RECOGNITION OF RESPIRATORY DISTRESS AND FAILURE
Respiratory distress and respiratory failure are among the leading causes of pediatric emergencies, and if not recognized and treated early, they can rapidly progress to cardiopulmonary arrest. Unlike adults, who often suffer cardiac arrest due to primary heart conditions, pediatric cardiac arrests are typically caused by hypoxia resulting from respiratory failure.
Why Early Recognition Matters
Children compensate well for respiratory problems—until they suddenly don’t. A child in distress may appear stable, but once they decompensate into respiratory failure, deterioration can be rapid and fatal.
Key Goals:
- Recognize respiratory distress early before it worsens.
- Differentiate distress from failure to determine appropriate interventions.
- Provide immediate support (oxygen, ventilation, or advanced airway management) to prevent respiratory arrest.
RECOGNIZING RESPIRATORY DISTRESS
Respiratory distress occurs when a child is still able to maintain oxygenation but is struggling to do so.
Common Causes of Respiratory Distress:
- Upper airway obstruction: Croup, epiglottitis, foreign body aspiration.
- Lower airway obstruction: Asthma, bronchiolitis.
- Lung tissue disease: Pneumonia, acute respiratory distress syndrome (ARDS).
- Disordered control of breathing: Neurological conditions, overdose.
Signs of Respiratory Distress:
| Sign | Description | Indicates |
|---|---|---|
| Tachypnea | Increased respiratory rate | Early sign of distress |
| Nasal flaring | Widening of nostrils with inspiration | Increased work of breathing |
| Retractions | Visible sinking of skin between ribs or above sternum | Increased effort to breathe |
| Grunting | Short, low-pitched sound on exhalation | Attempt to maintain airway pressure |
| Stridor | High-pitched inspiratory sound | Upper airway obstruction |
| Wheezing | Whistling sound, usually on exhalation | Lower airway obstruction |
| Head bobbing | Rhythmic head movement with breathing | Fatigue and impending failure |
| Prolonged expiratory phase | Exhalation is longer than inhalation | Air trapping (e.g., asthma, bronchiolitis) |
Key Actions for Respiratory Distress:
Provide supplemental oxygen to maintain SpO₂ >94%. Position the child upright to optimize breathing. Use nebulizers or bronchodilators if wheezing is present. Monitor for worsening signs, as distress can rapidly progress to failure.
RECOGNIZING RESPIRATORY FAILURE
Respiratory failure occurs when the child’s compensatory mechanisms fail, leading to inadequate oxygenation or ventilation. This is a life-threatening emergency that requires immediate intervention.
Signs of Respiratory Failure:
| Sign | Description | Indicates |
|---|---|---|
| Bradypnea | Slow or irregular breathing | Fatigue, impending arrest |
| Apnea/Gasping | Periods of no breathing | Severe hypoxia, pre-arrest |
| Cyanosis | Bluish skin (especially central cyanosis) | Hypoxemia |
| Altered mental status | Lethargy, unresponsiveness, poor interaction | Inadequate oxygenation to the brain |
| Hypotonia | Floppy or weak muscle tone | Poor oxygen delivery |
| Weak or absent cry | Faint or no vocalization | Severe respiratory compromise |
| Silent chest | No breath sounds despite effort | Severe obstruction or fatigue |
Red Flags: Immediate Intervention Required!
- A child who was working hard to breathe and suddenly becomes quiet or limp is in imminent respiratory arrest.
- Cyanosis despite oxygen therapy = life-threatening hypoxia.
- Bradycardia in a child is usually secondary to hypoxia and requires immediate oxygenation and ventilation.
Key Actions for Respiratory Failure: Initiate bag-mask ventilation (BMV) if inadequate breathing. Prepare for advanced airway management (endotracheal intubation or supraglottic airway). Administer 100% oxygen and ensure proper ventilation. Identify and treat the underlying cause.
DIFFERENTIATING RESPIRATORY DISTRESS VS. FAILURE
| Feature | Respiratory Distress | Respiratory Failure |
|---|---|---|
| Appearance | Alert, anxious | Lethargic, unresponsive |
| Work of Breathing | Increased effort (retractions, nasal 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 oxygen | Hypoxemia persists despite O₂ |
| Outcome | Can compensate | Impending arrest |
IMMEDIATE INTERVENTIONS BASED ON SEVERITY
Mild Respiratory Distress: Oxygen as needed (nasal cannula, face mask) Nebulizers or bronchodilators for airway diseases Close monitoring for worsening symptoms
Moderate to Severe Respiratory Distress: High-flow oxygen or non-invasive ventilation (e.g., CPAP/BiPAP) Consider steroids, racemic epinephrine, or antibiotics if appropriate Prepare for possible escalation to respiratory failure
Respiratory Failure (Impending Arrest!): Immediate airway management required! Bag-mask ventilation (BMV) for inadequate breathing Endotracheal intubation or supraglottic airway if needed Treat underlying cause (e.g., anaphylaxis → epinephrine, infection → antibiotics, opioid overdose → naloxone)
SUMMARY: WHY THIS MATTERS IN PALS
Respiratory distress is the warning sign—intervene early to prevent failure. Respiratory failure is life-threatening—requires immediate support. Children compensate well—until they suddenly don’t. Recognizing the shift from distress to failure is critical to preventing arrest.
Takeaway: If you see a child struggling to breathe, act fast. Oxygen, positioning, and early intervention can mean the difference between recovery and cardiac arrest. 