anatomical and physiological differences for infants (0-3 months) - chest wall structure
- ribs are cartilaginous -> good for being born/ high chest wall compliance
- ribs=horizontal & close together-> intercostals ineffective -> no effective chest wall expansion (no bucket handle movement)
-chest shape-> tight anterior chest wall; rounder looking from above (transverse plane); triangular shape from the front (frontal plane)
anatomical and physiological differences for infants (0-3 months) - lung structure
- immature alveoli-> less efficient gas exchange
- decreased lung compliance -> more pressure needed to expand lungs and higher elastic recoil on expiration; increased susceptibility to atelectasis (areas of lung collapse)
- less alveoli available to recruit
anatomical and physiological differences for infants (0-3 months) - airways
softer/floppier
-> more susceptible to collapse (malacia)
-> narrow (easily obstructed by edema, mucus etc.)
anatomical and physiological differences for infants (0-3 months) - muscle and energy stores
-> rely heavily on diaphragm to breathe (unable to effectively recruit accessory muscles)
-> less proportion of type 1 muscle fibers (more prone to fatigue)
-> glycogen supplies small and depleted more quickly
infants (0-3 months) are…
nose breathers
* Allows babies to feed without breaking suction
* Increased danger of nasal plugging with secretions
* Often clear secretions by sneezing rather than coughing
infants -> overall
- smaller tidal volume
- higher respiratory rate
- higher cost of respiratory metabolism (more - - oxygen consumption than in adults)
greater susceptibility to infection
anatomical and physiological differences for infants (3-6 months)
- Respiratory mechanics improve through muscle development
- Anterior chest opens up; chest shape becomes more rectangular
- Ribs continue to be horizontal
- Remain primarily diaphragm breathers with emerging accessory muscle use
- Respiratory rate (RR) decreases
- Tidal Volume (TV) increases
anatomical and physiological differences for infants (6-12 months)
- Most significant stage in chest development
- Gravity begins to act on ribs, rotating them downward
- Diaphragm insertion becomes more efficient
- Intercostals also more efficient
- Major changes in lung volumes, airway size, RR, TV and pulmonary reserves
- New danger: indiscriminate host curiosity (infants putting objects in mouth w/o judgment, increasing risk of airway obstruction)
anatomical and physiological differences for infants (1-8 yrs)
- Ribcage continues to develop into more mature/adult-like structure by age 7-8
- Continued alveoli growth
- 24 million at birth to 300 million at age 8
- Collateral ventilation develops
- New risk of upper airway obstruction due to rapid growth of lymphatic tissue
In general, cardiorespiratory differences that children present (in comparison to adults) are…
- Immature chest wall development/ mechanics
- Immature lung development
- Narrower airways
- Increased chest wall compliance (chest wall collapses inwards)
- Decreased lung compliance (lungs collapse inward)
- Diaphragm breathers with little to no ability to recruit accessory
muscles of ventilation - Initially nose breathers
- More susceptible to airway blockage
decreased lung compliance=??
- increased elastic recoil
- stronger inward collapsing of lungs
increased chest wall compliance=??
- chest is flexible and cannot resist inward forces well (gets pulled inwards by the lung’s elastic recoil)
What to consider -> subjective assessment
General health:
* Development, mobility and cognition
* Child’s baseline normal for feeding (history of aspiration?), sleeping, ability to interact and play
* Current status of feeding, sleeping, interaction, irritability
* Parental report of signs of distress, color changes
Birth History:
* Labour and delivery
* Gestational age and weight
* Corrected age (if premature)
* APGAR score out of 10 – indicates how the baby was doing just
after birth
* Tone, respiratory effort, heart rate, responsiveness, colour (2 points each)
* Length of hospital stay
IPPA -> inspection
- Physical observation for signs of respiratory distress:
- Head – bobbing
- Face – alertness, comfort, colour
- Nose – nasal flaring
- Mouth – open or closed, cyanosis
- Neck – tracheal tug (suprasternal indrawing)
- Chest – sternal depression, intercostal/subcostal indrawing
- Breathing pattern and level of effort
- Audible sounds – wheezing, stridor, grunting
- Intensity and quality of crying
- Quality of cough / sneeze (voluntary cough by about 2 years of
age) - Respiratory and heart rate
- Typically HR and RR elevated initially, then may see apnea and
bradycardia - Oxygen saturations
- Gaze avoidance
- Sleepiness
- Altered engagement
- Lack of play
- Irritability
Pectus excavatum – depression in anterior chest –
can be idiopathic or result from chronic breathing
difficulties and repeated sternal retraction - Pectus carinatum – protrusion of chest
- Scoliosis > 60 degrees can cause significant
thoracic restriction and decreased lung volumes - Barrel chest in chronic conditions
- Finger clubbing
IPPA -> palpation
- Chest wall movement less prominent in infants compared to
older children and adults - Thin chest wall makes tactile fremitus easy to palpate
IPPA -> percussion
Unreliable in younger children due to hyperresonnance
IPPA-> auscultation
- Less precision than with adults as sounds easily transmitted through thin chest walls
- May be harder to localize adventitia
- Auscultation is most useful to assess changes in air entry (pre and post treatment) and for immediate feedback during treatment
common conditions in paediatrics
bronchopulmonary dysplasia (infant born prematurely; crackles, wheezes, cyanosis, hypoxemia; can have a lifelong impact)
croup (inflammation of upper airway- caused by virus- cough/wheeze; PT contraindicated in acute attack)
bronchiolitis (inflammation of lower airway- caused by virus- atelectasis & increased work of breathing; PT indicated to treat atelectasis)
congenital hear defects (child may have lower oxygen saturations and limited energy for activities)
neuromotor disorders (muscular dystrophies, spinal muscular atrophy, spinal cord injuries, cerebral palsy)
-> potential associated resp issues: scoliosis, little reserve, inability to take deep breaths, ineffective cough, increased risk of aspiration due to poor muscle control
