RESPIRATORY SYSTEM

The respiratory system consists of the airway and respiratory department. The most
important function of the respiratory system - a function of external respiration. Nasal
passages, nasopharynx, larynx, trachea, bronchi and bronchioles provide air flow to
respiratory lungs. In the alveoli there is an exchange of gases, and the circulatory system
delivers oxygen to cells, where it is tissue respiration.

Anatomic and physiologic features of the respiratory system

Nasal cavity and paranasal sinuses

The structures of the nose warms the air and purify it of foreign particles. The mucous
membrane of the nasal passages and other parts of the airway is also involved in protective
reactions by the presence in it of secretory IgA.

Early childhood nasal passages are narrow, relatively thick shell, the lower nasal passage is
formed to 4 years. The mucosa is tender, richly vascularized, so even a slight swelling of
her during the development of rhinitis makes it difficult to breathe through the nose, which
creates difficulties in feeding. Malformation cavernous (cavernous) tissue-podslizis that
shell makes rare nasal bleeding in young children. Erectile tissue develops to 8.9 years. At
this age children can easily arise due to nasal bleeding tenderness mucosa, its vulnerability
and its ample blood supply.

Sinuses to the birth underdeveloped. Formed maxillary (maxillary), ethmoid (grid), and
sphenoid sinuses, but they have very small size. Frontal sinus is absent. These features
determine the rarity of sinusitis in infants. Complete formation of cavities occurs by 15
years.

Pharynx and larynx

Pharynx in the newborn is relatively narrow. Lymphoid ring is weak. After a year of
palatine tonsils extend beyond the arches, but the crypt of them are poorly developed, so
angina young children are rarely sick. Much more often in children reveal the expansion
epipharungeal lymphoid tissue (adenoids), which hampers the normal nasal breathing
children. Long-lived adenoids lead to the formation of the characteristic "adenoid face":
constantly open mouth, lack of nasal breathing, some puffiness face.

Larynx in children has a funnel shape, relatively narrow, and cartilage is soft and
supple. Vocal cords are shorter than adults, which determines the character voices. Up to 3
years old form of the larynx is the same for boys and girls. Then the boys corner connection
plates thyroid cartilage is more acute than in girls. Over time, the cords are much longer
(especially to 10.12 years). Narrow lumen, rich vaskulyari-tion and the tendency of the
mucosa to determine the swelling propensity of young children to stenosing laryngitis.

Breast

Chest newborn has a more rounded shape than in older children: sagittal size almost equal
to the cross. With age anteroposterior size gradually decreases. The inner surface of the
thorax is covered with parietal pleura adjacent to ribs, diaphragm and passing on the
mediastinum. Each lung is enclosed in a separate visceral pleural sac. Pleural cavity
contains a small amount of fluid, which facilitates the movement of the lungs during
inhalation and exhalation. In pathological conditions pleural cavity may contain gas
(pneumothorax) or fluid (pleural effusion), blood (hemopleura) or pus (pyothorax,
empyema). Inflammation of the esophagus causing pain during breathing.

In young children, unlike adults, the ribs are connected to the spine more horizontally
(almost at a right angle). Epigastric angle obtuse. These features, coupled with weak
respiratory muscles account for a small tour of the chest and superficial
breathing. Features of the anatomical structure of the chest rise predominantly
diaphragmatic breathing character in infants and children during the first months of
life. Newborn aperture decreases slower and weaker than that of older children.

With the growth of the child cross section of the chest takes an oval shape. Increasing the
size of its frontal, sagittal relatively decreases. Increasing the curvature of the
ribs.Epigastric angle becomes more acute. Being developed elastic structure of the lung
tissue, increases the efficiency of ventilation.

Trachea and bronchi

Newborn trachea is funnel-shaped form. Its skeleton consists of 14-16 cartilaginous

semirings connected behind a fibrous membrane (instead of closing the elastic plate in
adults).The diameter of the trachea varies during the respiratory cycle, and during
coughing. The softness of cartilage of the larynx, poor development of elastic tissue and
high mobility may lead to its slit spadeniyu and the emergence of noisy snoring breathing
(stridor).

Bronchial tree to the birth formed. The basis of the bronchi are cartilaginous semiring
connected fibrous membrane. The trachea divides into right and left main bronchi. The
right main bronchus is

Borders shares light

Front Rear
Right lung: Right and left lungs:
 IV over the edge - upper lobe; over the spina scapulae - upper lobe;
IV under the edge - the average percentage. under the spina scapulae - a lower proportion
The left lung: upper lobe

smaller angle with the trachea than the left, so if aspirated foreign body often falls into the
right bronchus.

The mucous membrane of the bronchi and bronchioles, tender, rich in blood vessels,
covered with a thin layer of mucus, is lined with multi-row cylindrical ciliated epithelium,
providing evacuation of mucus.

Newborn respiratory tract contain very little smooth muscle, but in children 4-5 months of
muscle tissue is already sufficiently developed. Because of the underdevelopment of the
muscular and elastic tissue in infants, effects are less severe bronchial spasm, bronchial
obstruction associated mainly with a swelling of the mucous membrane and produce a
viscous secretion.

Light

Lungs in children as in adults, have a segmental structure, but aci-nusy

underdeveloped. The birth of the lungs contain about 60 million primary alveoli, their
number is increasing rapidly in the first 2 years of life. Then the rate of growth is slowing,
and by 8-12 years in the number of alveoli is approximately 375 million, which
corresponds to the number of alveoli in adults.

Lungs in infants, are rich in connective tissue, are abundant blood supply, elastic tissue is
poorly developed. Because of this, light a small child less air and fuller than in adults. These
factors predispose to obstruction and development atelectases. Atelectases Ease of
development is also due to a small amount of surfactant or low content of lecithin in it,
which is characteristic for immature lungs. Lack of surfactant - one of the reasons
neraspravleniya lungs in premature babies.

The right lung has 3 lobe (upper, middle and bottom), left - 2 (upper and lower). Middle
lobe of right lung corresponds to the proportion of reed left lung. The boundaries between
the lobes of lungs (Table 2-4) are as follows:

is an upper front left, right - the upper and middle lobe (the boundary between them
passes through the edge IV);

on the right side are determined by 3 shares left - 2 shares;

back on both sides are the upper and lower portion; boundary between them passes
through a line drawn on the spina scapulae, to its intersection with the spine.
Table 2 -4. Borders shares light

In the right lung distinguished 10 segments in the left - 9 (Figure 2-11).

Right lung: apical segment (upper lobe, 1), posterior segment (II), anterior segment (III),
the lateral segment (IV), the medial segment (V), apical segment (the lower the share, VI),
medial basal segment (VII ), anterior basal segment (VIII), lateral basal segment (IX),
posterior basal segment (X).

The left lung: apical-posterior segment (I + II), anterior segment (W), upper lingular
segment (IV), lower lingular segment (V), apical segment (the lower the share, VI), medial
basal segment (VII), anterior basal segment (VIII), lateral basal segment (IX), posterior
basal segment (X).

Mediastinum

Mediastinum in children is relatively greater than in adults. In its upper part, it enters the
trachea, major bronchi, arteries, veins, nerves (J. vagus, truncus sympathicus, n.
laryngeus recurrens, etc.), thymus and lymph nodes. In its lower part is the heart.

The root of lung - an integral part of the mediastinum, consists of large bronchi, blood and
lymph vessels and lymph nodes (near-tracheal, tracheobronchial, bronchopulmonary,
etc.). Compared with older children lymph nodes in the lungs (as well as lymph nodes in
other areas) are distinguished by the relative width of the sinuses, the rich-you
kulyarizatsiey, weak development of the capsule and a large number of major cellular
elements. All these features are favorable for development in these inflammatory
processes.The lymphatic system of the lungs in young children developed very well.

Functional features of the respiratory system

Inventories of oxygen in the body is very limited, they have enough for 5-6 minutes. To
provide the body with oxygen to breath. Beneath the breathing involve the exchange of
gases between the atmospheric air and blood capillaries mezhalveolyarnyh partitions. It is
implemented by simple diffusion of gases through the alveolar-capillary membrane due to
the difference of pressure of oxygen in the inspired (atmospheric) air and venous blood
coming in from the pulmonary artery in the lungs from the right ventricle.

Effectiveness of lung function depends on three processes: ventilation of the alveolar space,
the intensity of capillary blood flow (perfusion) and diffusion of gases through the alveolar-
capillary membrane.

In ensuring adequate ventilation involving nervous, skeletal, muscular, and we pulmonary

system. Violation of the functions of these systems increases the load on the respiratory
system and reduces the efficiency of their operation. Although ventilation consider
involuntary process, a person can control the frequency and depth of
breathing. Involuntary breathing is possible thanks to the automatism of the respiratory
center in the medulla oblongata. Activities of the respiratory center depends primarily on
the partial pressure of oxygen (P a 0 2) and carbon dioxide (p a C0 2) in the blood, and the
leading role is the latter.

Fig. 2-11. Diagram of the segmental structure of the lung: a - right lung, b - left lung. The numbers
correspond to the numbers of segments, (From: Sergienko VI, Petrosyan EA, Frauchi IV Topographic
Anatomy and Operative Surgery. M., 2001.)

4-3029

In the light comes from both the blood circulation. In the small circle from the right
ventricle through the pulmonary artery and blood vessels, gradually decreasing in
diameter, venous blood enters the capillaries mezhalveolyarnye. Here is the diffusion of
oxygen and carbon dioxide. The blood is separated from the alveolar air with a layer of
endothelial cells, the two ba-hall membranes, flat alveolar epithelium and a layer of
surfactant. Then, after gradually increasing in diameter vessels supply blood to the
pulmonary veins and enters the left atrium. Of the systemic circulation through the
bronchial arterial blood enters the artery to supply the lung tissue.

Diffusion occurs due to the difference of partial pressure of oxygen and carbon dioxide in
alveolar air and blood. Oxygen by diffusion from the alveoli enters the pulmonary
capillaries and is transported throughout the body, dissolved in plasma (about 3%) or
combines with hemoglobin (97%). The transport capacity of blood is largely dependent on
the concentration of hemoglobin (each gram of hemoglobin can bind 1.34 ml of
oxygen). The elimination of carbon dioxide from the blood flow in several ways: in the form
of bicarbonate and hydrogen ions, or in combination with certain plasma proteins and
hemoglobin. In the newborn during the first days of life the concentration of Hb higher
than in adults, so the ability of blood to bind oxygen with them more. This allows the infant
to survive a critical period of formation of pulmonary respiration. Is of great importance
and a high content of newborn HbF, having a greater affinity for oxygen than adult
hemoglobin DEFINITIVE (NA, NA 2). After the establishment of pulmonary respiration
concentration of HbF in the blood of children is rapidly declining. However, during hypoxia
or anemia is a compensatory increase in the concentration of HbF.

Breath (internal and external) plays a role in maintaining KSCHS organism. From the lungs
oxygen is transported to tissues and from tissues to the lungs is transported carbon dioxide
formed during cellular metabolism. Carbon dioxide dissolves in the blood to form
bicarbonate and a small amount of carbonic acid. In light bicarbonate is transformed into
carbon dioxide and water excreted in the breath. Respiratory Center, raspolo'zhenny in the
medulla oblongata, controls the content of oxygen and carbon dioxide in the blood.When
the displacement of equilibrium (eg, hypercapnia), under the influence of the respiratory
center to change the frequency and depth of breathing, which leads to the restoration of
normal parameters and p and p 0 2 and C0 2.

MATERIALS AND METHODS OF BREATH

Survey methodology respiratory includes history taking, examination, palpation,

percussion, auscultation, laboratory and instrumental investigations.

Inquiries

History taking includes the identification of patient complaints, the time of their origin and
relation to any external factors. The most common pathology of respiratory sick child (or
his parents) complaining about the following phenomena.

Obstruction of nasal breathing in infants in this case there are difficulties in feeding.

Nasal discharge (serous, mucous, mucopurulent, sukrovichnye, bloody).

Cough (dry or wet). In a survey to determine time of emergence or strengthening of the

presence of cough and its relationship with any triggers. Coughing may be accompanied by
vomiting.

-- Dry cough may be "barking" or paroxysmal.

-- Wet cough is productive (with the office of sputum) and unproductive (please note that
children often swallow the phlegm). When sputum discharge pay attention to its nature
(mucous, mucus-hundred-purulent, purulent), and quantity.

Pain in the chest (note whether the pain associated with breathing).

For questions find out what respiratory diseases before the child was ill, was the contact
with patients with acute infectious diseases, separately asked about contact with patients
with tuberculosis. Is also important allergologic and family history of the subject child.

General examination

The survey begins with a general examination, assessment of consciousness and motor
activity of the child. Then pay attention to the situation of the patient, the color of his skin
and mucous membranes (eg, note the pallor or cyanosis).
 Seen from the person of the child pay attention to the safety of nasal breathing, occlusion,
presence or absence pastosity, discharge from the nose or mouth. Required thorough
examination of the nasal cavity. If the entrance to the nose is stuffed up secretions or
crusts, remove them with a cotton swab. Inspection of the nasal cavity should be
undertaken with caution, since children can easily arise because of nasal bleeding
tenderness and abundant blood supply to the mucosa.

Features voices, shouting and crying of the child helps to judge the state of the upper
respiratory tract. Usually right after the birth of a healthy child makes the first deep breath,
straighten the lungs, and shouting. Loud energetic cry in infants and older children to
eliminate the destruction of the pleura, pleuropneumonia and peritonitis, as these diseases
are accompanied by pain during deep breaths.

Visit throat

Zev inspected at the end of the survey, as with the anxiety caused by the cry of a child and
may interfere with the survey. When viewed from the oral cavity pay attention to the
condition of the throat, tonsils and back of the throat.

In children the first year of life tonsils usually not go beyond the front of the bow.

In preschool children are often observed hyperplasia of lymphoid tissue-term, tonsils are
outside the front of the bow. They are usually dense and the color does not differ from the
mucous membrane of the throat.

If the collection of medical history revealed complaints of cough, during an inspection of

the throat can cause coughing, irritation of the throat with a spatula.

Examination of the chest

On examination, chest draw attention to its form and supporting muscles involved in
breathing.

Evaluate the synchronicity of the movements of both halves of the chest and shoulder
blades (particularly their corners) when breathing. When pleurisy, pulmonary atelectasis,
and chronic pneumonia with unilateral localization of the pathological process may be
noted that one of the halves of the chest (on the affected side) during respiration lagging
behind.

It is also necessary to assess the respiratory rhythm. In a healthy term infants are
possible instability of rhythm and short (up to 5 s) the cessation of breathing (apnea). At
the age of 2 years (especially during the first months of life) respiratory rate may be
incorrect, especially during sleep.
 Pay attention to the type of breathing. For young children characterized by abdominal
breathing. The boys in the future type of respiration does not change, but the girls from 5
to 6 years of age appears thoracic type of respiration.

NPV (Table 2-5) is more convenient to count for 1 min during the sleep of the child. In
newborn and young children can use a stethoscope (bell kept near the nose of the
child).The younger the child, the higher the NPV. Newborn superficial respiration is offset
by its high frequency.

Value NPV and heart rate in healthy children in the first year of life is 3-3,5, ie per
respiratory movement must 3-3,5 heart rate, in children over the year - 4 of cardiac
contraction.

Table 2-5. Age norms frequency of respiratory movements

Age NPV, in a moment

Newborn 40-60
1 year 30-35
5-6 years 20-25
10 years 18-20
Adult 16-18

Palpation

For the palpation of the chest, both hands symmetrically applied to the investigational
sites. Squeezing the chest from front to back and sides, determine its resistance. The lower
the age of the child, the more pliable chest. With an increased resistance of the chest
indicate rigidity.

Voice tremor - the resonant vibration of the chest wall of the patient in the pronunciation of
sounds (preferably low-frequency), which is perceived by hand palpation. To assess voice
shaking hands also have symmetrically. Then the child was asked to pronounce the words,
causing maximum vibration of the vocal chords and resonating structures (for example,
"thirty-three, forty-four", etc.). Young children a voice tremor can be studied during a
screaming or crying.

Percussion

In light percussion, it is important to position the child was correct, providing symmetrical
arrangement of both halves of the rib cage. If the wrong position on percussion sounds
symmetrical sections will be different, which may give rise to erroneous evaluation of the
data. For percussion backs appropriate to invite the child to cross his arms and bend
forward slightly at the same time, with percussion of the anterior surface of the chest child
lowers his hands along the body. Front surface of the chest in infants percuss easier when
the child lies on his back. To put the child back percussion, with small children someone
has to maintain. If the child is not able to keep your head, it can percuss, laying on his
stomach on a horizontal surface or his left hand.

There are direct and indirect percussion.

Direct percussion - percussion percussion with his finger (mostly middle or index)
directly on the surface of the patient's body. Plessesthesia often used during the
examination of young children.

Indirect percussion - percussion finger on the finger of the other hand (usually on the
phalanx of the middle finger of the left hand), tightly enclosed palmar surface of the
examined surface of the body of the patient. Traditionally percussion blows causing the
middle finger of his right hand.

-- Percussion in young children should be weak blows, because due to the elasticity of the
chest and its small size percussion concussion too easily transmitted to remote stations.

-- Since the intercostal spaces in children narrow (as compared with adults), finger-
plessimeter should be placed perpendicular to the ribs.

For percussion healthy lungs obtained clear lung sounds. At the height of inspiration, this
sound becomes even more clear, the peak expiratory flow somewhat shortened. At
different parts of a percussion sound is uneven. The right in the lower divisions because of
the proximity of the liver sound is shortened, to the left due to the proximity of the stomach
takes timpanichesky shade (so-called space Traube).

The boundaries of the lungs. Determining the height of the tops of the lungs begin
standing in front. Finger-plessimeter placed over the clavicle, the terminal phalanx of
touching the outside edge of the sternoclavicular-mastoid muscle. Percussing of finger-
plessimeter, moving it up to the shortening of the sound. Normally, this area is 2-4 cm
above the midpoint of the clavicle. Boundary is drawn along the side of the finger-
plessimeter, overlooking the clear sound. Behind percussion performed on the tops
of spina scapulaetoward the spinous processes of Su,,. At the first appearance of
shortening of a percussion sound percussion stop. In a normal standing height of the tops
of the rear is defined at the level of neural processes of C v ". The upper boundary of the
lungs in children of preschool age can not determine, as the tops of the lungs are over
collarbones. The lower boundary of the lungs are shown in Table 2-6.

Table 2-6. Percussion border of the lower edges of the lungs

Percussion border the lower edges of light

Line body Right Left
Sredneklyuchichnaya VI rib It forms a recess corresponding to the boundaries of the heart, moving away
from the chest at the height VI rib and descends steeply down

Front axillary VII rib VII rib

Average axillary VIH-IX VII-IX rib
rib
Posterior axillary IX rib IX rib
Shoulder X ray X ray

Paravertebral At the level of neural processes of T x,

The mobility of the lower edge of the lungs. First a percussion are the lower limit of light
on the middle or posterior axillary line. Then, ask your child to breathe deeply and hold
your breath, determine the distance the lower edge of the lung (a mark shall, at the side of
the finger, turned to a clear percussion sound). Similarly, define the lower limit of light in a
state of exhalation, which asks the patient to exhale and hold your breath.

Ausk / ltatsiya

Auscultation position of the child is the same as in percussion. Listen to symmetrical parts
of both lungs. Normally children up to 3-6 months listen attenuated vesicular breathing,
from 6 months to 5-7 years - pu-erilnoe (breathing noise louder and longer during both
phases of respiration).

Features of the structure of respiratory organs in children, accounts for the presence
puerilnogo breathing are listed below.

A short distance from the glottis to the point of auscultation of the small size of the chest,
which leads to partial listening of the respiratory noise of the larynx.

The narrow lumen of the bronchi.

Our flexibility and small thickness of the chest wall, increasing its vibration.

Significant development of the interstitial tissue, lung tissue decreases the lightness.

After 7 years of breathing in children gradually acquire the character of vesicular.

Bronhofoniya - conducting sound waves from the bronchi in the chest, determined by
auscultation. The patient speaks in a whisper words that contain the sounds "sh" and "h"
(eg, "cup of tea"). Bronhofoniyu necessarily exploring over symmetrical parts of the lungs.
INSTRUMENTAL AND LABORATORY STUDIES

X-ray and radiological

To study the respiratory system in children is most often used chest x-rays, CT (usually
used for a detailed investigation of the roots of the lungs), X-rays of paranasal sinuses,
bronhografiyu, pulmonary arteriography and / or aortography (assess the state of
pulmonary circulation), radioisotope scanning of the lungs.

Endoscopic techniques

To study the glottis spend laryngoscopy. Young children spend a direct laryngoscopy under
general anesthesia. In older children using indirect laryngoscopy (using mirrors).

Bronchoscopy in young children spend with hard broncho-osprey under anesthesia. Older
children may conduct fibrobronhosko-FDI under local anesthesia in nasal mucosa.

Microbiological Methods

Explores swabs from throat and nasal, bronchial secret. If necessary to

bakterioskopicheskoe and bacteriological study of pleural fluid.

Allergic methods

Apply skin (ointment, sponge), vnutrikozh-WIDE and provocation tests with allergens.
Determines the total content of IgE and the presence of specific IgE and IgG to various Ag.

An investigation of external respiration

With spirography determine the vital capacity (VC), total lung capacity, inspiratory reserve
volume, expiratory reserve volume, functional residual capacity, residual volume, air
velocity in expiration or inspiration (FZHEL, FEV,, peak flow 25, 50, 75% of VC).

Determination of blood gas

Define p and p 0 2 and C0 2 and pH of capillary blood. If you need long-term continuous
monitoring of blood gas hold percutaneous determine blood oxygen saturation (S a 0 2) in
the dynamics.

SEMIOTICS lesions BREATHING IN CHILDREN

Stimulated situation is typical of an attack of bronchial asthma. Child is sitting, leaning his
hands on the edge of the bed, with raised shoulders. Excitation and motor agitation appear
at stenosing la ringotraheite and attack of asthma.
Cyanosis. The degree of cyanosis, its localization, the constancy or growth in a scream or
cry of a baby can judge the degree of respiratory failure (p less than 0 and 2, the more
pronounced and extended cyanosis).

Typically, lung increased cyanosis during crying, because breath holding leads to
pronounced decrease in P and G r

Acute respiratory disorders (stenosing laryngotracheitis, foreign body in the bronchi,

rapidly progressive pneumonia, ex-sudativny pleurisy, etc.) usually cause a general
cyanosis.

Acrocyanosis more characteristic of chronic diseases. Deformation of the fingers in the

form of "drumsticks" (clubbing) indicates a stagnation in the lesser circulation, chronic
hypoxia. This symptom is characteristic of children with chronic lung disease.

The expansion of the surface capillary network in the skin of the back and chest
(symptom Frank) may indicate an increase in tracheobronchial lymph nodes. Pronounced
vascular network in the skin of the breast is sometimes a symptom of hypertension in the
pulmonary artery.

Inspection of individual patient often provides important diagnostic information.

Pallor and puffiness face, open mouth, malocclusion is often in preschool and school age
in the adenoids.

Pale and pasty face, including eyelids (due to violations of lymph drainage), cyanosis of
the lips, swollen skin veins, hemorrhages in the conjunctiva and subcutaneous tissues - are
often signs of frequent or prolonged cough (pertussis with chronic nonspecific lung
diseases).

Foamy allocation in the corners of the mouth are in young children (up to 2 to 3 months
of age) with bronchiolitis and pneumonia due to infiltration of inflammatory exudate from
the lower respiratory tract in the oral cavity.

Particular attention should be given to inspection of the nose and nasal cavity.

-- Swelling of the wings of the nose (in young children is the equivalent of supporting the
participation of muscles in the act of breathing) indicates respiratory failure.

-- Clear mucous discharge from the nose is usually detected at an acute catarrhal
inflammation of the mucous membrane of respiratory tract (eg, acute rhinitis or flu) and
allergic rhinitis.

-- Muco-purulent discharge mixed with blood (sukrovichnye allocation) are characteristic

of diphtheria and syphilis.
-- The presence of the film is dirty-gray color on the nasal septum allows the diagnosis of
diphtheria of the nose to the bacteriological study.

-- Bloody discharge from one nasal passage caused by ingestion of a foreign body (bones,
seeds, buttons, etc.).

-- Breathing through the mouth, especially at night, celebrate with adenoids; for them is
also characteristic of the child snores during sleep.

Features screaming and a child's voice changes observed in many diseases.

Creek and painful cry - often signs of otitis media. Pain (hence the tears) increases with
pressure on tragus, swallowing and sucking.

The monotonous cry, sometimes interrupted by a single sharp outcry, occurs in children
with increased intracranial pressure (eg, meningitis, encephalitis).

A weak, squeaky cry baby cry or not makes think about the overall weakness of the child
(on the background of disease) or severe birth trauma.

Hoarse voice or aphonia (lack thereof) may be a manifestation of pathology mucosal

lesions of the larynx and vocal cords.

Nasal shade (snuffle) vote is chronic rhinitis, adenoids, retropharyngeal abscess, paresis
of the velum (eg, diphtheria).

Cough, often accompanied by respiratory disease, can have many shades.

Robust barking cough happens when catarrhal inflammation of the mucous membrane of
the larynx (with true and false croup).

Agonizing dry cough, growing in the conversation and the cries of the child, watching in
the early stages of bronchitis, as well as with tracheitis.

In resolving bronchitis cough becomes wet, began to separate sputum.

Any damage to the pleura and pleuropneumonia occurs painful short cough, growing at a
deep breath.

With a significant increase in bronchial lymph nodes, cough gets bitonalny

character. Bitonalny cough - spastic cough, which has a rough main tone and musical high-
second tone.It arises from the stimulation of cough zone bifurcation of the trachea enlarged
lymph nodes or tumors of the mediastinum and accompanies tuberculous bronhadenit,
lymphogranulomatosis, lymphosarcoma, leukemia, tumors of the mediastinum (timomu,
sarcoma and others).

Agonizing dry cough occurs with pharyngitis and nasopharyngitis. Indirect symptom of a
spastic fits of coughing in a child - sore on the hyoid bond (bridle language), arising from
injury to her incisors during coughing.

Inflammation of the tonsils (bluetongue, follicular, or lacunary angina, see Chapter 23

"Quinsy") reveal when viewed throat.

Bluetongue angina is manifested by flushing throat, swelling arches, swelling and

loosening of the tonsils. Usually catarrhal sore throat accompanied by ARI.

When tonsillitis against a background of bright flushing, diarrhea and an increase in the
tonsils are visible on the surface point (or having a small size) overlay, usually white or
yellowish color.

When lacunar angina inflammatory exudate is seen in white in the gaps, hyperemia of the
tonsils is also bright. Follicular and the lacunarity angina usually have a bacterial etiology
(for example, streptococcal or staphylococcal).

For diphtheria the throat on the tonsils usually reveal a dirty-gray plaque with moderate
hyperemia. If you try to raid spatula mucous membrane bleeding, and plaque is removed
very bad. The shape of the chest may vary in certain lung diseases.

In severe obstructive diseases (asthma, cystic fibrosis) before-nezadny size increases,

there is a so-called "barrel" shape of the chest.

When pleural effusion on the affected side note the bulging of the chest, and in chronic
pneumonia - zapadenie. Indrawing yielding seats of the chest shows the disorder of the
airways, accompanied by inspiratory dyspnea. Significant indrawing of intercostal gaps,
jugular fossa during inspiration is characteristic of stenotic breathing with croup.

The asymmetry of chest excursion. In pleurisy, pulmonary atelectasis, pneumonia,

chronic unilateral localization can be seen that one of the halves of the chest (on the
affected side) behind breathing.

The rhythm of breathing: the peculiar rhythm disturbances of respiration are known as
Cheyne-Stokes respiration and biota (see Chapter 33, Disorders of consciousness "). Such
violations are detected in children with severe meningitis and encephalitis, intracranial
hemorrhage in newborns, uremia, poisoning and t. E.

When breathing Cheyne-Stokes breathing after a pause, resume, first is superficial and
infrequent, then its depth with each breath increases and the pace is accelerating, reaching
a maximum breathing gradually slowed down, it becomes superficial and again stopped for
a while. In infants breathing Cheyne-Stokes equations may be an option rules, especially
during sleep.

Breath Biota is characterized by alternating uniform rhythmic breathing and prolonged

(up to 30 seconds or more) pauses.

NPV varies with many diseases of respiratory organs.

Tachypnea - increased frequency of breathing (NPV exceeds the age limit of 10% or
more). In healthy children there with excitement, physical exertion, etc. Tachypnea at rest
is possible with extensive lesions of the respiratory and cardiovascular systems, blood
diseases (eg, anemia), fever diseases, etc. Breathing becomes more frequent, but it becomes
superficial in all cases associated with painful deep breaths, which usually indicates a
lesion of the pleura (eg, acute pleuritis or pleuropneumonia).

Bradypnea - reduction NPV, very rarely diagnosed in children (in childhood usually
occurs when the oppression of the respiratory center). Usually this happens when
comatose states (eg, uremia), poisoning (eg, hypnotics drugs), increased intracranial
pressure, and the newborn - in the terminal stages of the syndrome of respiratory failure.

Value NPV and heart rate changes with the defeat of the respiratory system. Thus, in
pneumonia, it becomes equal to 1:2 or 1:3, as well as breathing becomes more frequent in
more than a heartbeat.

Shortness of breath is characterized by difficulty breath (inspiratory dyspnea) or

exhalation (expiratory wheezing) and represents a subjective feeling of lack of air.

Inspiratory dyspnea occurs during upper airway obstruction (croup, foreign bodies, cysts
and tumors, congenital narrowing of the larynx, trachea or bronchus, retropharyngeal
abscess and T. Etc). Shortness of breath during inspiration clinically manifested
epigastrium indrawing, intercostal intervals, and supraclavicular jugular pits and voltage
sternoclavicular-mastoid muscle (ie sternocleidomastoideus) and other supporting
muscles. Early childhood equivalents of breathlessness are fanning the wings of the nose
and nodding head movements.

Expiratory dyspnea characterized by difficult expiration and active participation of the

abdominal muscles. Thorax inflated, the respiratory excursions are reduced. Expiratory
dyspnea observed in bronchial asthma, asthmatic bronchitis and bronchiolitis, as well as
obstacles to the passage of air below the trachea (eg, in large bronchi).

Mixed breathlessness (expiratory-inspiratory) manifested swelling chest indrawing and

yielding seats of the chest. It is typical of bronchiolitis and pneumonia.
Changing voice shaking.

Strengthening the voice tremor associated with sealing of lung tissue (dense tissue
conducted sound better).

Voice tremor diminished when an occlusion of the bronchus (lung atelectasis) and the
marginalization of the bronchi of the chest wall (fluid, pneumothorax, pleural tumor).

Changes percussion sound is of great diagnostic value. If percussion is easily obtained is

not clear lung sounds, and more or less subdued, the talk of shortening, blunting or
absolute stupidity (depending on mute percussion sound).

Shortening percussion sound occurs for the following reasons. - Reducing airy lung
tissue:

About the inflammatory process in the lung (infiltration and edema of the alveoli and
mezhalveolyarnyh partitions);

About hemorrhage in lung tissue;

Considerable pulmonary edema (usually in the lower divisions);

On the presence of scar tissue in the lungs;

About spadenie lung tissue (atelectasis, compression of the lung tissue of pleural fluid,
greatly enlarged heart or tumor).

-- Education in the airless lung tissue: On the tumor;

On the cavity containing the fluid (mucus, pus, etc.).

-- Filling the pleural space than ever:

About exudate (with pleural effusion) or transudate; About fibrinous pleural imposed on
the sheets.

Timpanichesky nuance of sound appears in the following cases.

-- Education containing air cavities:

On the destruction of lung tissue in the inflammatory process (cavity in pulmonary

tuberculosis, abscess), tumors (decay), cysts; About diaphragmatic hernia; About
pneumothorax.

-- Lowering the elastic properties of lung tissue (emphysema).

-- Compression of light above the location of fluid (pleural effusion and other forms of
atelectasis).

-- Pulmonary edema, thinning of the inflammatory exudate in the alveoli.

Boxed sound (loud percussion sound with timpanicheskim tint) appears when the
elasticity of lung tissue is weakened, and its lightness increased (emphysema).

Lower mobility edges of light is accompanied by the following states.

Loss of elasticity of lung tissue (emphysema, bronchial asthma).

Shrinkage of lung tissue,

Inflammation or swelling of lung tissue.

Adhesions between the pleural leaves.

Complete disappearance of the mobility edge can easily be observed in the following
cases.

Filling the pleural cavity fluid (effusion, hydrothorax) or gas (pneumothorax).

Full imperforate pleural cavity.

The paralysis of the diaphragm.

Pathological types of breathing occur in many diseases of the respiratory system.

Bronchial breathing is characterized by coarse tint and the predominance of expiration of

the breath and the presence of the respiratory noise sound "x".

-- In interscapulum increases sharply exhale compression of light, such as large packages

bronchopulmonary lymph nodes in mediastinite.

-- Bronchial breathing in other places of light often indicates the presence of inflammatory
infiltration of lung tissue (pneumonia, tuberculosis infiltrative processes, etc.) often listen
to it over the pleural exudate of squeezed his lung.

Bronchial breathing becomes loud blowing nature of air cavities with smooth walls
(cavity, revelations abscess, pneumothorax), and in these cases is called "amforicheskoe
breath.

Weakened breathing may be due to the following reasons.

-- The general weakening of the respiratory act with a decrease in income in the alveoli air
(strong narrowing of the larynx, trachea, paresis of the respiratory muscles, etc.).

-- Difficult access of air in a certain part of the share or share with the formation of
atelectasis due to obturation (eg, foreign body), compression of the bronchus (tumors, etc.),
significant bronchospasm syndrome obstruction caused by edema and accumulation of
mucus in the lumen of the bronchi.

-- The ousting of the lung in accumulation of fluid in the pleura (pleurisy fluids-tion), air
(pneumothorax), with easily loose inside, the alveoli during breathing do not straighten.

-- Loss of lung tissue elasticity, rigidity (low mobility) of the alveolar walls (emphysema).

-- Significant thickening of the pleura (when resorption of fluid), or obesity.

-- Initial or final stage of inflammation in the lungs with only a violation of elasticity of lung
tissue without its infiltration and compaction.

Increased respiration detected in the following cases.

-- Narrowing of small or the smallest bronchi (gain occurs due to expiration), inflammation
or spasm (attack of bronchial asthma, bronchiolitis).

-- Feverish illness.

-- The compensatory increase in respiratory healthy side in the case of a pathological

process to another.

Rigid breath usually indicates a failure of small bronchi occurs with bronchitis and
lobular pneumonia. In these diseases, inflammatory exudate reduces the lumen of the
bronchi, which creates conditions for the emergence of this type of breathing.

Wheezing. Pathologic processes in the lungs accompanied by various wheezing. Rales

better heard at a height of inspiration.

Dry rales are whistling (treble, high) and bass (low, more music). The first tend to occur
when luminal narrowing of the bronchi, especially small, the latter formed from
fluctuations in the thick phlegm, especially in the major bronchi. Dry rales different
volatility and variability are characteristic of laryngitis, pharyngitis, bronchitis, asthma.

Moist rales are formed during the passage of air through the liquid. Depending on the
caliber of the bronchus, where they are formed, rales are finely, and srednepuzyrchatymi
krupnopuzyrchatymi. Also, moist rales are divided into voiced and nezvonkie.
-- Voiced moist rales bugged during compaction of the lung tissue, which lies close to the
bronchi (eg, pneumonia). They may occur in the cavities (cavities, bronchiectasis).

-- Nezvonkie wheezing meet with bronchiolitis, bronchitis, pulmonary edema, atelectasis.

Crepitus in contrast to wheeze formed by razlipanii alveoli. Locally defined crepitation

indicates pneumonia. In lobar pneumonia differentiate crepitatio indux (start crackling in
the first 1-3 days of illness) and crepitatio redux (a crackling, identified in the permit
stages of pneumonia and fluid resorption - to 7-day 10 of illness).

Noise pleural friction that occurs during sliding of visceral and parietal sheets, listen to
the following pathological conditions.

Inflammation of the pleura, with its coated with fibrin or her education at the centers of
infiltration, leading to the formation of irregularities, roughness pleural surface.

Education gentle pleural adhesions as a result of inflammation.

Tumor or tuberculosis of the pleura.

Strengthening bronhofonii occurs when compacted lung (pneumonia, tuberculosis,

atelectasis), over the cavities and bronchiectasis cavities, if not corked leading
bronchus. When compaction of lung tissue due to increased bronhofonii best holding votes,
and in cavities - resonance.

Weakening bronhofonii watch with a good development of the muscles of the upper
shoulder girdle and excessive subcutaneous adipose tissue, as well as the presence of fluid
in the pleural cavity (swampy pleurisy, hydrothorax, hemopleura) or air (pneumothorax).

Features of the localization of the pathological focus in pneumonia in

children

In children, pneumonia, most often localized in certain market segments, due to the
peculiarities of aeration of these segments, the drainage function of bronchi, the evacuation
of these secretions and the possibility of getting infections.

Early childhood center pneumonia most often localized in the apical segment of lower
lobe. This segment is to a certain extent isolated from the other segments of the lower lobe,
and its segmental bronchus departs higher than others and are at right angles and straight
back. It creates conditions of poor drainage, as well as children of the first year of life is
usually a long time are in a supine position.

Also, the pathological process is often localized in the posterior (II) segment of the upper
lobe and posterior basal (X) segment of lower lobe.
 A special place is occupied by the defeat of the middle lobe (so-called "mid-shared
Syndrome"). Average lateral (4 th) and anterior (5 th) segmental bronchi are located in the
bronchopulmonary lymph nodes, have a relatively narrow lumen, a considerable length
and depart at a right angle. Consequently, the bronchi are compressed easily enlarged
lymph nodes, which can cause a sudden disabling much of the respiratory surface and the
development of respiratory failure.