creation date: 2026-09-18 18:49
tags: Workups
Respiratory Distress (Pediatric)
Background
Respiratory distress (in children) results when breathing does not meet the body’s metabolic demand for oxygen. This may be due to failure of oxygenation and/or ventilation.
Pathophysiology
Respiratory distress in children, especially neonates and infants, must be promptly recognized and treated aggressively because of their tendency to decompensate quickly. This is because:
- Smaller airways
- Increased metabolic demand
- Decreased respiratory reserve
- Inadequate compensatory mechanisms
Differential Diagnosis
Emergency conditions
- Acute upper airway obstruction
- Pneumo- or hemothorax
- Impending respiratory arrest
- Acute cardiac tamponade
- Pulmonary embolism
- Traumatic conditions (flail chest, pulmonary contusion, smoke inhalation, submersion injury)
Respiratory tract
Infections
- Peritonsillar abscesses
- Retropharyngeal abscesses
- Croup
- Bacterial tracheitis
- Bronchiolitis
- Pneumonia
- COVID-19 infection
Others:
- Asthma
- Anaphylaxis
- Foreign body
- Airway anomalies
- Pulmonary edema
- Chest wall and thoracic cavity abnormalities
Cardiovascular
- Congenital heart disease (right-to-left shunting of deoxygenated blood)
- Acute decompensated heart failure
- Pericarditis
- Cardiac arrhythmia (most commonly supraventricular tachycardia)
- Myocardial infarction
Neurologic and muscle diseases
Congenital causes
- CNS malformation
- Neuromuscular disease
- Seizures
Acquired
- Intoxication
- CNS infection
- Seizures
- Brain or spinal cord trauma
Gastrointestinal conditions
GERD can cause stridor via irritation of infraglottic structures or penumonia due to aspiration.
Abdominal processes that cause pain (eg. appendicitis) can cause respiratory distress due to interference of diaphragm.
Metabolic and endocrine diseases
Tachypnea may be compensatory for metabolic acidosis.
Hematologic conditions
Conditions with decreased oxygen delivery:
- Acute onset of severe anemia (eg. hemolytic conditions)
- Neonatal polycythemia
Acute on chronic conditions
Acute worsening of chronic respiratory conditions:
- Upper airway obstructions
- Chronic pulmonary disease (eg. cystic fibrosis)
- Acute chest syndrome
Initial Evaluation
Rapid Assessment & Stabilization
Initial assessment on appearance, breathing, and circulation is used to identify life-threatening conditions:
- Appearance
- Early hypoxia: restlessness, agitation, combativeness
- Severe hypoxia/ hypercarbia/ respiratory fatigue: somnolence, lethargy
- Breathing
- Tachypnea (usually first sign)
- Abnormal airway sounds (eg. stridor, wheezing)
- Nasal flaring
- Head bobbing
- Increased accessory muscle use
- Positioning to maximize airway opening
- Upper airway obstruction - “sniffing position”
- Lower airway obstruction - “tripod position”
- Circulation
- Pallor
- Ashen colour
- Cyanosis
Stablize ABCs:
- Airway
- Administer 100% inspired oxygen
- Position child in comfortable position
- Clear airway with suction
- Insert artificial airway if jaw thrust / chin lift insufficient
- Breathing
- Intubate and assist ventilation if needed
- Circulation
- Monitor heart rate and rhythm
- Establish vascular access
History
Once stabilized, a detailed history should be obtained:
- Symptoms
- Onset and duration
- Associated symptoms (eg. infectious, abdominal)
- Contributing history
- Trauma
- Exposures (toxins, infections, allergens, water submersion)
- Recent travel or immigration
- Past medical and family history
- Previous episodes
- Underlying medical conditions
- Family history
Physical Exam
- Vitals
- Breathing
- Position (sniffing, torticollis, upright, tripoding)
- Pattern (rapid/shallow, Kussmaul, Cheyne-Stokes, ataxic)
- Tracheal deviation
- Accessory muscle use
- Auscultation for abnormal sounds
Investigations
Laboratory testing include:
- CBC with differential
- Viral studies (multiplex)
- Rapid blood glucose, electrolytes, blood gas (suspected DKA)
- Troponin, BNP, D-dimer (if chest pain)
- Blood, urine, CSF cultures (if fever and altered mental status)
Imaging
- Plain radiograph (neck, chest, abdomen)
- Ultrasound for pulmonary/cardiac/abdominal causes