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Key Points

  • Respiratory disorders are potentially life-threatening and must be identified and treated rapidly.

  • Certain physiologic differences make pediatric patients more at risk of respiratory failure than adults.

  • Conduct patient assessment in a calm, efficient manner, attempting to localize the underlying source of distress.

  • Initial treatment may be required for stabilization before a complete history and physical examination can be performed.

  • Patient appearance and clinical status always supersede lab values and imaging.


Respiratory distress is a very common presentation in the emergency department (ED). It accounts for 10% of pediatric visits to the ED, 20% of pediatric admissions, and 20% of deaths in infants. Respiratory distress can potentially lead to respiratory failure (the inability of oxygenation and ventilation to meet metabolic demands) and should be recognized and treated promptly.

Several anatomic and physiologic characteristics put pediatric patients at higher risk for respiratory compromise. Infants <4 months of age are obligate nose breathers. Nasopharyngeal obstruction significantly increases the work of breathing. The location of the narrowest part of the airway, where a foreign body is likely to lodge, differs in adults (vocal cords) and children (cricoid cartilage). The diameter of the pediatric airway is a third that of adults. Narrowing of the airway leads to a greater relative increase in resistance to airflow (1-mm occlusion decreases cross-sectional diameter by 20% in adults vs. 75% in children). Abdominal musculature is a primary contributor to respiratory effort in children. Abdominal distension and muscle fatigue can negatively impact ventilation. Pediatric lungs have a lower functional residual capacity (FRC) with less reserve potential. PaO2 decreases more rapidly when ventilation is interrupted.

Respiratory distress may result from either upper airway obstruction, lower airway disorders, or other organ dysfunction compromising the respiratory system. Upper airway obstruction is the leading cause of life-threatening acute respiratory distress. Upper airway obstruction is defined as blockage of airflow in the larynx or trachea. It is characterized by stridor, an inspiratory sound caused by air flow through a partially obstructed upper airway. The age of the patient can aid in diagnosis.

Common causes of upper airway obstruction in children <6 months include laryngotracheomalacia (chronic, usually resolves by age 2) and vocal cord paresis or paralysis. Laryngomalacia and tracheomalacia are congenital conditions that affect the structural integrity of supporting structures in the upper airway. This leads to collapse of the affected tissues into the airway during respiration.

In children >6 months, important causes of upper airway obstruction include viral croup, foreign body aspiration, epiglottitis, bacterial tracheitis, retropharyngeal abscess, peritonsillar abscess, airway edema from trauma, thermal or chemical burn, or allergic reaction. Croup (laryngotracheobronchitis) is the most common cause of upper airway obstruction and stridor in children aged 3 months to 3 years. It occurs in 5% of children during their second year of life and is caused by a viral infection affecting the subglottic region. The patient presents with a barking cough, inspiratory stridor, and fever.

Upper airway obstruction from foreign body aspiration is most common in children aged 1 to 4 years. About 3,000 patients die each year from asphyxia related to foreign body aspiration.

Bacterial infections in the upper airway include epiglottitis and tracheitis. Epiglottitis is less common now since routine immunization against Haemophilus influenzae type B. Currently, tracheitis is more likely to be the cause of acute respiratory failure from airway obstruction than epiglottitis.

Lower airway obstruction has several causes, including asthma, bronchiolitis, pneumonia, allergic reaction, respiratory distress syndrome, aspiration, and environmental or traumatic insults. Asthma is the most common chronic disease in children, affecting 5–10% of the population. Bronchiolitis is most famously caused by respiratory syncytial virus (RSV), although other pathogens include parainfluenza, influenza, and adenovirus. It is a respiratory infection that causes inflammation of the bronchioles. Edema and mucous production lead to obstruction ...

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