Pediatric emergency medicine trisk 1406 1406
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interrupted irregularly by periods of apnea) suggest CNS infection, injury, or
drug-induced depression. Asymmetric chest wall movement and/or expansion
suggest unilateral chest wall or thoracic cavity pathology. Nasal flaring and
supraclavicular, suprasternal, and subcostal retractions of accessory muscles of
respiration usually reflect upper airway obstruction but may occur with lower
processes ( Table 71.8 ). Intercostal retractions are usually a sign of inadequate
tidal volume as a result of lower airway disease. Head bobbing, more common in
neonates and young infants, is another sign of accessory muscle use.
Thoracoabdominal dissociation, also called respiratory alternans or see-saw
respirations, in which the chest collapses on inspiration and the abdomen
protrudes, is a sign of respiratory muscle fatigue. Peripheral cyanosis should be
distinguished from central cyanosis.
TABLE 71.7
NORMAL RESPIRATORY RATES
Age group
Neonates
Older infants/toddlers
Elementary schoolaged children
Older
children/adolescents
Respiratory rate (breaths/min)
35–50
30–40
20–30
12–20
Palpation of the chest commonly reveals vibratory rhonchi over the large
airways, which suggests fluid in the airway. Increased tactile fremitus suggests
bronchopulmonary consolidation or abscess, when decreased or absent, it
suggests bronchial obstruction or space-occupying processes of the pleural cavity.
Crepitus on palpation of the chest or neck may reveal subcutaneous emphysema
caused by pneumothorax or pneumomediastinum.
Auscultation is useful for localizing the site of respiratory distress ( Table 71.8
). Stertor, gurgle, dysphonia, aphonia, hoarseness, barky cough, and inspiratory
stridor localize the respiratory distress to the upper airway. A lower airway cause
is suggested by decreased or asymmetric breath sounds, changes in pitch of
breath sounds, expiratory stridor, grunting, and/or adventitious sounds, including
crackles, rhonchi, wheeze, rub, bronchophony, egophony, and whispered
pectoriloquy. Transmission of breath sounds across the small pediatric chest may
