Asthma: Physical Exam (Pediatric Nursing)

00:01 On physical exam, the clinician will begin by inspecting the patient.

00:04 Just look at their breathing effort.

00:06 First, you're just going to look at the shape of the chest.

00:08 The lungs can become hyper inflated in severe asthma, and the chest can also appear hyperinflated.

00:15 Next, you look for the movement of the chest, including the breathing depth and the rate.

00:20 When the patient's airway becomes too constricted and tight, and the patient becomes tired and fatigued, they're not able to move air in quite well.

00:28 And sometimes, they might not even wheeze.

00:30 This is called a silent chest, and this is an ominous sign of impending respiratory failure.

00:36 When I have a patient come in to the clinic and I know they have asthma, and they come in and I listen to them and I do not hear wheezing, this is an example of a silent chest and this is a high Red Alert.

00:47 I will often administer bronchodilation to the patient and administer nebulizer treatments, and then they will start to wheeze.

00:54 So they're actually improving when they start to wheeze.

00:56 Then you continue administering medications to try to treat their wheeze.

01:02 Next, you look for any obvious chest deformities, and you look for retractions.

01:07 Here's an example of the retractions.

01:09 They're based on mild, moderate, and severe.

01:12 So, at the bottom, you see mild, substernal, and subcostal retractions, and you actually need to look at the patient's chest to look for these.

01:19 You look under the gown and under the clothes.

01:22 Moderate retractions are noted in the supraclavicular and intercostal space.

01:27 And severe retractions are in the suprasternal area.

01:30 Patients may have combinations of these and they may move along the continuum from mild to moderate to severe and back as you start to bronchodilate the patient.

01:39 The next step in the physical exam is palpation.

01:42 The clinician's going to palpate for symmetric chest expansion, and will assess the tactile fremitus.

01:48 To assess chest expansion, the clinician's going to place their hands on the patient's back with their thumbs pointed toward the spine.

01:55 The hands should lift symmetrically outward when the patient takes a big deep breath.

01:58 In the setting of asthma, the chest expansion is symmetrical, but the overall chest expansion may be decreased if the obstruction is severe as they trap their air.

02:08 Next, you perform tactile fremitus.

02:10 So a normal lung is going to transmit a palpable vibratory sensation to the chest wall.

02:15 This is referred to as fremitus, and it can be detected by placing the ulnar aspect of both hands firmly against either side of the chest, while the patient says the words, "Ninety nine." This maneuver is repeated until the entire posterior thorax is covered.

02:29 The bony aspects of the hands are used as a particularly sensitive area in detecting these vibrations.

02:36 In the setting of asthma, tactile fremitus is decreased, indicating that there's increased air in the pleural space and a decrease in lung tissue density.

02:44 This happens, again, due to the air trapping and the hyperinflation.

02:49 The next part of the physical exam is percussion.

02:52 This technique makes use of the fact that striking a surface that covers an air filled structure, like the normal lung, will produce a resonant sound.

03:00 While repeating the same maneuver over a fluid-filled or tissue-filled cavity will generate a dull sound.

03:06 In the setting of asthma, percussion's going to reveal a hyperresonant sound, which is more drum-like because, again, the air is trapped in the lungs.

03:15 The last component of the respiratory exam is auscultation.

03:19 This is where you listen to your patient.

03:21 Using a stethoscope, the clinician's going to listen in a stepwise and patterned fashion, comparing sounds bilaterally and in all fields.

03:29 The breath sound should be vesicular.

03:32 Now, you may hear an inspiratory wheeze, an expiratory wheeze, or both.

03:37 The improvement or worsening of a patient's wheezing is important to track to see if they're improving in their condition or decompensating.

03:46 Rhonchi.

03:47 These are continuous, low-pitched rattling sounds that often resemble snoring.

03:51 During an asthma exacerbation, one can note diffuse rhonchi in the expiratory phase, and this can suggest a generalized airway obstruction.

04:01 Normally, exhalation, when you breathe out, is a passive action, meaning it should be effortless.

04:06 But during an asthma exacerbation, the airways are so constricted and plugged with mucus, it's hard to move the air in and out.

04:13 Since it's so hard to exhale during an asthma attack, more and more air gets trapped inside the lungs.