Access provided by
London Metropolitan University
• To refresh your knowledge of the purpose and components of a respiratory assessment
• To understand the steps involved in undertaking respiratory auscultation with infants and children
• To assist you in interpreting the findings of respiratory auscultation and to recognise when assistance from the medical team is required
Rationale and key points
Respiratory auscultation involves listening to and interpreting sounds from within the chest. Undertaking respiratory auscultation effectively requires appropriate equipment, knowledge of physiology and pathophysiology and experience in listening to and interpreting breath sounds. Nurses undertaking this procedure must ensure they have the knowledge and skills to do so and work within the limits of their competence. This article provides a step-by-step guide that explains how to undertake respiratory auscultation with infants and children aged 0-16 years.
• Respiratory auscultation is an essential procedure for informing differential diagnoses and assessing the trajectory of a child’s illness and response to treatment.
• In children with structurally normal, healthy lungs and a regular breathing pattern, the respiratory sound should be relatively quiet, with regular movement of air along the trachea and bronchioles, in and out of the lungs.
• Any breath sounds heard in unexpected areas requires further investigation, while a complete absence of breath sounds must be treated as a clinical emergency and assistance from the medical team must be sought immediately.
Reflective activity
‘How to’ articles can help to update your practice and ensure it remains evidence based. Apply this article to your practice. Reflect on and write a short account of:
• How this article might improve your practice when undertaking respiratory auscultation with infants and children.
• How you could use this information to educate nursing students or your colleagues on the procedure for undertaking respiratory auscultation with infants and children.
Nursing Children and Young People. doi: 10.7748/ncyp.2024.e1528
Peer reviewThis article has been subject to open peer review and checked for plagiarism using automated software
Correspondence Conflict of interestNone declared
Peto R (2024) How to undertake respiratory auscultation with infants and children. Nursing Children and Young People. doi: 10.7748/ncyp.2024.e1528
DisclaimerPlease note that information provided by Nursing Children and Young People is not sufficient to make the reader competent to perform the task. All clinical skills should be formally assessed according to policy and procedures. It is the nurse’s responsibility to ensure their practice remains up to date and reflects the latest evidence
Published online: 20 August 2024
Respiratory changes, such as alteration in respiratory rate and pattern, are often the most apparent symptoms of illness in infants and children to parents or carers and healthcare professionals (Keeble and Kossarova 2017). Alterations in respiratory rate and pattern may be the result of a respiratory condition or infection, structural abnormalities, or cardiac, metabolic or neurological pathologies (Advanced Life Support Group and Smith 2023). This is the case for most patients, but particularly so in infants and children because they will have anatomical differences to adults, such as a more pliable chest wall and a flatter diaphragm (Trachsel et al 2022), as well as a limited ability to compensate for other changes in their body. The body’s attempt to compensate may present as a change in breathing to improve oxygenation or normalise the acid-base balance (Advanced Life Support Group and Smith 2023).
Auscultation is undertaken as part of a respiratory assessment to determine the cause of respiratory changes and is commonly undertaken by a children’s nurse or another qualified professional, such as a doctor or physiotherapist. A comprehensive respiratory assessment involves:
• Observation – a visual assessment of the chest.
• Palpation – the use of the hands to feel for movement of air and/or secretions during inhalation and exhalation.
• Percussion – tapping of the chest to produce audible sounds that can determine the density of areas within the chest wall.
• Vital signs measurement.
• Obtaining a history of the presenting issue and previous medical history.
The outcome of auscultation is interpreted alongside the information gathered from the other parts of the assessment to inform diagnosis. Respiratory auscultation can also be used to determine the efficacy of treatment and to enhance patient safety, for example by checking for the appropriate placement of an artificial airway (along with end-tidal carbon dioxide measurement) (Advanced Life Support Group and Smith 2023). Therefore, it is important that nurses caring for infants and children develop their respiratory assessment skills, including in undertaking effective auscultation.
This article details the procedure for undertaking respiratory auscultation with infants and children aged 0-16 years, in the context of a planned assessment. In the event of an emergency the practical procedure will remain the same, but the preparation for it will need to be adapted depending on the level of urgency.
• Develop a rapport with the child and their parent or carer. Although this can be time consuming initially, it will make further interactions easier and help them to feel relaxed and comfortable in preparation for the procedure. How the nurse approaches this will depend on the child’s chronological and developmental age; for example, for younger children this may include the use of play or a play therapist, whereas for older children it may involve engaging in general conversation. Using open body language and a friendly, unrushed and collaborative approach is recommended.
• Locate an appropriate environment. The Code: Professional Standards of Practice and Behaviour for Nurses, Midwives and Nursing Associates (Nursing and Midwifery Council 2018) states that nurses must respect people’s right to privacy and confidentiality, and this applies to infants and children in the same way as adults. Where possible, use a private room or draw the curtain around the child’s bed and reassure them that no one will walk in while they are undergoing the procedure. The parent or carer should remain in attendance, depending on the child’s age, or the child may choose to be accompanied by a play therapist or a member of staff who they know well.
• Explain the procedure to the child and their parent or carer so that they understand what will happen and your expectations of them, for example that they will need to try to be quiet while you undertake the auscultation. This is intended to further reassure the child and to support the effectiveness of the procedure. Emotional distress alters the rate and pattern of breathing, while crying or shouting will be heard through the stethoscope, making the auscultation ineffective. In addition, if the child is talkative this will mask their breath sounds. Explain that a stethoscope will be placed against the child’s skin and ascertain whether they are happy to remove their top or if they would prefer to keep it on, in which case the stethoscope can be slipped underneath their clothing. Removing clothing can be a particular concern for older children, whose bodies may be undergoing changes.
• Gain consent for the procedure from the parent or carer, which can be verbal or implied (NHS 2022).
• Ensure the child is in an upright position, if possible. This is the preferred position because it is easier for the child to take deep breaths (Sarkar et al 2015). If this positioning is not possible, for example due to the child’s age, mobility or level of consciousness, the supine position is advised (Proctor and Rickards 2020).
• Select a stethoscope with the appropriately sized chest piece, which is determined by the age and size of the child. Various sizes are available, including neonatal, paediatric and adult (Figure 1). The chest piece of the stethoscope (Figure 2) should be small enough to isolate each lung field but large enough to enable the nurse to hear breath sounds through the chest wall. Electronic stethoscopes are also available, which can amplify sounds for healthcare professionals with hearing impairments.
• Many stethoscopes chest pieces have a bell and a diaphragm side (Figure 2). The diaphragm is the larger and flatter side and should be used for respiratory auscultation because it is more effective in transmitting higher frequency sounds (such as breath sounds) than the bell. The bell side is smaller and more concave and is designed to transmit lower frequency sounds (such as heart murmurs) (Landry 2024).
• Clean the stethoscope chest piece in line with local infection prevention and control guidelines. You should also clean your hands with soap and water or alcohol gel before carrying out the procedure, but it is not necessary to wear gloves unless stipulated by local infection prevention and control policy.
1. Auscultation is usually undertaken after the other aspects of the respiratory assessment.
2. Find a comfortable position. You may wish to sit on a stool or chair so that you are at eye level with the child – standing over a smaller child may feel intimidating. Maintain good posture to avoid unnecessary strain on your back.
3. Place the stethoscope earpieces into your ears, ensuring they are facing forward so that the sounds are directed to your ear canal (Figure 3).
4. Ensure the diaphragm is ‘active’. Only one side of the chest piece can be used at a time, so twist the end of it to activate, or open, the side you want to use. Gently tap the diaphragm to ensure you can hear the sound amplified in the earpieces. If you cannot hear the tap, twist the end of the chest piece and re-check.
5. Warm the chest piece with your hand.
6. Place the diaphragm flat against the child’s skin over the right apex on the front (anterior) of the chest (Figure 4) to listen to the sounds from the lobe of the lung below. Listen for long enough to identify the sounds clearly. Listen for any adventitious sounds (that is, sounds heard in addition to the expected breath sounds, for example crackles or wheezing) (Table 1). You may need to ask the child to take deep breaths. Listen to their inspiration and expiration sounds and do not rush the process.
7. Repeat this over all the lung fields – you are aiming to hear breath sounds in each lung lobe, so place the stethoscope accordingly (Figure 4). For example, the inferior (lower) lobes are more lateral (that is, they lie towards the sides of the chest) so the stethoscope should be placed towards the edges of the chest rather than the centre. Figure 4 shows the chest anatomy (anterior, posterior and lateral) and auscultation points.
8. If the child is lying down, ask or help them to turn onto their side to listen to the lung fields through the posterior chest wall. In addition, think about the way each lung lobe lies within the posterior aspect and avoid placing the stethoscope over the large scapulae (Figure 4), which would obscure the underlying breath sounds.
9. When you have completed the auscultation, document in the child’s clinical notes what you have heard and not heard. This should include a description of the areas of the chest you have listened to, air entry sounds and any adventitious sounds, as well as the date and time. This detailed information will provide a baseline for comparison with subsequent auscultations, if required. Examples of useful terms when documenting the outcome of respiratory auscultation are shown in Table 2.
Respiratory auscultation enables the nurse to listen to the movement of air within a child’s airways through the chest wall; interpretation of the sounds heard will inform differential diagnoses. The sounds heard on auscultation are created by turbulence in the air flow, caused by either the irregular walls within the airways, such as the cartilaginous rings of the trachea, or the branching of the airways as they divide (Sarkar et al 2015). In children with structurally normal, healthy lungs and a regular breathing pattern, the respiratory sound should be relatively quiet, with regular movement of air along the trachea and bronchioles in and out of the lungs. Moreover, the smaller airways, such as the bronchioles, are much smoother in health than in the presence of illness and experience laminar flow, which does not produce any breath sounds (Sarkar et al 2015). Compared with adults, breath sounds will be louder in most infants and children due to their thinner chest walls (Sarkar et al 2015).
Types of breath sounds are differentiated by pitch, caused by the size of the airways the air is moving through – the larger the airways the higher the pitch. For example, the sound of air moving through the trachea (bronchial sounds) is at a higher pitch than the sound of air moving through smaller airways at the periphery of the lung (vesicular sounds) (Sarkar et al 2015). There is an intermediate area over the main bronchi where the sounds, referred to as bronchovesicular, have a mid-range pitch (Zimmerman and Williams 2023). Tracheal sounds are heard directly over the trachea and produce a high-pitched sound, since there is little tissue between the trachea and the stethoscope to dampen the sound (Sarkar et al 2015). The frequency and pitch of breath sounds heard in infants and children will be similar to those heard in adults. Figure 5 shows where to hear breath sounds.
It is useful for nurses to familiarise themselves with breath sounds by regularly undertaking respiratory auscultation on children with no lung pathology as part of a holistic assessment and/or by listening to recorded breath sounds online (see further resources). If any breath sounds are heard in unexpected areas, this requires further investigation. For example, bronchial sounds that are heard over an area other than the trachea could be caused by consolidation, when the air in the small airways is filled with mucus (potentially due to infection) or fluid (such as a pleural effusion) or blocked by a foreign body causing atelectasis (lung collapse) (Sarkar et al 2015).
It is important that the nurse observes and documents the volume of breath sounds, which is dictated by the thickness of the chest wall. In infants, the chest wall is generally thinner than in an older child, who will have developed some muscle and subcutaneous fat, so it is usually easier to hear breath sounds in smaller children. The presence of fluid or tissue between the skin and lungs, such as subcutaneous oedema, subcutaneous fat, blood (for example caused by traumatic haemothorax) or pleural effusion can reduce the volume of the sound heard on auscultation (Advanced Life Support Group and Smith 2023).
The nurse also needs to document absent breath sounds, including the exact location of the absence. If no breath sounds are heard in any lung fields this must be treated as a clinical emergency and the nurse must seek assistance from the medical team immediately. Complete lack of breath sounds could indicate insufficient air flow or obstruction (Advanced Life Support Group and Smith 2023).
Auscultation involves noticing any changes in the expected breath cycle. A normal breath cycle has a 1 (inspiratory):2 (expiratory) ratio (Sembroski et al 2023). Prolonged expiration, such as a 1:4 ratio, may indicate possible obstruction, for example bronchoconstriction in asthma (Advanced Life Support Group and Smith 2023). Changes in the breath cycle may be accompanied by adventitious sounds, which also needs to be noted.
Documentation of the outcomes of respiratory auscultation should be precise and clear, since what is heard may vary on subsequent assessments and recognising this will inform the diagnosis. Respiratory auscultation alone rarely provides a definitive diagnosis and is subjective. However, it is an essential procedure for informing differential diagnoses and assessing the trajectory of the child’s illness and response to treatment (Sarkar et al 2015).
05 September 2024 / Vol 36 issue 5
How play specialists can reduce use of anaesthesia during radiotherapy
Radiotherapy practice is complex and daunting for children....
Nursing care for patients undergoing pelvic exenteration for rectal cancers
Pelvic exenteration is an established surgical procedure...
Oral cancer: diagnosis, management and nursing care
Oral cancer is estimated to be the ninth most common cancer...
Diagnosis and treatment of meralgia paresthetica
Many patients present to emergency departments with lower...
Brain tumours in children: reducing time to diagnosis
Although the leading cause of childhood, cancer-related...
