Anatomy

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Anatomy Physiologyof the respiratory system
in children
prof. Pavlyshyn H.A., MD, PhD
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Respiratory system

• The respiratory system is divided into two parts
  upper and lower respiratory tract
• The border of this division is the lower edge of
  the cricoid cartilage.
• Upper respiratory tract includes the paranasal
  sinuses, nasal cavity, pharynx and the Eustachian
  tube and other parts
• Lower respiratory tract includes the trachea,
  bronchi, bronchial and alveolar capillary.

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Anatomical characteristicsUpper respiratory tract

• The nose, nasal passages (airways), sinuses
  infancy are comperatively narrow Mucosa is
  rich for vascular tissue ? that makes child
  vulnerable to infection and oedema
• Infection, swelling of the nasal cavity and
  nasal congestion contribute more narrow or
  blocked of nasal airways, causing difficulty in
  breathing and sucking.
• There are not inferior (lower) nasal passages
  (until 4 years) and as a result rarely epistaxis
  in infants

• Nasolacrimal duct is short, the opening valve,
  hypoplasia valve may be the cause of
  conjunctivitis with upper respiratory tract
  infection
• Development sinuses of infants continued after 2
  years of age and finished to 12 years the
  maxillary sinuses is usually present at birth
  the frontal sinuses begin to develop in early
  infancy Babies can suffer from sinusitis the
  ethmoid, maxillary sinuses are most vulnerable to
  infection.

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Upper respiratory tract in children

• Larynx is located on level the 3-4th (neck)
  vertebrae
• Vocal and mucous membranes are rich blood vessels
  and lymphatic tissue, prone to inflammation,
  swelling, due to babies suffering from laryngitis
  (viral croup), airway obstruction, inspiratory
  dyspnea

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Anatomical characteristicsLower respiratory tract

• The trachea is short
• Tracheal and bronchial passes in children is
  relatively small, cartilage soft, the lack of
  elastic tissue

LRT vulnerable, easy to cause airway narrowing
and obstruction
Trachea
Bronchi Tubes
Right bronchus more straight, like a direct
extension of the trachea (causing the right lung
atelectasis or emphysema) Left bronchus is the
separation from the trachea The bronchus is
divided into inter-lobe bronchus, segmental
bronchus, bronchioles.
Bronchioles - no cartilage, smooth muscle
imperfect development, mucosa rich in blood
vessels, mucous glands hypoplasia, lack of
secretion of mucus, poor mucociliary movement
Bronchiole
Alveoli
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Anatomy and physiology

• The ribs are cartilaginous and perpendicular
  relative to the vertebral column (horizontal
  position), reducing the movements of the rib
  cage.
• The infant chest wall is remarkably compliant and
  compliance decreases with increasing age.
• The orientation of the ribs is horizontal in the
  infant by 10 years of age, the orientation is
  downward.

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The mecanizm of breathing

• Contraction of diaphragm
• diaphragm moves
• downward
• gtincreases vertical dimension of
• thoracic cavity
• ?

• Contraction of external intercostal muscles gt
  elevation of ribs sternum
• gt increased front- to-back dimension of thoracic
  cavity
• ?

• lowers air pressure in lungs
• air moves into lungs

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Anatomy and physiology

• The intercostal muscles and accessory muscles of
  ventilation are immature.
• As a result, children are more reliant on the
  diaphragm for inspiration.
• Increased respiratory effort causes subcostal
  and sternal recession, and the mechanical
  efficiency of the chest wall is reduced.

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Summary

• The considerable differences in respiratory
  physiology between infants and adults explain why
  infants and young children have a higher
  susceptibility to more severe manifestations of
  respiratory diseases, and why respiratory failure
  is common problem in neonatal and pediatric
  intensive care units.
• The appreciation of the peculiarities of
  pediatric respiratory physiology is not only
  essential for correct assessment of any ill
  child, but also for correct interpretation of any
  pulmonary function test performed in this
  population.

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An average respiratory rate at rest of the child
of different age is

• newborn 40-60 per minute,
• infant at 6 months 35-30 per minute,
• at 1 year 30 per minute,
• 5 years 25 per minute,
• 10 years 20 per minute,
• 12-18 years 16-20 per minute.

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Disorders of the respiratory rate

• Tachypnea is the increase of the RR
  (Interstitial, vascular and multitude of
  diseases, anxiety)
• Bradypnea is the decrease of the RR (Narcotics,
  raised intracranial tension, myxedema)
• Dyspnea is the distress during breathing
• Apnea is the cessation of breathing

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Disorders of the respiratory depth

• Hyperpnea is an increased depth.
• Hypoventilation is a decreased depth and
  irregular rhythm.
• Hyperventilation is an increased rate and depth.

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Pathological respiration

• Seesaw (paradoxic) respirations the chest falls
  on inspiration and rises on expiration. It is
  usually observed in respiratory failure of third
  degree, RDS
• Cheyne-stokes breathing cyclical increase and
  decrease in depth of respiration (CHF,
  cerebrovascular insufficiency)
• Kussmaul slow deep breathing, hyperventilation,
  gasping and labored respiration (Ketoacidosis)
• Biot's breathing totally irregular with no
  pattern (CNS injury)

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Percussion

• Resonant sounds are low pitched, hollow sounds
  heard over normal lung tissue.

• Flat or extremely dull sounds are normally heard
  over solid areas such as bones.

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Percussion

• Percuss the lung fields, alternating, from top
  to bottom and comparing sides
• Percuss over the intercostals space.
• Keep the middle finger firmly over the chest
  wall along intercostals space and tap chest over
  distal interphalangeal joint with middle finger
  of the opposite hand.

• The movement of tapping should come from the
  wrist.
• Tap 2-3 times in a row.

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Percussion
Percuss the chest all around. Stand back, have
the patient cross arms to shoulder. This
maneuver will wing the scapula and expose the
posterior thorax.
Then, have the patient keep their hands over
head and percuss axilla.

• Then move to the front and percuss anterior
  chest , clavicles and supraclavicular space.

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Percussion

• The lung is filled with air (99 of lung is
  air).
• Percussion of it gives a resonance. This step
  helps identify areas of lung devoid of air.
• Appreciate the dullness of the left anterior
  chest due to heart and right lower chest due to
  liver.
• Note the hyper-resonance of the left lower
  anterior chest due to air filled stomach.
• Normally, the rest of the lung fields are
  resonant.

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The pathological dullness is heard in cause of

• Dull or thud like sounds are normally heard over
  dense areas such as the heart or liver.
• Dullness replaces resonance when fluid or solid
  tissue replaces air-containing lung tissues, such
  as occurs with pneumonia, pleural effusions
  (hydro-, haemothorax), or tumors.

• Decreased resonance is noted with pleural
  effusion and all other lung diseases.

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The hyper resonant sounds is heard in cause of
Increased resonances can be noted either due to
lung distention as seen in asthma, emphysema or
due to Pneumothorax.

• Hyper resonant sounds that are louder and lower
  pitched than resonant sounds are normally heard
  when percussing the chests of children and very
  thin adults.
• Hyper resonant (ban-box) sounds may also be
  heard when percussing lungs hyperinflated with
  air, such as emphysema of lungs, patients with
  COPD, asthma, asthmatic bronchitis.
• An area of hyper resonance on one side of the
  chest may indicate a pneumothorax.

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The tympanic sounds is heard in cause of

• Tympanic sounds are hollow, high, drum like
  sounds.
• Tympany is normally heard over the stomach, but
  is not a normal chest sound.
• Tympanic sounds heard over the chest indicate
  excessive air in the chest, such as may occur
  with pneumothorax.

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Anatomy of lobes of lungs
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Auscultation method of exam

• Auscultate the lungs from the apices, middle and
  lower lung fields posteriorly, laterally and
  anteriorly.
• Alternate and compare sides.

• Listen to at least one complete respiratory cycle
  at each site.
• First listen with quiet respiration. If breath
  sounds are inaudible, then have him take deep
  breaths.
• First describe the breath sounds and then the
  adventitious sounds.

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Auscultation method of exam

• Note the intensity of breath sounds and make a
  comparison with the opposite side.

• Assess length of inspiration and expiration.
  Listen for the pause between inspiration,
  expiration.
• Compare the intensity of breath sounds between
  upper and lower chest in upright position.
• Note the presence or absence of adventitious
  sounds.

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Begin by auscultation the apices of the lungs,
moving from side to side and comparing as you
approach the bases. If you hear a suspicious
breath sound, listen to a few other nearby
locations and try to delineate its extent and
character.

• To assess the posterior chest, ask the patient
  to keep both arms crossed in front of his/her
  chest, if possible.

• It is important that you always compare what you
  hear with the opposite side.

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Normal breath sounds

• tracheal, bronchial, broncho-vesicular and
  vesicular sounds.
• Breath sounds are described by
• duration (how long the sound lasts),
• intensity (how loud the sound is),
• pitch (how high or low the sound is), and
• timing (when the sound occurs in the respiratory
  cycle).

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Breath sounds can be divided into the following
categories
 Normal Abnormal Adventitious
tracheal absent/decreased crackles (rales)
vesicular bronchial wheeze
bronchial   rhonchi
bronchovesicular   stridor
    pleural rub
    mediastinal crunch (Hamman's sign)
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Normal breath sounds

• Bronchial sounds are present over the large
  airways in the anterior chest near the second and
  third intercostal spaces (trachea, right
  sternoclavicular joints and posterior right
  interscapular space)
• These sounds are more tubular and hollow-sounding
  than vesicular sounds, but not as harsh as
  tracheal breath sounds.
• Bronchial sounds are loud and high in pitch with
  a short pause between inspiration and expiration
  (inspiration and expiration are equal)
  expiratory sounds last longer than inspiratory
  sounds.

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The Bronchial Breath Sound

• has the following characteristics
• An IE Ratio 11 or 11 1/4 with a pause in
  between inspiration expiration
• Thoracic Geography over the manubrium of the
  sternum
• Sound Characteristics high pitched, tubular,
  hollow sound
• Indication that an area of consolidation exists
  - pneumonia, atelectasis, fluid infiltration

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The Bronchovesicular Breath Sound

• has the following characteristics
• An IE Ratio 11 or 11 1/4 with a pause in
  between inspiration expiration
• Thoracic Geography They are best heard in the
  1st and 2nd ICS (anterior chest) and between the
  scapulae (posterior chest) - over the main stem
  bronchi
• Sound Characteristics high pitched, tubular,
  hollow sound
• Indication an area of consolidation -
  pneumonia, atelectasis, fluid infiltration

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Abnormal breath sounds include

• the absence of sound and/or
• the presence of sounds in areas where they are
  normally not heard.
• For example, bronchial breath sounds are
  abnormal in peripheral areas where only vesicular
  sounds should be heard.
• When bronchial sounds are heard in areas distant
  from where they normally occur, the patient may
  have consolidation (as occurs with pneumonia) or
  compression of the lung. These conditions cause
  the lung tissue to be dense. The dense tissue
  transmits sound from the lung bronchi much more
  efficiently than through the air-filled alveoli
  of the normal lung.

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Summery
Type Characteristic Intensity Pitch Description Location
Normal tracheal loud high harsh not routinely auscultated over the trachea
Normal vesicular Soft low . most of the lungs
Normal bronchial very loud high sound close to stethoscope gap between insp exp sounds over the manubrium (normal) or consolidated areas
Normal bronchovesicular Medium medium . normally in 1st 2nd ICS anteriorly and between scapulae posteriorly other locations indicate consolidation
Abnormal absent/decreased . . heard in ARDS, asthma, ateletasis, emphysema, pleural effusion, pneumothorax .
Abnormal bronchial . . indicates areas of consolidation .
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The term adventitious breath sounds

• refers to extra or additional sounds that are
  heard over normal breath sounds.
• crackles (or rales)
• wheezes (or rhonchi)
• pleural friction rubs
• stridor

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Adventitious sounds

• Wheeze
• Stridor
• Crackles
• Pleural Rub

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Crackles (or rales)

• Crackles are discontinuous, intermittent,
  nonmusical, brief, "popping" sounds that
  originate within the airways.
• are caused by fluid in the small airways or
  atelectasis.
• Crackles may be heard on inspiration or
  expiration. The popping sounds produced are
  created when air is forced through respiratory
  passages that are narrowed by fluid, mucus or
  pus.
• Crackles are often associated with inflammation
  or infection of the small bronchi, bronchioles
  and alveoli (pneumonia, atelectatic lung).
• Crackles are often described as fine (high
  pitched, soft, very brief), coarse (low pitched,
  louder, less brief).
• Fine crackles are soft, high-pitched, and very
  brief. You can simulate this sound by rolling a
  strand of hair between your fingers near your
  ear.
• Coarse crackles are intermittent "bubbling" sound
  somewhat louder, lower in pitch, and last longer
  than fine crackles.

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Wheeze Lung Sounds

• These are continuous, high pitched, hissing,
• whistling or sibilant sounds.
• They are caused by air moving through airways
  narrowed by constriction or swelling of airway or
  partial airway obstruction (asthma, CHF, chronic
  bronchitis, COPD).
• Wheezes are sounds that are heard continuously
  during inspiration or expiration, or during both
  inspiration and expiration.
• Wheezes that are relatively high pitched and have
  a shrill or squeaking quality may be referred to
  as sibilant rhonchi. These wheezes occur when
  airways are narrowed, such as may occur during an
  acute asthmatic attack.
• Wheezes that are lower-pitched sounds with a
  snoring or moaning quality may be referred to as
  sonorous rhonchi. Secretions in large airways,
  such as occurs with bronchitis, may produce these
  sounds

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Rhonchi Lung Sounds

• These are low pitched, continuous, musical,
  snore-like sounds that are similar to wheezes.
• They are caused by airway secretions and airway
  narrowing.
• They usually clear after coughing.

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Pleural friction rubs

• are low-pitched, grating, or creaking sounds that
  occur when inflamed pleural surfaces rub together
  during respiration.
• More often heard on inspiration than expiration,
  the pleural friction rub is easy to confuse with
  a pericardial friction rub.
• To determine whether the sound is a pleural
  friction rub or a pericardial friction rub, ask
  the patient to hold his breath briefly. If the
  rubbing sound continues, its a pericardial
  friction rub because the inflamed pericardial
  layers continue rubbing together with each heart
  beat - a pleural rub stops when breathing stops.

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Summery
Type Characteristic Intensity Pitch Description Location
Adventitious crackles (rales) soft (fine crackles) or loud (coarse crackles) high (fine crackles ) or low (coarse crackles) discontinuous, nonmusical, brief more commonly heard on inspiration assoc. w/ ARDS, asthma, bronchiectasis, bronchitis, consolidation, early CHF, interstitial lung disease may sometimes be normally heard at ant. lung bases after max. expiration or after prolonged recumbency
Adventitious wheeze high expiratory continuous sounds normally heard on expiration note if monophonic (obstruction of 1 airway) or polyphonic (general obstruction) assoc. w/ asthma, CHF, chronic bronchitis, COPD, pulm. edema can be anywhere over the lungs produced when there is obstruction
Adventitious rhonchi low expiratory continuous musical sounds similar to wheezes imply obstruction of larger airways by secretions .
Adventitious stridor . inspiratory musical wheeze that suggests obstructed trachea or larynx medical emergency heard loudest over trachea in inspiration
Adventitious pleural rub . insp. exp. creaking or brushing sounds continuous or discontinuous assoc. w/ pleural effusion or pneumothorax usually can be localized to particular place on chest wall
Adventitious mediastinal crunch . not synchronized w/ respiration crackles synchronized w/ heart beat medical emerg. assoc. w/ pneumomediatstinum best heard w/ patient in left lateral decubitus position
Adventitious          
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