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