Pediatric emergency medicine trisk 1409 1409
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Flaring: reflexive opening of nares during inspiration with airway obstruction
Retractions: accessory muscle use manifest as inward collapse of chest wall as
a result of high negative intrathoracic pressure from increased respiratory
effort; supraclavicular, suprasternal, and subcostal retractions usually reflect
upper airway obstruction, intercostal retractions reflect lower airway
obstruction or disease but may be seen with severe upper airway obstruction
Head bobbing: extension of head and neck during inhalation and flexion during
exhalation, seen in neonates, young infants, reflects accessory muscle use
Stertor: snoring with nasal congestion, adenotonsillar hypertrophy,
neuromuscular weakness
Gurgle: inspiratory and expiratory bubbling sounds caused by secretions in the
oropharynx, trachea, or large bronchi
Aphonia/dysphonia: vocal cord obstruction, dysfunction
Muffled voice: oropharyngeal obstruction
Hoarseness: laryngeal obstruction, dysfunction
Barky cough: subglottic, tracheal obstruction
Stridor: abnormal turbulence over airway obstruction; (i) inspiratory: quiet,
high pitched from glottic, subglottic region; (ii) expiratory: loud, harsh from
carina or below; and (iii) biphasic: loud, harsh from trachea
Grunt: expiration against a closed glottis to maintain expiratory lung volume
with lower airway, gastrointestinal process
Tracheal deviation: shifting of trachea to nonaffected side of chest due to air,
fluid space-occupying process on contralateral side
Wheeze: continuous, musical; (i) obstructed bronchi, bronchioles—polyphonic
(variable pitched, regional differences) expiratory as in asthma; (ii)
obstructed central airway—monophonic (low pitched, same in all lung fields)
expiratory ± inspiratory as with tracheal foreign body, tracheomalacia
Crackles (rales): discontinuous, usually high pitched, inspiratory; moist, from
thin secretions in (i) bronchi, bronchioles (medium rales), or (ii) alveoli (fine
rales)
Rhonchi (coarse rales): discontinuous, usually low pitched, inspiratory; moist
or dry, from exudate, edema, inflammation of larger bronchi
Pericardial friction rub: saw-like sound, inspiratory, expiratory between
sternum and apex of heart due to pericardial inflammation, fluid
Hamman crunch/sign: pericardial crackles synchronous with heart beat due to
heart beating against pneumomediastinum, left-sided pneumothorax
