PHISICAL EXAMINATION OF RESPIRATORY SYSTEM
One can use inspection, palpation, percussion and auscultation for objective examination of respiratory system.
INSPECTION: General inspection begins with the face, then doctor examines the thorax. Pay attention, whether the child breathes through a mouth or a nose, whether there are discharges from a nose and their character, whether there is an inflating of nose wings.
It is important to note color of skin. At presence of cyanosis specify a degree of its expressiveness, is it constant or periodical (appears at a suction, cry of the child, at physical strain).
During inspection of thorax it is necessary to note symmetry of movement of scapulas, backlog of one half of thorax in the act of respiration. Pay attention to participation of auxiliary muscles in the act of respiration.
It is important to characterize a voice of the child, his cry and cough. In older children it is recommended to ask the child to make forced inspiration and an exhalation and thus to pay attention to participation of thorax in the act of respiration.
Depending on primary participation of a chest or an abdomen define type of respiration (thoracal, diaphragmal). Define depth of respiration. A rhythm of respiration defines on a regularity of respiratory acts. It is necessary to count up number of respiratory movements in one minute.
Calculation of frequency of respiration make or approximately, or by hand putting on a chest or an abdomen. At newborn and infants calculation of number of respiration can be made by a present of a stethoscope to a nose of the child (better during slip).
PALPATION: by palpation one receives imagine about condition of a skin in the field of chest (local sweating, hyperesthesia, edema). The palpation is made with both hands: hands put on symmetric researched sites of a chest. Define an elastance of a thorax by squeezing it by both hands in front to back and from sides.
Backlog of one half of thorax in the act of respiration may be defined, putting fingers at angles of scapulas. The palpation allows finding out also a place and a degree of morbidity of a chest.
The palpation is applied for definition of vocal fremitus. It is necessary to put hands on a chest symmetrically from both sides. Doctor asks the child say words such as "раз-два-три", “ninety nine” in yang children use the cry. In norm the vocal fremitus is symmetric, however more expressed in the top parts of a chest, especially from the right.
PERCUSSION: At percussion of lungs the special attention should be paid on the correct position of the child providing a symmetric position of a chest. The forward surface of a thorax of children of the earliest age is more convenient for percussion in a lying position on a back; the back is percussed in a sitting position, and the child needs to be supported. Older children are percussed in a standing position. At a percussion of a forward surface of a thorax the child stands, having hands lowered. At a percussion of a back surface shoulders of the child are lowered, the head is a little bent forward. At research of interscapular space the child moves scapulas little outside to enlarge space accessible to examination. It is not necessary to cross arms on a chest since it causes the strain of muscles. During percussion of lateral surfaces of a thorax it is necessary to remove arms in the sides, and it is better – to get them for a head. In children younger than 5 years you can use immediate (direct) percussion, in older children is applied mediate percussion .
Distinguish topographic and comparative percussion.
TOPOGRAPHICAL PERCUSSION: The finger - plessimeter is put to in parallel-required border, in intercostals. A mark of border make on the side of a finger - plessimeter inverted to a clear sound.
Definition of height of standing of lung apexes begins in front. Doctor puts finger - plessimeter above a clavicle, makes percussion, moving a finger - plessimeter upwards before occurrence of dullness. In norm this site is on distance of 2-4 cm from the middle of a clavicle. Behind a percussion of apexes conduct from spina scapulae upwards up to dullness. In norm the height of standing of apexes behind is defined at a level of an acantha of VII cervical vertebra. At children till 7 years the top border of lung is not defined, as lung apexes do not leave for a clavicle.
Definition of the lower borders of lungs begins with right lung on medioclavicular, axillary and scapular lines. Then define the lower borders of left lung on axillary and scapular lines.
COMPARATIVE PERCUSSION: compare anatomicaly equally posed sites of lungs from the right and left side on medioclavicular, axillary, scapular and paravertebral lines. In front at the left above area of heart percussion do not make. The finger - plessimeter above all sites of lungs, except for an interscapular space, settles down in parallel ribs, in interscapular area – in parallel a backbone.
At percussion of lungs it is possible to catch the following sounds:
1) clear vesicular resonance - a sound of healthy lung, containing air;
2) blunted and dull resonance with various shades (depending on intensity of dullness speak about blunted or absolute dullness of sound).
3) tympanic resonance - high, long - is defined above cavities.
4) bandbox resonance – a high, short sound is defined at rising lightness of a pulmonary tissue (an emphysema).
At presence of an exudate in pleura the border of a dullness has settles down on line Ellis – Damoiseau. It is a parabolic line, which lasts from a backbone upwards up to a back axillary line, then goes to forward. Simultaneously above exudate the triangular space of clear sound, circumscribed by a backbone, the top border of dullness and the horizontal line bridging the highest point of dullness on a scapular line with a backbone — triangle Garland is found out. This is an area of collapsing lung. On the healthy side the dullness (owing to shift of a mediastinum) as paravertebral triangle Rauchfus-Grocco is found out. The top side of it corresponds to the top border of exudate, other side is made with a line of a backbone, the basis is the lower edge of healthy lung.
By means of percussion it is possible to define a condition of intrathoracic lymph nodes.
Koraniy Sign: the percussion on acanthus of thoracic vertebrae from below upwards is made. In norm the dullness at a level of 3-4 thoracic vertebrae turns out. In this case Koraniy sign is considered negative. In case of presence of blunt below specified vertebrae the sign is considered positive.
Phylosofoff’s Sign of "bowl": the loud percussion in the first and the second intercostals from both sides is made in the direction of a breast bone, (the finger - plessimeter settles down in parallel a breast bone). In norm the bent is marked on a breast bone, in this case the sign is considered negative. In case of presence of dullness on both sides from a breast bone, the sign is considered positive.
AUSCULTATION: To make auscultation the child, as well as to make percussion, is possible in any position – standing, sitting, laying. It is better to auscultate seriously ill patients in a lying position. Symmetric sites are auscultated: apexes, a forward surface of lungs, axillaries, behind - above scapulas, paravertebral areas, under scapulas. At an auscultation first of all it is necessary to define character of the basic respiratory noise, and then to estimate supplementary noises.
In children till 3-6 months the weakened vesicular respiration is listened, from 6 months till 5-7 years puerile respiration, which in essence is strengthened vesicular, is listened. It is louder and longer in both phases of respiration. In children older than 7 years respiration gradually gets vesicular character: reminds a soft sound "F", the exhalation makes one third of inspiration. At healthy children above a larynx, a trachea, large bronchi, in interscapular area at a level of Th III – IV the bronchial respiration is auscultated: reminds a sound "Õ", the expiration is louder and longer, than an inspiration.
Pathological changes of respiration:
1. rough respiration is vesicular respiration with a prolonged expiration (an expiration is longer than one thirds of inspiration)
2. bronchial respiration (if it is auscultated not in areas typical for it) – specifies about infiltration of a pulmonary tissue, or defines above cavities;
At auscultation it is possible to hear rhonchuses (rales). Distinguish dry rales (whistling, buzzing) and moist (coarse, medium and fine). At auscultation of rales it is necessary to note their localization, quantity, character, a phase of an auscultation (on an inspiration or expiration).
Crepitation - the hum arising in slept alveoli on inspiration. Crepitation reminds a sound arising at grinding by fingers of a fascicle of hair near the ear.
Pleural friction rub – the hum arising at "dry" pleuriyis. It is auscultated in both phases of respiration, can be silent, gentle, or, on the contrary, rasping, loud.