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The Silverman-Anderson Index is an assessment scoring system that evaluates five parameters of work of breathing and assigns a numerical score for each parameter (see Table 1, below). Each category is scored as 0 for normal, 1 for moderate impairment or 2 for severe impairment. Parameters assessed are retractions of the upper chest, lower chest and xiphoid; nasal flaring; and expiratory grunt. (3) Normally functioning children should have a cumulative score of 0, whereas critically ill and severely depressed children will have scores closer to 10. SILVERMAN ANDERSON SCORING SYSTEM SCORE 0 Chest/Abdominal Movement Intercostal spaces Xiphoid area Nares Expiratory grunting No retraction No retraction No dilation No expiratory grunting Retraction just visible Retraction just visible Minimal dilation Marked retractions Marked retractions Marked dilations Synchronized respirations

1 Lag in inspiration

2 Seesaw inspiration

Expiratory grunting by Expiratory grunting by stethoscope unaided ear Sources: Sanders M: Mosbys Paramedic Textbook, Third Edition Elsevier. St. Luis, Mo, 2007. p. 1113. The last physical assessment tool used to evaluate work of breathing should be auscultation of the lower airways with a stethoscope. Because a childs chest is so small, stethoscope placement differs slightly from auscultation of an adults chest. The transmission of sounds from areas distant from the stethoscope can be a problem when assessing breath sounds in small children. For this reason, place the stethoscope bell near the armpit to maximize transmitted breath sounds. (4) Wheezing, the movement of air through partially blocked smaller airways is the most common lower airway sound heard in children with respiratory compromise. Initially, wheezing is heard only on exhalation and upon auscultation with a stethoscope. But as the degree of obstruction increases, it may be heard in both inspiration and expiration, and may even be audible to the naked ear. Once a patient becomes extremely fatigued, airflow velocity begins to fatigue and wheezing may attenuate and disappear, a pre-arrest finding. Therefore, its necessary to treat wheezing aggressively in the early stages before the increased work of breathing leads to fatigue and respiratory arrest.(1) Circulation: The goal is to determine the adequacy of cardiac output.(1) Key findings in the distressed child are related to signs of poor oxygenation, such as peripheral or central cyanosis. Bluish tinting to the skin and/or mucous membranes reflects significant hypoxemia. Corrective action regarding airway management and optimal oxygenation must be made a priority.