the trachea with it.

Central examination

With the child’s permission expose and observe the chest to begin. It is easier to inspect, palpate, percuss and auscultate the front and then move on to the back. This avoids asking the child to sit forwards and back repeatedly.

Inspection

Observe the child breathing at rest and calculate the respiratory rate (RR). The respiratory rate should be assessed for one minute and any differences in the inspiratory and expiratory phases of breathing should be noted. If you are in a clinical exam with limited time, you can just say you would assess the RR for 1 minute and move on.

Obstructive lung diseases (asthma, bronchitis) often have a prolonged expiratory phase

Next, you should take note if there any signs of increased WOB and respiratory distress, such as:

• Tachypnoea: an increased respiratory rate
• Nasal flaring: this is when the nostrils widen with breathing and it could be a sign of respiratory distress in young infants and babies since they are obligate nasal breathers.
• Grunting: this is an expiratory noise made my infants in attempt to maintain a positive end expiratory pressure. The grunt closes the glottis and prevents loss of functional residual capacity. An example of grunting can be heard in this video.
• Use of accessory muscles: this is recognised as inspiratory contraction of the sternocleidomastoid (may manifest as head bobbing) and scalene muscles
• Recessions: recessions can be intercostal, subcostal, supraclavicular or tracheal tug. Recessions occur due to high negative intrathoracic pressures that cause indrawing of parts of the chest
• Inability to complete full sentences: this can be seen in severe asthma
• Kussmaul’s breathing: this is a type of rapid and deep breathing. It is usually seen in patients who present with diabetic ketoacidosis, and is a compensatory mechanism to breathe off the excess acid

Chest wall deformity: this is when there are structural irregularities in the child’s chest. Deformities include:

• Barrel chest: this is when there is an increase in the diameter of the chest wall resulting in a bulging chest that looks like a barrel. It’s seen in obstructive lung diseases such as asthma and emphysema.
• Pectus excavatum: this occurs when there is ingrowing of the sternum which gives the chest a caved in appearance. It can cause mildly decreased lung volumes and air trapping.
• Pectus carinatum: this is the opposite of pectus excavatum. The sternum protrudes outwards, giving the appearance of a ‘pigeon chest’
• Harrison’s sulci: this refers to a groove seen beneath the rib cage in children with chronic respiratory disease (e.g. uncontrolled asthma). It can also be seen in rickets due to ineffective bone mineralisation.

Fig 10: Pectus excavatum

Sourced from: UTSWMed- Chest wall disorders

Fig 11: Pectus carinatum

Sourced from: London Orthotics – pectus carinatum

Scars: inspect the chest for any scars suggestive of underlying illness or previous surgery, such as from:

• Central venous catheter
• Tracheostomy: could be seen in children with upper airway obstruction e.g. Pierre Robin, or in children who require long term ventilation such as those with BPD.
• Sternotomy: median sternotomy scars are seen in children with congenital heart defects who have undergone surgical repair e.g. pulmonary artery banding
• Portacath or Hickmann line: these are ways of establishing long term IV access to manage exacerbations of CF or PCD
• Lung transplant scars
• Thoracotomy scars
• Left sided: left sided thoracotomy is performed in pulmonary artery banding, PDA ligation, repair of TOF (Blalock-Taussig [BT] shunt) and repair of coarctation of the aorta
• Right sided: right sided thoracotomy is used for a BT repair, lobectomy, some ASD repairs

Fig 12: Location of chest scars

Sourced from MRCPCH Examination Guide

• Chest drains sites
• Abdominal scars: for example, from a congenital diaphragmatic hernia repair (this would be an upper abdominal horizontal scar) or from meconium ileus (caused by CF, occurs in neonates, usually these children have a midline laparotomy scar +/- an ileostomy)

Palpation

Assess chest expansion for equal and symmetrical movements during inspiration and expiration. Reduced chest expansion may be seen in restrictive lung diseases, atelectasis, and pneumonia whereas overexpansion of the chest could indicate an obstructive lung disease.

Next palpate the apex beat: this is felt in the 5^th intercostal space, midclavicular line. You should palpate the left and right side in a respiratory and cardiovascular exam so that you don’t miss a possible dextrocardia (seen in Kartagener’s syndrome). Leftwards displacement of the apex beat occurs when there is cardiomegaly and rightwards displacement occurs in congenital diaphragmatic hernia.

To assess tactile vocal fremitus, ask the child to repeat a phrase, such as ‘ninety-nine’ or ‘blue balloon’ and rest the medial edge of your hand at different levels of the back. A decreased fremitus is seen in pleural effusion or pneumothorax whilst an increased fremitus is seen in cases of consolidation, as in pneumonia.

Percussion

Before starting the percussion, to avoid startling the child explain to them that you’ll be tapping your finger on their chest and back, like you’re playing a drum and assure them that it won’t be painful! You should gently percuss the supraclavicular and infraclavicular areas, the chest wall and axilla comparing both sides as you go along. Percussion is not routinely done on younger children (< 2 years old)

The normal finding is resonant on percussion, but in some cases other notes can be heard:

• Dullness on percussion is heard when there is increased density e.g. mass, consolidation (pneumonia), fibrosis
• Stony dull percussion is indicative of pleural effusion
• Hyper-resonance on percussion occurs in situations when there is decreased density e.g. emphysema, pneumothorax

Auscultation

Without a stethoscope, first listen for any audible sounds that may be heard from beside the child, such as:

• Stridor: an inspiratory sound indicative of upper airway obstruction
• Hoarse voice: due to involvement of the larynx
• Audible wheeze: an expiratory sound heard in lower respiratory diseases

Next listen to the anterior and posterior chest with your stethoscope. It may help introducing your stethoscope to the child before auscultating or even demonstrating on their toys to put them at ease. Ask child to take deep breaths in through mouth and listen to all lung fields, comparing each side for the quality of sounds and any added sounds. The normal quality of breath sounds is vesicular, however harsh bronchial breath sounds are heard in cases of consolidation.

Added breath sounds include:

• Wheeze: is it polyphonic or monophonic? A polyphonic wheeze can be heard in asthma and a monophonic wheeze in foreign body inhalation. Usually, wheezes are an expiratory sound however in severe respiratory disease, there may be an inspiratory wheeze too
• Stridor
• Coarse crackles
• Find end inspiratory crackles
• OR you may have reduced or no air entry in the case of a lobectomy which may be performed for bronchiectasis

At the end of the examination, you should thank the child and allow them to get dressed again or help them to get dressed.

You should plot their height and weight on the appropriate growth chart and should ask for a full set of observations.

Depending on your findings, you’ll likely want spirometry, to do an ENT and cardiovascular examination, and to get a CXR and a sputum.

References

Abigail Whitehouse, C. N. (n.d.). Respiratory examination guide. Retrieved from MRCPCH Clinical Revision: https://mrcpch.paediatrics.co.uk/respiratory/respiratory-examination-guide

Bonfield, A. (2018, October 8). Respiratory exam. Retrieved from TeachMe Paediatrics: https://teachmepaediatrics.com/examinations/resp/respiratory-exam/

Churcher, L. (2017, April 14). Paediatric respiratory system examination. Retrieved from OSCE Aid: http://m.osce-aid.co.uk/osce.php?code=osce_paediatricrespiratoryexamination

Finnerty, D. T. (2023, October 28). Paediatric Respiratory Examination. Retrieved from Geeky Medics: https://geekymedics.com/paediatric-respiratory-examination-osce-guide/

Kliegman R, S. G. (2020). Nelson Textbook of paediatrics, 21e. Elsevier .

Rathod DG, S. S. (2023). Spoon Nails. StatPearls.

Tasker R, M. R. (2013). Oxford handbook of Paediatrics, 2e. Oxford: Oxford University press.

Written by Nikhita

Written by Nikhita Rathod, Final Year Medical Student at the Medical University of Varna, Bulgaria

Edited by Dr Rebecca Evans, Paediatric Registrar