As children age, the lung examination becomes similar to that for adults. Cooperation is critical. Auscultation is usually easiest when a child barely notices (as when in a parent's lap). Let a toddler who seems fearful of the stethoscope play with it before it touches the child's chest.

Assess the relative proportion of time spent on inspiration versus expiration. The normal ratio is about 1:1. Prolonged inspirations or expirations are a clue to disease location. Degree of prolongation and effort or "work of breathing" are related to disease severity.

Young children asked to "take deep breaths" often hold their breath, further complicating auscultation. It is easier to let preschoolers breathe normally. Demonstrate to older children how to take nice, quiet, deep breaths. Make it a game. To accomplish a forced expiratory maneuver, ask the child to blow out candles on an imaginary birthday cake or use pinwheels (Fig. 1).

FIGURE 1. Getting a child to perform a forced expiration.

Older children will be cooperative for the respiratory examination and can even go through the maneuvers of assessing fremitus or listening to "E to A" changes. As children grow, the evaluation by observation discussed on the previous page, such as assessing the work of breathing, nasal flaring, and grunting, becomes less helpful in assessing for respiratory pathology. Palpation, percussion, and auscultation achieve greater importance in a careful examination of the thorax and lungs.

Children in respiratory distress may assume a "tripod position" in which they lean forward to optimize airway patency (Fig. 2). This same position can also be caused by pharyngeal obstruction.

FIGURE 2. A child in respiratory distress

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