Pediatrics

Module -2- 2018-2019

Prof Yusra AR Mahmood
Chest and CVS

Note: please refer to the previous H&E of module -1- ,for complete information,
here in this paper I will concentrate on the relevant point concerning Respiratory
and CVS.
History :

The complete respiratory history includes :

• onset, duration,and frequency of respiratory symptoms ; e.g.:
(cough, noisy breathing, work of breathing/exercise tolerance, nasal congestion,
sputum production),
• swallowing function (especially in infants), and exposure to others with
respiratory illness.
• It is important to obtain information concerning the severity, for e.g.:
(hospitalizations, emergency department visits, missed school days) and
• pattern (acute, chronic, or intermittent) of symptoms.
• For infants, a feeding history should be obtained, including questions of
coughing or choking with feeds.
• Family history should include questions about asthma and atopy,
immune deficiencies, and CF.
• The environmental history queries exposure to smoke, pets, and pollutants.
• Travel history may also be relevant.

Physical examination:

• Exposure :
Clothing should be removed from the upper half of the child’s body so that the thorax
may be inspected, although maintaining modesty for adolescents should be respected.
• observe the respiratory pattern ( abdominal , thoracic, both), rate, and work of
breathing
• keep the child quiet,
• noting the shape and symmetry of the chest wall and
• the anteroposterior (AP) diameter.
• Any factor that impairs respiratory mechanics is likely to increase the
respiratory rate. However, non-respiratory causes of tachypnea include fever,
pain, and anxiety.
Respiratory rates vary with age and activity .
It is important to observe the respiratory pattern and degree of effort (work of
breathing).
1

• Hyperpnea (increased depth of respiration) may be observed with fever,

metabolic acidosis, pulmonary and cardiac disease, or extreme anxiety.
• Hyperpnea without signs of respiratory distress suggests an extrapulmonary
etiology (metabolic acidosis, fever, pain).
• Increased work of breathing can be described as inspiratory
(intercostal, supraclavicular, or substernal retractions)
• or expiratory (use of abdominal muscles to actively exhale).
• In children, increased inspiratory effort is also manifested by nasal flaring.
Grunting (forced expiration against a partially closed glottis) suggests
respiratory distress, but it may also be a manifestation of pain.
Causes of increased work of breathing during inspiration include :
ü extrathoracic airway obstruction (laryngomalacia, croup, subglottic stenosis)
and/or
ü decreased pulmonary compliance (pneumonia, pulmonary edema).
ü Increased expiratory work of breathing usually indicates intrathoracic airway
obstruction.
Ë Stridor is a harsh sound caused by a partially obstructed extrathoracic airway,
more commonly heard on inspiration.
Ë Wheezing is produced by partial obstruction of the lower airways, more
commonly heard during exhalation. Wheezes can be monophonic and low-
pitched (usually from large, central airways) or high-pitched and musical (from
small peripheral airways).
Ë Secretions in the intrathoracic airways may produce wheezing but more
commonly result in irregular sounds called rhonchi.
Ë Fluid or secretions in small airways may produce sounds characteristic of
crumpling cellophane (crackles or rales).
Having the child take a deep breath and exhale forcefully will accentuate many
abnormal lung sounds.
Ë Decreased breath sounds may be due to atelectasis, lobar consolidation
(pneumonia), thoracic mass, or a pleural effusion. Observation of respiratory
rate, work of breathing, tracheal and cardiac deviation, and chest wall motion,
combined with percussion and auscultation, helps to identify intrathoracic
disease
Ë Digital clubbing is seen in:
o CF and in other,
o less common chronic pulmonary diseases (such as interstitial lung
disease).
o nonpulmonary chronic diseases (cardiac, gastrointestinal, or hematologic)
o or, rarely, as a familial trait.
o It is generally not seen in asthma

Cough:
ü results from stimulation of irritant receptors in the airway mucosa.
ü Acute cough generally is associated with respiratory infections or
irritant exposure (smoke) and
ý subsides as the infection resolves or the exposure is eliminated.

The characteristics of the cough and the circumstances under which the cough occurs
help in determining the cause.:
ý Sudden onset after a choking episode suggests foreign body aspiration.
ý Morning cough may be due to the accumulation of excessive secretions during
the night from sinusitis, allergic rhinitis, or bronchial infection.
ý Nighttime coughing is a hallmark of asthma and can also be caused by
gastroesophageal reflux disease.
ý Cough exacerbated by lying flat may be due to postnasal drip, sinusitis, allergic
rhinitis, or reflux.
ý Recurrent coughing with exercise is suggestive of exercise-induced asthma /
bronchospasm.
ý Paroxysmal cough suggests pertussis or foreign body aspiration.
ý A repetitive, staccato cough occurs in chlamydial infections in infants.
ý A harsh, brassy, seal-like cough suggests croup, tracheomalacia, or
psychogenic (habit) cough (it is most common in teenagers, disappears during sleep).

Chronic cough is defined as a daily cough lasting longer than 3 weeks. Common
causes of chronic cough are:
asthma,
postnasal drip (allergic rhinitis, sinusitis), and
postinfectious tussive syndromes.
It can also be caused by:
gastroesophageal reflux disease,
swallowing dysfunction (infants),
anatomic abnormalities (tracheoesophageal fistula, tracheomalacia),
and chronic infection.
exposure to irritants (tobacco and wood stove smoke) or foreign body
aspiration,
or it may be psychogenic in origin.