PALS Provider: Course

Recognition of Respiratory Distress and Failure

Respiratory distress and respiratory failure are among the leading causes of pediatric emergencies. If not recognized and treated early, they can rapidly progress to cardiopulmonary arrest. Unlike adults, pediatric arrests are usually hypoxic in origin—stemming from respiratory failure.

Why Early Recognition Matters

  • Children compensate well for respiratory issues—until they suddenly crash.
  • A child may appear stable even while deteriorating. Once decompensation begins, decline is rapid and often fatal.

Key Goals:

  • Recognize respiratory distress early before it worsens.
  • Differentiate distress from failure to choose the right intervention.
  • Provide immediate support—oxygen, ventilation, or advanced airway—to prevent arrest.

Recognizing Respiratory Distress

Respiratory distress occurs when the child can still oxygenate but is working hard to do so.

Common Causes:

  • Upper airway obstruction: Croup, epiglottitis, foreign body.
  • Lower airway obstruction: Asthma, bronchiolitis.
  • Lung tissue disease: Pneumonia, ARDS.
  • Disordered breathing control: Neurologic issues, overdose.

Signs of Respiratory Distress:

Sign Description Indicates
Tachypnea Increased respiratory rate Early sign of distress
Nasal flaring Widening of nostrils during inspiration Increased work of breathing
Retractions Visible sinking of chest wall Increased effort to breathe
Grunting Low-pitched sound on exhalation Maintaining airway pressure
Stridor High-pitched inspiratory sound Upper airway obstruction
Wheezing Whistling sound on exhalation Lower airway obstruction
Head bobbing Rhythmic head motion Fatigue, impending failure
Prolonged expiration Exhalation longer than inhalation Air trapping (e.g., asthma)

Actions:

  • Supplemental oxygen to maintain SpO₂ > 94%
  • Upright positioning to ease breathing
  • Nebulizers/bronchodilators if wheezing present
  • Closely monitor for signs of decompensation

Recognizing Respiratory Failure

Respiratory failure occurs when compensatory mechanisms fail and oxygenation or ventilation is inadequate. This is a life-threatening emergency requiring immediate intervention.

Signs of Respiratory Failure:

Sign Description Indicates
Bradypnea Slow or irregular breathing Fatigue, pre-arrest
Apnea/Gasping Absent or gasping respirations Severe hypoxia
Cyanosis Bluish skin/lips Hypoxemia
Altered mental status Lethargy, unresponsiveness Low oxygen to the brain
Hypotonia Floppy tone Poor oxygen delivery
Weak/absent cry Minimal vocalization Severe compromise
Silent chest No breath sounds despite effort Severe obstruction or fatigue

Red Flags: Immediate Intervention Required

  • Child suddenly quiet or limp = imminent arrest
  • Cyanosis despite oxygen = life-threatening hypoxia
  • Bradycardia = likely hypoxia; prioritize oxygenation/ventilation

Actions:

  • Initiate bag-mask ventilation (BMV)
  • Prepare for advanced airway (ETT or SGA)
  • Administer 100% oxygen, ensure effective ventilation
  • Treat the underlying cause

Distress vs. Failure: Key Differences

Feature Respiratory Distress Respiratory Failure
Appearance Alert, anxious Lethargic, unresponsive
Work of Breathing Increased effort (retractions, flaring) Decreased effort, gasping
Breath Sounds Wheezing, stridor, grunting Diminished or absent
Skin Color Normal or pale Cyanotic, mottled
Heart Rate Elevated Bradycardia (late sign)
Oxygenation Responds to O₂ Persists despite O₂
Outcome Compensating Impending arrest

Immediate Interventions by Severity

1. Mild Distress

  • Oxygen (nasal cannula or mask)
  • Nebulizers or bronchodilators
  • Close monitoring

2. Moderate to Severe Distress

  • High-flow oxygen or non-invasive ventilation (CPAP/BiPAP)
  • Consider steroids, racemic epinephrine, antibiotics as needed
  • Prepare for escalation to respiratory failure

3. Respiratory Failure (Impending Arrest!)

  • Initiate bag-mask ventilation (BMV)
  • Prepare for intubation or supraglottic airway
  • Treat the underlying cause:
    • Anaphylaxis → Epinephrine
    • Infection → Antibiotics
    • Overdose → Naloxone

Summary: Why This Matters in PALS

  • Respiratory distress is a warning sign—intervene early.
  • Failure is life-threatening—requires immediate support.
  • Children compensate—until they don’t. Know when that tipping point happens.

Takeaway: If a child is struggling to breathe, act fast. Early oxygenation, positioning, and intervention can prevent arrest.