Respiratory station

• Inhalers, spacers, nebuliser equipment, peak flow meters

From the end of the bed, inspect child with top off:

• Are they comfortable? signs of respiratory distress-check respiratory rate, attached to sats monitor?
• Harrisons’s sulcus
• Signs of long term steroid use (Cushing’s syndrome)
• Small for age (is there nutritional compromise)

Examining the patient:

• Hands and arms -scars from previous cannulas, signs of eczema
• Face – check mouth – signs of candida from poor inhalation technique of steroids)
• Chest – tracheal position, check where apex beat is, expansion (may be hyperinflated), auscultation – clear or may have scattered wheeze if recovering from acute deterioration (don’t just say ‘wheeze’ – is this just expiratory is there a prolonged expiratory phase, is it low pitched, high pitched and is it polyphonic in nature). Chest expansion and auscultate on posterior as well as anterior chest.

To complete examination:

• Growth chart, peak flow record (if >5yrs), review medications, review recent CXR, review history for atopy

• Check apex beat!!!
• Check side of liver (to confirm that this isn’t a case of situs invertus with CF – rare but potentially possible!)

• Home oxygen, nasal cannulae, inhalers, spacer (especially if aged 3-5yrs – may have been an ex-prem who now has frequent viral induced wheeze episodes)

From the end of the bed:

• Child <18 months with nasal cannulae
• +/-Soft subcostal recessions
• Signs of being ex-prem (may be small considering the age given), abdominal scars following NEC

Examining the child:

• Multiple scars on the hand from cannulas whilst on NICU
• Bruising (if on steroids)
• Round face (long term steroid use)
• Plagiocephaly
• Nasal cannulae in situ
• Chest – equal air entry, may be generally reduced or a little quiet, no wheeze unless intercurrent illness

To complete the examination

• Plot height and weight, review oxygen requirement/night time oxygen requirement, review medications, review CXR, developmental examination, check glucose levels ( if signs of Cushing’s syndrome)

• Well looking child, usually without any signs of respiratory distress
• ALWAYS, ALWAYS ALWAYS ask patients to put hands on hips and really check the axillary regions so you don’t miss a scar
• Is there an additional scar on the left side of the praecordium. This can be due to aortopexy following the initial TF repair. If there is a scar, then check the radial pulses bilaterally! The aortopexy will often reduce blood flow to the left radial artery.
• The most important aspect of this exam is to ASK THE PATIENT TO COUGH! You’ll hear a harsh, grunting-like cough, which is caused from the collapse of the non-cartilage containing part of the trachea formed following repair of the TOF
• Any other thoracic/abdominal scars

Examining the child:

• Usually very well looking
• Hands – may have healed scar marks
• Neck – central line scars
• Face – +/-syndromic
• Chest – scar in either right or left axillary region, equal chest expansion, equal air entry, normal vesicular breath sounds, resonant percussion note

To complete your examination

• Plot height and weight, oxygen sats, review recent CXR
• Ask about the neonatal period (taken immediately to NICU), discovered during infancy following recurrent aspiration

• Inhalers, nebulisers, supplemental oxygen

Looking at the patient from the end of the bed:

• Pink or cyanosed? midline sternotomy scars (need to think about whether this is a BT shunt scar), stats probe attached (may have sats target of around 75% if palliative procedure for hypoplastic left/right heart)
• Appears syndromic?
• Ask patient to put hands on hips before examining to make sure you don’t miss scar in axilla skin fold
• Ask patient to cough (TOF cough)

Examining the patient:

• Hands – assess for clubbing, peripheral cyanosis, small scars on hands
• Check radial pulse bilaterally, may be absent on side of BT repair (unless a modified BT shunt in which case the pulse is usually still present)
• Neck – scars from central lines
• Face – syndromic appearance? central cyanosis
• Praecordium – midline sternotomy, axillary scars, posteriolateral thoracotomy scars (pneumonectomy following unilateral lung disease/lobar emphysema/CCAM)
• Listen for a murmur – may be part of staged palliative repair and therefore child has had a BT shunt inserted. Note if a BT shunt, then usually a continuous mumrur will be heard under either the right of left clavicle depending on side or surgery
• Air entry usually vesicular, but may be reduced depending on extent of lung removal)
• Abdomen – feel for hepatomegly (especially if there is pulmonary fibrosis or element of cardiac failure)

To complete your examination

• Growth charts, observations (RR, saturations and BP), review recent CXR or HRCT if one has been performed, review medications (are they on immunosuppressants for pulmonary fibrosis), full neonatal history