When a child presents with a respiratory issue, much of the phyical exam is completed by simply observing the patient. Before we even pick-up our stethescopes, it's important to spend time noting the child's general appearance, the respiratory rate, pattern and work of breathing. Accessory muscle use can be an indicator of respiratory distress in infants and children. Below is a review of a few key physical exam findings that are illustrated in the videos below.

Types of Retractions:

- Supraclavicular: indrawing of the soft tissue above the clavicle or above the sternal notch

- Suprasternal: indrawing of the soft tissue above the sternun

- Intercostal: indrawing of skin between the ribs

- Subcostal: occur at or below the costal margins

* Severe retractions of more than one muscle group indicate significant distress

Other Exam Findings:

Nasal Flaring: enlargement of both openings of the nose during inspiration

Grunting: repetitive short upper reispiratory tract sound produced by partial vocal cord closure during expiration. It slows expiratory flow and increases lung volume and alveolar pressure. Typcially a sign of moderate to severe distress. 

Head Bobbing: extension of the head and neck during inhalation and falling forward of the head during exhalation

 All of these findings are illustrated in the videos below.

 * note the tachypnea, retractions, grunting and nasal flaring in this video

* note the head bobbing. Child on high flow nasal oxygen.

This child was ultimately diagnosed with RSV and Adenovirus Bronchiolitis. After the child failed to respond to deep nasal suctioning and high flow oxygen (above), he was ultimately placed on Bipap in the ED and admitted to the PICU. Dr. EM Mom still feels a bit guilty that she didn't bring her son to the ED sooner for care. The boy in the video, however, is now a happy, healthy toddler.

References:

1. Margolis, Peter and Anne Gadomski. "Does this Infant Have Pneumonia." JAMA, January 28, 1998-Vol 279, No.4.