Patient is breathing comfortably

No use of accessory muscles

Normal respiratory rate

Respiratory Distress

Increased work of breathing

Accessory muscle use, abnormal breath sounds

Abnormal respiratory rate

Impending Failure

Ineffective respirations, gasping

Declining mental status

In need of immediate positive pressure support


Always start with general appearance to assess level of respiratory distress.

To remember to be thorough, start from the outside in: level of distress, rate, retractions, prolongation of expiratory phase, position (tripod, relaxed, anxious), then palpation/percussion, and lastly, auscultation.

resp rate percentiles - pat brady article

Bonafide, Christopher P., et al. “Development of heart and respiratory rate percentile curves for hospitalized children.” Pediatrics 131.4 (2013): e1150-e1157.


  • Note pattern of breathing, use of accessory muscles, positioning, and chest wall deformities


  • Check for tracheal deviation, chest wall symmetry
  • Fremitus can be palpated in pleural effusion
  • Crepitus can be palpated in pneumomediastinum
  • Vibration in back can be palpated in infants with tracheomalacia or bronchomalacia


  • Dullness – over liver normally, consolidation or pleural effusion abnormally
  • Hyperresonance – can be normal in smaller children, can be heard with asthma or pneumothorax in an older child


  • Can gently squeeze chest in smaller child, to get better appreciation of expiration
  • Listen in stepladder pattern, to compare side to side

Respiratory Distress

Big picture questions:

How do you know where the distress is coming from?

How do you specifically identify and describe it?


Upper Airway


  • High pitched inspiratory noise
  • Worsens during periods of distress
  • Usually viral etiology in croup, causing upper airway swelling

Laryngomalacia and subglottic stenosis

  • Inspiratory squeaks
  • More prominent when supine
  • May be worsened by GERD

Partial upper airway obstruction

Can be due to foreign body, retropharyngeal abscess (RPA), epiglottitis, mass, etc.

  • Often also see gagging, choking, or difficulty handling secretions
  • Worse when supine and when patient is agitated

Lower Airway

Present with signs of increased work of breathing


Heard at the chest


Heard at the mouth

  • Continuous sounds, more often during expiration but can be both, polyphonic due to variation in vibration of partially obstructed airways


  • Discontinuous sounds, more often during inspiration, due to popping open of small airways, not alveoli (too small to hear)


  • Pooled secretions in central airways
  • Also called “transmitted upper airway sounds”


  • Decrease or absence in lung sounds in an area; crackles due to fluid popping in small airways


  • In smaller child, may not be able to generate whoop, but may gasp or vomit
Kraman S. Lung Sounds: An Introduction to the Interpretation of Auscultatory Findings. MedEdPORTAL; 2012. Available from:


Consider other causes if treatment of respiratory etiologies are not working:

  • Vascular ring – monophonic wheeze due to structural narrowing
  • Anaphylaxis
  • Ingestions
  • Foreign body
  • Congenital heart disease
  • Congenital diaphragmatic hernia
  • Sepsis
  • Guillain-Barre syndrome
  • Neuromuscular disorders
  • GER
  • Anemia



  • Staccato cough that is often unrelenting
  • Coughing fits last 30 seconds or more, ending with gasp, whoop, emesis, or apnea
  • Sometimes called “100 day cough”


  • Some children can have cough-variant asthma; may not present with wheezing
  • Usually dry hacking cough, triggered by exercise, allergens, or URI’s
  • Improvement with bronchodilator differentiates it from other types of cough


  • Also known as laryngotracheobronchitis
  • Often described as seal-like “barky” cough
  • Improvement with racemic epinephrine and dexamethasone


  • Harsh or hoarse sound, chronic in nature, may be accompanied by throat-clearing
  • No longer present when patient is asleep
  • No improvement with bronchodilators or cough suppressants


  • Triggered by upper airway secretions
  • Often described as “wet productive cough”


  • Seen in bronchiolitis
  • May be accompanied by wheezing, tachypnea, and retractions

 Impending Failure

You must recognize this, as patient may require positive pressure support and/or a higher level of care.

General appearance

  • Tripoding
  • Inability to speak in sentences
  • Tachypnea
  • Head bobbing

Accessory muscle use

  • Severe retractions
  • Belly breathing

Breath sounds

  • May be silent or shallow
  • Tiring out, very prolonged expirations
  • May see apnea in pertussis

Lack of response to treatment

  • Long duration of continuous Albuterol

Chronic medical conditions placing patient at higher risk

  • Neuromuscular disorders, including Duchenne’s muscular dystrophy
  • Cerebral palsy with hypoventilation
  • Child with technology dependence, including tracheostomy or ventilator
  • Prematurity with chronic lung disease
  • Infant with botulism