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Dr. Rudy Ciulianto
Bagian Ilmu Kesehatan Anak
Anatomy of The Respiratory System
• Nose
• Nasal turbinates
– Warm, humidity and filter the inspired air
• Pharynx
– Carry secretions draining from the paranasal sinuses
by the mucociliary action of the ciliated respiratory
• Lymphoid tissue (adenoids)
• Epiglottis
– Protect the larynx during swallowing by deflecting
material toward the esophagus
• Arytenoid cartilages
– Assist in opening and closing the glottis, less
prominent in children than in adults.
• Subglottic space (below glottis)
• Cricoid Trakea

• In children < 3yo, the cricoid ring (1st tracheal

ring and a complete ring) is the narrowest
portion of the airway, and in older children
and adults the glottis is the most narrow.
• Rings of cartilage extending approximately
320⁰ around the airway circumference
support the trachea and mainstem bronchi.
• The posterior wall of the trachea is
• Beyond the lobar bronchi, the cartilaginous
support for the airways becomes
• The right lung:
– Upper, middle, lower
– Comprises approx. 55% of the total lung volume
• The left lung:
– Upper, lower
– The inferior division of the left upper lobe, the
lingula, is analogous to the right middle lobe
• A full term infant has approx. 25 million
alveoli; an adult nearly 300 million.
• Most growth of new alveoli occurs during the
first 2 years of life and is complete by 8 years
of age after which lung volume increases with
linear growth, but new alveoli are not usually
Pulmonary Physiology
• Pulmonary Mechanics
– The major function of the lungs is to exchange
oxygen (O2) and carbon dioxide (CO2) between
the atmosphere and the blood.
– The anatomy of the airways, mechanics of the
respiratory muscles and rib cage, nature of the
alveolar-capillary interface, pulmonary circulation,
tissue metabolism, and neuromuscular control of
ventilation all influence gas exchange.
• Air enters the lungs when the pressure in the
thorax is less than that of the surrounding
• During inspiration, negative intrathoracic
pressure is generated by contraction and
lowering of the diaphragm.
• The accessory muscles of inspiration (external
intercostal, scalene, and sternocleidomastoid
muscles) are not used during quiet breathing but
are recruited during exercise or in disease states
to raise and enlarge the rib cage.
• Exhalation is normally passive but, with active
exhalation, the abdominal and internal
intercostal muscles are recruited.
• Airway resistance is influenced by the
diameter and length of the conducting
airways, the viscosity of gas, and the nature of
the airflow.
• At higher flow rates, turbulent flow, especially
in the larger airways, increases resistance.
• When mechanical forces acting on the lung
are at equilibrium (at the end of a normal
relaxed breath), the volume of gas in the lung
is termed the functional residual capacity
– Maintains exchange of O2 during exhalation.
• Lung compliance (change in volume for a
given change in pressure) is a measure of the
ease with which the lung can be inflated.
• Processes that decrease lung compliance
(surfactant deficiency, pulmonary fibrosis,
pulmonary edema) may lead to decreases in
• FRC may be increased in obstructive lung
diseases (asthma and cystic fibrosis)
secondary to gas trapping in the lungs.
• Residual volume (RV) is the volume of gas left
in the lung at the end of a maximal exhalation,
and total lung capacity (TLC) is the volume of
gas in the lungs at the end of maximal
• Vital capacity (VC) is the maximal amount of
air that can be expelled from the lungs and is
the difference between TLC and RV.
• Alveolar ventilation is defined as the exchange of
CO2 between the alveoli and external
• Normally, about 30% of each tidal breath fills the
conducting (non-gas-exchanging) airways
(anatomic dead space).
• Because the anatomic dead space is relatively
constant, increasing the TV may increase the
efficiency of ventilation. Conversely, if the TV
decreases, then the dead space/TV ratio
increases, and alveolar ventilation decreases.
• Excessive airway secretions, bronchospasm,
mucosal edema and inflammation, airway
stenosis, foreign bodies, loss of airway wall
integrity (as with bronchiectasis), and airway
compression may all produce symptomatic
airway obstruction (ex.asthma and bronchiolitis).
• Restrictive lung disease is less common and is
characterized by normal to low FRC and RV, low
TLC and VC, decreased lung compliance, and
relatively normal flow rates.
• Restrictive lung disease can result from
neuromuscular weakness, an alveolar filling
process (lobar pneumonia, pulmonary
edema), pleural disease (pleural effusion,
inflammation, or mass), thoracic
narrowing/stiffness (scoliosis, severe pectus
excavatum), and abdominal distention.
• Respiratory Gas Exchange
– Depends upon alveolar ventilation, pulmonary
capillary blood flow, and the diffusion of gases
across the alveolar-capillary membrane.
– Exchange of CO2 is determined by alveolar
ventilation, while the exchange of O2 is influenced
primarily by the regional matching of ventilation
(V) with pulmonary blood flow (Q) (V/Q
• V/Q matching is maintained, in part, by hypoxic pulmonary
vasoconstriction (local constriction of the pulmonary vessels in
areas that are hypoventilated).
• There are five causes of hypoxemia:
– Ventilation-perfusion mismatch (asthma, BPD, pneumonia)
– Hypoventilation (apnea, narcotic overdose, neuromuscular disease)
– Extrapulmonary shunt (cyanotic heart disease)
Intrapulmonary shunt (pulmonary arteriovenous malformation,
pulmonary edema)
– Low FiO2 (high altitude)
– Diffusion defect (scleroderma, hepatopulmonary synd., pulmonary
• Disorders resulting in V/Q mismatching are the most common
cause of hypoxemia.
• Lung Defense Mechanisms
– The lungs are constantly exposed to particles and
infections agents.
– The nose is the primary filter for large particles.
– The ciliated epithelium of the paranasal sinuses
and nasal turbinates propagate filtered particles
toward the pharynx.
– Particles < 10µm in diameter may reach the
trachea and bronchi and deposit on the mucosa, <
1µm may reach the alveoli.
– Ciliated cells lining the airways from the larynx to the
bronchioles continuously propel a thin layer of mucus
toward the mouth.
– Alveolar macrophages and polymorphonuclear cells
engulf particles and pathogens that have been opsonized
by locally secreted IgA antibodies or transudated serum
– Cough, important in protecting the lungs, is a forceful
expiration that can clear the airways of debris and
• may be voluntary or generated by reflex irritation of the nose,
sinus, pharynx, larynx, trachea, bronchi, and bronchioles.
• The loss of the ability of cough results in poor secretion clearance
and predisposes to atelectasis and pneumonia.
Respiratory system assessment in pediatrics

• History
• Physical examination
• Diagnostic measures
• Therapeutic measures
• Onset
• Duration
• Frequency
• Swallowing function ( infants)
• Exposure to others with respiratory illness

Respiratory symptoms: cough, noisy breathing,

work of breathing/exercise tolerance, nasal
congestion, sputum production.
• Ontain information: the severity (hospitalizations,
emergency department visits, missed school
days) and pattern (acute, chronic, or intermittent)
of symptoms.
• For infants, a feeding history should be obtained.
• Family history (asthma and atopy, immune
deficiencies, and cystic fibrosis).
• Environmental history (exposure to smoke, pets,
and pollutants.
• Travel history may also be relevant.
Physical Examination
• Inspection (the respiratory pattern, rate, and
work of breathing, shape and symmetry of the
chest wall and the anteroposterior (AP)
• Palpation (vocal fremitus, symmetrical chest
expansion, chest wall)
• Percussion (chest wall)
• Auscultation (breath sounds)
• Normal breath sounds (vesicular) are
characterized by long inspiratory and short
expiratory phases.
• Bronchial (short inspiratory and long
expiratory phases and are normally heard over
the trachea but suggest pulmonary
consolidation or compression of the lung
when heard elsewhere.
• Hyperpnea (increased depth of respiration): fever,
metabolic acidosis, pulmonary and cardiac disease, or
extreme anxiety.
• Retractions (intercostal, supraclavicular, or substernal)
• Nasal flaring (increased inspiratory effort)
• Grunting (forced expiration against a partially closed
glottis): respiratory distress, pain.
• Stridor (usually heard on inspiration, is a harsh sound
emanating from the upper airway and caused by a
partially obstructed extrathoracic airway)
• Wheezing (partial obstruction of the lower
airways and heard more prominently during
exhalation but may be present on inspiration)
• Rhonchi (secretions in the intrathoracic airways
may produce wheezing but irregular sounds)
• Fine crackles or rales (fluid or secretions in small
airways produce sounds characteristic of
crumpling cellophane)
• Cough results from stimulation of irritant
receptors in the airway mucosa.
Table – Breathing Patterns
Pattern Features
Normal rate (breaths/min) Age: < 2mo < 60; 2 – 12mo < 50; 1 – 5yo < 40; 6 – 8yo <
Mild Reduced rate, ↑TV, slighly prolonged expiratory phase
Severe ↑rate, ↑ use of accessory muscles, prolonged expiratory
Restrictive Rapid rate, ↓TV
Kussmaul respiration ↑ rate, ↑TV, regular deep respiration; consider
metabolic acidosis or diabetic ketoacidosis
Cheyne-Stokes respiration Cyclic pattern of waxing and waning of breathing
interposed by central apneas/hypopneas; consider CNS
injury, depressant drugs, heart failure, uremia (rare in
Biot respiration Ataxic or periodic breathing with a respiratory effort
followed by apnea; consider brainstem injury or posterior
fossa mass
Gasping Slow rate, variable TV; consider hypoxia, shock, sepsis, or
Diagnostic Measures
• Imaging Techniques
– Chest radiographs
– Barium esophagogram
– Computed tomography (CT) scan
– Magnetic resonance imaging (MRI)
– Ultrasonography
• Measures of Respiratory Gas Exchange
– Arterial blood gas (ABG)
– Pulse oximetry
– End-tidal CO2
– Transcutaneous electrodes
• Pulmonary Function Testing
– Spirometry
– Peak expiratory flow rate (PEFR)
– Inhalation challenge tests
• Endoscopic Evaluation of the Airways
– Nasopharyngoscopy
– Bronchoscopy
• Examination of Sputum
• Lung Biopsy
– Transbronchial lung biopsy
– Thoracoscopic procedure or thoracotomy
Therapeutic Measures
• Oxygen Administration
• Aerosol Therapy
• Chest Physiotherapy and Clearance Techniques
• Intubation
• Tracheostomy
• Mechanical Ventilation
• Medications (Antibiotics, Cough supressant,
Mucolitics, Antihistamin, Corticosteroid)