Learning Issues
Retractions
O2 Sat:
Oxygen saturation normal range Child
Normal oxygen saturation limit in children may
change by age and altitude (20,21). Mean oxygen
saturation is accepted as normal at 93-100% of
moderate altitudes (22, 24).
Source:
https://www.researchgate.net/publication/7866114_N
ormal_oxygen_saturation_values_in_pediatric_patien
ts
FYI Pedia: 95%
The lower the oxygen level, the more severe the
hypoxemia. This can lead to complications in body
tissue and organs. Normally, a PaO2 reading below 80
mm Hg or a pulse ox below 95 percent is considered
low.
Source: https://www.healthline.com/health/normal-
blood-oxygen-level
Ideal Weight formula: Age in years x 7 - 5 /2
Source: Soronio, 2017. FYI Pedia. 3rd ed.
Retractions Locations:
Retractions are classified by their location.
 Subcostal retractions: Indrawing of the
abdomen just below the rib cage (sometimes
referred to as belly breathing).
 Substernal retractions: Indrawing of the
abdomen just below the sternum
(breastbone).
 Intercostal retractions: Indrawing of the
skin in between each rib
 Suprasternal retractions (tracheal tug):
Indrawing of the skin in the middle of the
neck above the sternum (breastbone).
 Supraclavicular retractions: Indrawing of
the skin of the neck above the collarbone.
The location of a patient’s retractions can roughly tell
you where an obstruction is in the respiratory tract. If
the obstruction is in the upper airways, suprasternal
and supraclavicular retractions will be visible. If the
obstruction is in the lower airways, subcostal and
substernal retractions will be visible.
Retractions are usually seen in infants and children
(because their chests are more malleable than adults)
with conditions like bronchiolitis and croup, but
patients with asthma, anaphylaxis, pneumonia, or
epiglottitis can have retractions at any age. Seeing
retractions on a patient is usually serious.
indicate the patient is working very hard to breath
and soon maybe become too tired to continue
breathing.
Source:
https://www.khanacademy.org/science/health-and-
medicine/respiratory-system-diseases/intro-to-
pulmonary-diseases/a/respiratory-distress
Inspiratory wheezing
Wheezing upon inhalation
Common causes include infection, an allergic
reaction or a physical obstruction, such as a tumor or
a foreign object that's been inhaled.
Other tests:
 Spirometry: You blow into a device that shows
how well your lungs are working.
 Chest x-ray: This scan uses small amounts of
radiation to create a picture of your lungs. A chest x-
ray can look for growths in your lungs that might be
causing your symptoms.
 Sputum tests: The doctor will take a sample of
the mucus you cough up from your lungs. The
sputum is tested for bacteria to find out if you have
an infection.
Test for IgE
An immunoglobulin E (IgE) test measures the level
of IgE, a type of antibody. Antibodies are made by
the immune system to protect the body from bacteria,
viruses, and allergens. IgE antibodies are normally
found in small amounts in the blood, but higher
amounts can be a sign that the body overreacts to
allergens.
Normal chest xray
The airway, or trachea, should be midline without
any deviation or stenosis after taking into account
any rotational variations. PA view
On the PA chest-film it is important to examine all
the areas where the lung borders the diaphragm, the
heart and other mediastinal structures.
At these borders lung-soft tissue interfaces are seen
resulting in a:
  Line or stripe - for instance the right para
tracheal stripe.
 Silhouette - for instance the normal
silhouette of the aortic knob or left ventricle

These lines and silhouettes are useful localizers of

disease, because they can be displaced or obscured
with loss of the normal silhouette. This is called the
silhouette sign, which we will discuss later.

The paraspinal line may be displaced by a

paravertebral abscess, hemorrhage due to a fracture
or extravertebral extension of a neoplasm.

Widening of the paratracheal line (> 2-3mm) may be

due to lymphadenopathy, pleural thickening,
hemorrhage or fluid overload and heart failure.

Displacement of the para-aortic line can be due to

elongation of the aorta, aneurysm, dissection and
rupture.

The anterior and posterior junction lines are formed

where the upper lobes join anteriorly and posteriorly.
These are usely not well seen and we will not discuss
them.

An important mediastinal-lung interface to look for is

the azygoesophageal line or recess (arrow).

The azygoesophageal recess is the region inferior to

the level of the azygos vein arch in which the right
lung forms an interface with the mediastinum
between the heart anteriorly and vertebral column
posteriorly.
It is bordered on the left by the esophagus.

Deviation of the azygoesophageal line is caused by

(5):

 Hiatal hernia
 Esophageal disease
 Left atrial enlargement
 Subcarinal lymphadenopathy
 Bronchogenic cyst

Chest X-ray or CT scan of the chest will show an
intact diaphragm with elevation of a portion or one
side (left or right) of the diaphragm muscle.
The diaphragm separates the comparatively dense
(whiter) abdominal organs below it, from the
relatively less dense (blacker) lung above. Each
hemidiaphragm should appear as a rounded, domed
structure with a crisp white edge contrasted against
the adjacent dark lung.
Flattening of the diaphragm is the most sensitive
sign on chest radiographs for the presence of
hyperinflation of the lungs.
ABG Results
Asthma vs Bronchitis:
Both asthma and bronchitis can cause these
symptoms:
 wheezing, or a whistling sound when you
breathe
 shortness of breath
 coughing
 tightness in the chest
If you have bronchitis, you’ll produce a thick, goopy
substance called mucus when you cough. The mucus
can be clear, yellow, or green.
Acute bronchitis also causes these symptoms:
 low fever, or a temperature of 100°F
(37.7°C)-102°F (38.8°C)
 chills
 body aches
In acute bronchitis, the cough, chest tightness, and
wheezing usually last for a few days to a few weeks
until the infection clears up. Chronic bronchitis
symptoms continue long-term.
Symptoms of asthma come and go. Some people may
have asthma that’s triggered by certain events, such
as exercise, allergies, or even your workplace.
Causes
Doctors don’t know exactly what causes asthma. It
may be from a combination of genes and the
environment. Genes you inherit from your parents
may make your airways more sensitive to allergic
triggers like smoke, pollen, and pet dander.
You’re more likely to get asthma if:
 your parents have asthma or allergies
 you had a lot of respiratory infections as a
child
 you have allergies or the skin condition
eczema
 you are regularly exposed to chemicals or
dust at work
 you smoke or are often around someone who
smokes
Usually something in the environment sets off asthma
symptoms. Asthma triggers include:

 dust
 mold
 pet dander
 pollen
 pollution
 smoke
 changes in the weather
 cockroaches
 chemical fumes or gases at work
 exercise
 stress
 colds and other infections

Bronchitis can be acute or chronic. Acute bronchitis

is caused by a virus or bacteria. Chronic bronchitis is
triggered by something in the environment, such as:

 tobacco smoke
 chemical fumes
 air pollution
 dust

These substances irritate and inflame the airways.

You’re more likely to get bronchitis if you:

 smoke cigarettes or are exposed to tobacco

smoke
 have a weakened immune system that makes
you more likely to catch infections
 work in an industry where you’re exposed to
dust and chemical fumes, like coal mining,
textiles, or farming
 are over age 45

Management of Asthma
See at the back