🌬️ PALS: Recognizing Respiratory Distress vs. Respiratory Failure — High-Yield Study Guide

⚠️ Respiratory problems are the #1 cause of pediatric cardiac arrest. Early recognition = survival.

1️⃣ Respiratory Distress — The Compensation Phase

The child is still maintaining oxygenation + ventilation by working harder.

🔥 Key Signs (“WORK OF BREATHING ↑”)

• Tachypnea (earliest sign)
• Nasal flaring 👃
• Retractions (intercostal, suprasternal, subcostal)
• Head bobbing 🧠↕️ (infants)
• Grunting (auto-PEEP to keep alveoli open)
• Wheezing or stridor (depends on upper vs. lower airway)
• Anxious, irritable

🫁 Breath Sounds

• Upper airway: stridor, barking cough
• Lower airway: wheezing, prolonged expirations

📈 O2 Sat

• Usually normal or mildly low because compensation still works.

2️⃣ Respiratory Failure — Decompensation Phase

The child cannot maintain oxygenation or ventilation. CO₂ retention, hypoxemia, fatigue → arrest.

🚨 Key Signs (“WORK OF BREATHING ↓ — they are giving up”)

• Bradypnea (late + ominous)
• Apnea or gasping
• Weak or absent cry
• Silent chest ❗
• Seesaw respirations
• Cyanosis 💙 (central)
• Poor muscle tone, floppy infant
• Decreased LOC → lethargy → unresponsiveness

🫁 Breath Sounds

• Very diminished or silent chest = impending arrest.

📉 O2 Sat

• Low despite oxygen

💀 Remember:

Kids crash fast. Once they tire out, cardiac arrest follows within minutes.

3️⃣ Causes by Category (PALS Mnemonic)

Upper Airway 🟥

• Croup, anaphylaxis, foreign body
• Signs: Stridor, hoarse voice, barking cough

Lower Airway 🟦

• Asthma, bronchiolitis
• Signs: Wheezing, prolonged expiration

Lung Tissue/Parenchymal 🟩

• Pneumonia, pulmonary edema
• Signs: Crackles, hypoxemia

Disordered Control of Breathing 🟨

• Seizure, head injury, OD
• Signs: Irregular respirations, apnea

4️⃣ Nursing Management & Immediate Actions (High Yield)

In Respiratory Distress:

• Position: sniffing or tripod
• Oxygen: blow-by → NC → NRB
• Nebulizers: albuterol, racemic epi (if indicated)
• Suctioning for infants
• Avoid agitation in upper-airway obstruction
• Prepare for escalation

5️⃣ Red Flags You NEVER Ignore 🚩

• Silent chest
• Bradypnea
• Cyanosis unresponsive to O₂
• Diminishing retractions (NOT improvement—this means fatigue)
• Altered mental status