Synopsis
Distinguish respiratory distress from failing oxygenation or ventilation, identify the anatomical and physiological cause, support breathing in an ordered sequence, and escalate from oxygen to bag-mask ventilation, non-invasive support or a protected advanced airway before exhaustion becomes arrest.
- Respiratory distress has increased effort with preserved effectiveness; failure has inadequate oxygenation or ventilation, fatigue, altered consciousness or cardiovascular compromise.
- Assess work, effectiveness and systemic effect: rate, recession, sounds, position, chest excursion, air entry, saturation, colour, heart rate and consciousness.
- Falling respiratory effort is dangerous when chest movement, air entry or alertness also declines.
- First-line emergency management is airway positioning, suction of visible secretions when needed, 100% oxygen for failure and immediate support of inadequate ventilation.
- Bag-mask ventilation is the first-line ventilation method; use correct head position, a suitable mask, airway adjunct and preferably a two-person seal.
- Aim for mild visible chest rise at an age-appropriate rate and avoid excessive volume, pressure and gastric inflation.
- Once saturation is reliable, titrate oxygen to 94–98% in a previously healthy child using the lowest FiO2 that achieves the target.
- High-flow nasal oxygen or non-invasive ventilation can be considered when conventional oxygen is inadequate and respiratory drive is still sufficient.
- Use a supraglottic airway or tracheal tube early when bag-mask support is ineffective or prolonged ventilation is expected; oxygenation remains the priority during airway attempts.
- Confirm and continuously monitor every advanced airway with waveform capnography, as well as clinical chest movement and bilateral air entry.
- Use DOPES for sudden deterioration after an airway is placed: displacement, obstruction, pneumothorax or pathology, equipment, and stomach, stacking or sedation.
- Treat the cause in parallel, including foreign-body relief, anaphylaxis adrenaline, bronchodilator therapy, antibiotics, naloxone or decompression as indicated.
Key red flags
A child who becomes quieter with less recession can be deteriorating if air entry, respiratory rate or alertness is falling.
Bradypnoea, irregular breathing, apnoea, grunting, cyanosis, a silent chest or reduced consciousness indicates respiratory failure rather than compensated distress.
Bradycardia in an unwell child usually reflects severe hypoxia and requires immediate effective oxygenation and ventilation.
Stridor at rest, drooling, inability to swallow, tripod positioning or rapidly increasing neck swelling signals a threatened upper airway; do not force the child supine or inspect the throat with distressing instruments.
Sudden unilateral loss of air entry with shock during positive-pressure ventilation suggests tension pneumothorax and is treated clinically before imaging.
A tracheostomy child in distress with an impassable suction catheter may have a blocked tube requiring immediate removal and replacement under the emergency algorithm.
Normal oxygen saturation while receiving supplemental oxygen does not exclude rising carbon dioxide, exhaustion or inadequate minute ventilation.
Investigation priorities
Measure oxygenation while repeatedly assessing work, chest excursion, air entry and consciousness.
Assess pH, carbon dioxide, oxygen where arterial, lactate, glucose and electrolytes when failure is suspected.
Management branches
Effort is increased but gas exchange and interaction remain adequate.
- Position comfortably, minimise distress and apply continuous observations.
- Give cause-appropriate oxygen and treatment and reassess response frequently.
- Escalate early if work rises, air entry falls or systemic signs develop.