Respiratory Distress Approach in Children
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Direct answer
Respiratory distress in children is increased work of breathing, recognised by fast breathing, chest indrawing, nasal flaring, grunting and altered sensorium, and it signals the need for a structured assessment. The approach begins with airway, breathing and circulation, followed by a differential diagnosis that depends on the child's age. Early recognition matters because hypoxia and respiratory exhaustion can progress quickly in a small child.
What you must remember
- Tachypnoea (IMNCI cut-offs): 60 or more breaths a minute under two months, 50 or more at two to 11 months, and 40 or more at 12 to 59 months.
- Indrawing: lower chest wall indrawing signals increased work of breathing, and nasal flaring, grunting and head nodding add to the picture.
- See-saw breathing: paradoxical abdominal movement during inspiration indicates severe respiratory muscle fatigue.
- Danger signs: central cyanosis, inability to feed or drink, convulsions and lethargy need immediate action.
- Infants: bronchiolitis, pneumonia, croup and tracheo-oesophageal fistula are typical causes, and neonates also show transient tachypnoea and respiratory distress syndrome.
- School-age children: asthma, foreign body aspiration, pneumothorax, pleural effusion and diabetic ketoacidosis with deep breathing are important considerations.
- Oxygen: given when hypoxaemia is present, with the saturation target set by the local protocol.
A stepwise approach to a toddler with fast breathing
A 14-month-old has fast breathing, chest indrawing and an oxygen saturation of 90 per cent on room air, after two days of cough and fever. The steps run in a fixed order, and each one changes the next.
- Start with ABC. Check the airway, breathing effort and circulation, and give oxygen early when the saturation is low.
- Grade the severity. Use the danger signs, the degree of recession and grunting, and the level of consciousness to decide between ward care and intensive care.
- Count the breaths properly. Crying and fever raise the rate, so the count is repeated for a full minute when the child is calm.
- Narrow the differential by age. In infants, consider bronchiolitis, pneumonia and croup, whereas in older children asthma, foreign body and pleural disease come first.
- Investigate selectively. A chest X-ray, blood gas and sepsis screen follow the clinical picture and the response to the first treatment.
- Treat the cause and reassess. Start specific treatment, such as bronchodilators for wheeze or antibiotics for pneumonia, and reassess the work of breathing and saturation frequently.
Where the exam tries to catch you
The exam tests age-specific thresholds and the danger signs that must not be missed.
- Trap: using the adult respiratory rate as the threshold for a child Correct: cut-offs are age-specific, and 40 breaths a minute is fast for a child aged one to five years.
- Trap: treating fast breathing as trivial in a febrile infant Correct: fast breathing is the key sign of pneumonia in infants under IMNCI, so it must be counted and acted on.
- Trap: stopping at a normal chest X-ray in a child with wheeze and stridor Correct: a normal film does not exclude a foreign body, so the history and examination guide the next step.
Frequently asked questions
What respiratory rate counts as fast breathing in a child?
Fast breathing in a child is 60 or more breaths a minute under two months, 50 or more at two to 11 months, and 40 or more at 12 to 59 months. These WHO cut-offs are used in IMNCI, and the count should be repeated when the child is calm.
Why is chest indrawing important in respiratory distress?
Chest indrawing is important because it shows that the child's respiratory muscles are working harder against increased airway resistance or stiff lungs. Lower chest wall indrawing signals significant distress, and when it is combined with grunting or nasal flaring, the child needs prompt assessment.
What does see-saw breathing indicate in a child?
See-saw breathing, with paradoxical abdominal movement during inspiration, indicates severe respiratory muscle fatigue and a risk of respiratory failure. It is a late sign that calls for urgent oxygen, support and specialist review.
Which conditions cause respiratory distress in neonates?
Transient tachypnoea of the newborn, respiratory distress syndrome, meconium aspiration and congenital causes such as diaphragmatic hernia cause respiratory distress in neonates. Sepsis and congenital heart disease are also considered in the same babies.