It is important for pediatricians to recognize the signs and symptoms of respiratory distress, as it is a common presenting complaint for children. With a careful history and physical exam, it is possible to narrow down the broad differential for respiratory distress so that appropriate treatment may be started. Respiratory distress is characterized by increased work of breathing (i.e., tachypnea, flaring, retractions) often in association with pulmonary exam findings such as stridor, wheezing, and rales.

Important elements of the history for a child with respiratory distress include trauma, voice changes (i.e., muffled, hoarse), and associated symptoms, such as fever. Prior episodes of respiratory distress or any chronic medical conditions are also significant parts of the history. Physical exam should start with vital signs, especially respiratory rate and oxygen saturation. The World Health Organization defines tachypnea (in breaths per minute) based on age: >60 for age <2 months, >50 for ages 2 months to 1 year, >40 for ages 1 to 5 years, >20 for age >5 years. Remember that for febrile children, each degree Celsius increase may cause an increase of up to 10 breaths per minute. In addition to the respiratory rate, pay attention to the respiratory pattern. For instance, Kussmaul breathing and Cheyne-Stokes breathing occur with metabolic acidosis and central nervous system (CNS) processes, respectively.

Prior to auscultation, careful observation of the child in respiratory distress may provide important clues to the diagnosis. Mental status changes, such as combativeness or somnolence, may indicate severe hypoxia or hypercarbia. Cyanosis is a late sign in the hypoxic child. The child will assume a position that decreases work of breathing. For example, a child with upper airway obstruction may assume the “sniffing position.” Observe whether there is nasal flaring, head bobbing, retractions (supraclavicular, intercostal, substernal), or grunting, all of which signify respiratory distress. If there is cough, listen to the quality: hoarse or barky (suggests upper airway problem), tight and persistent (suggests lower airway obstruction), or loose and productive (suggests infection). On auscultation, particularly note stridor,
wheezing, rales, and decreased breath sounds. Stridor is generally an inspiratory noise from upper airway obstruction. Wheezing is usually an expiratory noise from lower airway obstruction. Rales are typically an inspiratory noise from lower airway reinflation, which occurs in pneumonia and pulmonary edema. Decreased breath sounds may indicate local areas of collapse, consolidation, or fluid.