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