Pediatric emergency medicine trisk 1410 1410
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Bronchophony, egophony, whispered pectoriloquy: alterations in voice sounds
as a result of lobar pneumonia, pleural effusion
Tactile fremitus: vibration on percussion increased with consolidation,
abscess, decreased/absent with bronchial obstruction, pleural cavity spaceoccupying lesion
Percussion of the chest may reveal either hyperresonance, suggesting air
trapping, or dullness, suggesting an area of consolidation, atelectasis, a mass in
the lung or pleural space, or pleural fluid ( Table 71.8 ). Air trapping is suggested
by depressed position of the diaphragm. Diaphragmatic excursion can be
accessed by measuring the difference between the level of dullness on percussion
during full inspiration and full expiration. Poor diaphragmatic excursion may
reflect diaphragmatic dysfunction.
The remainder of the physical examination should concentrate on the
neurologic, cardiac, gastrointestinal, renal, skin, metabolic/endocrine, and
hematologic systems as potential source of respiratory distress.
Approach
The approach to the child with respiratory distress ( Fig. 71.1A,B ) begins with
the assessment of airway patency, oxygenation and ventilation. For patients in
extremis, appropriate resuscitation as per Basic and Advanced Life Support
guidelines, should be initiated immediately. Patients in extremis ( Fig. 71.1A )
also require rapid identification and emergent treatment of underlying conditions.
Etiologies of extremis due to trauma most commonly include airway obstruction,
tension pneumothorax, flail chest, CNS depression and cardiac tamponade. The
most common causes of extremis in patients with no history of trauma are foreign
body, infection, and anaphylaxis.
For patients with mild to moderate respiratory distress, the initial focus of the
examination should be on the respiratory and cardiac systems. Assessment begins
with the observation of patient position, general appearance, work of breathing,
and respiratory sounds that can be appreciated without a stethoscope. This is
followed by evaluation of oxygenation and ventilation, and auscultation to assess
abnormal cardiopulmonary sounds. The remainder of the examination is
performed when the child is sufficiently stable to tolerate the examination.
All patients with respiratory distress should have their oxygenation tested
immediately by pulse oximetry. Capnography measures end-tidal carbon dioxide
(EtCO2 ) and CO2 waveform as a rapid means of assessing ventilation and can
help identify upper or lower airway obstruction. Stridor, altered phonation, and/or
