Medical / Surgery

Pointers for pediatric respiratory assessment?

If you’re a med-surg nurse, you probably don’t care for pediatric patients often. But when the occasion arises, are you confident of your pediatric knowledge base?
In children, little things can mean a lot. For instance, did you know that a 1-mm occlusion (as from mucus or edema) in a child’s respiratory tract increases airway resistance 16%, causing immediate respiratory compromise?
To help ensure proper diagnosis, aid early preventive treatment, and promote improved outcomes, you need to be familiar with normal pediatric assessment findings. If you’re alert for subtle or seemingly minor details, you can help your patient avoid the lasting effects of hypoxia, or—worst case scenario—loss of life. This article provides a basic review of pediatric respiratory assessment. (If you’re a pediatric nurse, think of it as a quick refresher course.)

Pediatric points of difference
Keep in mind these essential facts about a child’s respiratory system:
•    At birth, the respiratory system isn’t fully developed. Consequently, respiratory decompensation occurs more rapidly in children and recovery takes longer.
•    Alveoli keep expanding and replicating until about age 4. The lungs develop completely between ages 5 and 6, and alveolar maturation reaches adult capacity during adolescence.
•    Age and respiratory rate have an inverse relationship: the younger the child, the faster the respiratory rate.
•    Preterm infants have weak respiratory muscles. They also experience periodic breathing, marked by episodes of rapid breathing and apnea, which may lead to hypoxia.
•    Children breathe mainly through the nose until about age 4 weeks (or in some cases, up to several months).
•    A child’s diaphragm is flatter than an adult’s.
•    Infants and children have smaller airways than adults, leading to increased airway resistance, which manifests as a rapid respiratory rate.
•    Because of increased airway resistance and nasal breathing, children are at high risk for airway obstruction, even with minimal amounts of mucus or edema. (See Common respiratory disorders in children in pdf format available by clicking download now.)
•    Infants and children have abnormally large tongues, which can cause airway obstruction.
•    Children have thinner chest walls than adults and therefore louder breath sounds.
•    A child’s chest has cartilaginous structures that increase lung compliance (and also promote cooperation during auscultation).

Make age-appropriate alterations
Gear your respiratory assessment not just to the child’s age and size but also to cognitive and functional status. One way to gauge cognitive status is to maintain a steady dialogue during the exam.
With a child who’s too young to provide a medical history or describe symptoms, direct your questions to the parent or other accompanying adult. Ask open-ended questions to help elicit a full description of the problem.
Try to get an older child or adolescent to describe the symptom or concern in his or her own words. Ask about the history of the problem, including when it began; its location, quality, severity, and timing (frequency); whether it has changed or progressed (and if so, how); and what makes the symptom better or worse.

Use the right stethoscope
Be sure to use a stethoscope with a smaller bell and diaphragm than an adult stethoscope—especially for an infant or toddler. If you use a stethoscope that’s too large, you will have a harder time isolating respiratory sounds and may miss important findings.

Put the child at ease
If appropriate, have the child sit on the parent’s lap during the exam to promote calm and quiet. To put the child at ease, make the exam go more smoothly, and promote more accurate findings, let the child “help” with the exam. Explaining what you’re doing (in simple terms, of course) also helps calm the child. Consider role-playing, too; for instance, let the child handle the stethoscope while holding it against your chest or a parent’s or doll’s chest.

Initial inspection
Check for nasal flaring, which indicates accessory muscle use in an infant or toddler. Look for signs of respiratory effort, retractions, bulging of intercostal muscles, and head bobbing (an attempt to take in more air).

Chest auscultation
You should be able to auscultate a child’s chest fairly easily. (See Comparing normal and abnormal breath sounds in pdf format available by clicking download now.) Before auscultating, clear the nasal passages of a small child, if needed, to prevent distorted nasal sounds, which may be misinterpreted as abnormal (adventitious) breath sounds.
Timing is important: Auscultate at the start of the exam, when the child is most attentive and cooperative. Perform auscultation on a bare chest. (Clothing distorts the quality of respiratory sounds.) Hold the diaphragm of the stethoscope firmly against the child’s chest; to promote cooperation, have the child help with this maneuver.
Move the stethoscope from side to side to compare areas. Evaluate the child’s breath sounds along both the anterior and posterior chest walls. Listen for one full cycle of inspiration and expiration in all chest areas. Keep in mind that for both children and adults, the normal inspiratory-to-expiratory ratio is 1:2. An abnormal ratio may signal respiratory distress. In children with restrictive disease, the ratio may be 1:1; in those with acute upper airway obstruction, it may be 2:2 to 4:2. Such diseases as cystic fibrosis and acute asthma increase expiratory time. To differentiate the breath sounds you’re hearing, you may need to listen for several minutes.

Speak for the child
Remember—when assessing a pediatric patient, the smallest red flag could signal respiratory distress and warrants further investigation. Infants and young children can’t verbalize their symptoms; it’s your responsibility to conduct a full assessment accurately and report your findings promptly to the attending clinician or practitioner. You’re not just the child’s nurse; in many cases, you’re the child’s voice.

Selected references
Burns C, Dunn A, Brady M, Starr N, Blosser C. Pediatric Primary Care: A Handbook for Nurse Practitioners. 3rd ed. Saunders: St. Louis, MO; 2004.
Duderstadt K. Pediatric Physical Examination: An Illustrated Handbook. Mosby: St. Louis, MO; 2006
MacLean S, Désy P, Altair J, Perhats C, Gacki-Smith J. Research education needs of pediatric emergency nurses. (2006). J Emerg Nurs. 2006;32(1):17-22.
McCaskey M. Pediatric assessment: the little differences. Home Healthc Nurse. 2007;25(1):20-24.

Patricia Vanderpool is a Nurse Practitioner, Nurse Educator at American Health Network in Edinburgh, Indiana and at Shelby Community Health Center in Shelbyville, Indiana.

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