Pediatric Respiratory Distress and Failure (PALS)

Distress and failure sit on one continuum, and they need different responses. Distress is compensation. The child raises the respiratory rate and works harder to meet oxygen needs. Failure is the point where breathing is no longer adequate, so oxygenation and ventilation fall short (2025 AHA Guidelines for CPR and ECC, Part 6). Cardiac arrest in children usually does not start with a primary heart problem. It follows progressive respiratory failure or shock (Part 6). So you fix the breathing before any drug.

Why Kids Are Different

• Breathing control is immature: premature babies slide into distress from mild causes. Irregular breathing in the first days of life can mean a blunted response to hypoxia and hypercapnia.
• Narrow, collapsible airways: airway resistance climbs as the radius falls. The walls of the pharynx, larynx and trachea collapse more easily than an adult's.
• Little collateral ventilation: in infants, the channels between alveoli are not fully developed. Bronchial obstruction causes atelectasis, and the result is ventilation–perfusion mismatch.
• Muscles tire quickly: horizontal ribs and a horizontal diaphragm insertion make each breath less efficient. Fewer fatigue-resistant fibers mean they deteriorate faster as the rate climbs.

For the arrest pathway that follows failing breathing, see the pediatric cardiac arrest page.

Sort distress from failure with three things: the work of breathing, oxygenation and level of consciousness. Each column is a stage, not an age.

Age-Specific Presentation

• Neonate and young infant: premature babies drift into distress from mild causes. Irregular breathing in the first days of life is common. It does not reassure you on its own.
• Under 1 year and 1–8 years: with an advanced airway, the ventilation rate is 30/min under 1 year and 20–30/min at 1–8 years.
• 8–18 years: with an advanced airway in a healthcare setting, 10–20/min at clinical discretion.

A small group of causes explains most respiratory failure in children. Each row pairs a cause with the feature that tells it apart.

Rapid breathing also shows up with sepsis and shock, pulmonary edema and cardiac causes. For those, go to the shock page.

Manage by stage. Escalate when the child does not respond or the work of breathing gets worse.

Distress (Compensated)

1. Oxygen: give oxygen when SpO₂ is below 94% or the child shows respiratory distress, and titrate to 94–99% or the child's own normal level (Paramedic/RN/CCT, per local protocol).
2. Treat the cause: nebulized albuterol for bronchospasm, with ipratropium for moderate to severe asthma; nebulized epinephrine and dexamethasone for moderate to severe croup; IM epinephrine first for anaphylaxis.
3. Reassess: repeat the work of breathing, SpO₂ and perfusion after each intervention.

Foreign-body obstruction: sudden choking, then a cough, wheeze or one-sided breath sounds. A forceful cough is moving air, so encourage it. Weak or silent cough? Treat it as airway obstruction at once (current choking first aid, per local protocol).

For cause-specific drugs and thresholds, use the croup and bronchiolitis pages.

Failure (Decompensated)

1. Position and suction: open the airway (sniffing position, with a shoulder roll under an infant's shoulders), suction secretions, and give oxygen.
2. Ventilate: with a pulse but inadequate breathing, bag-mask ventilate at 20–30 breaths per minute with oxygen (2025 AHA Guidelines for CPR and ECC, Part 6, COR 2a, LOE C-EO).
3. Noninvasive support as a bridge: for an alert child whose breathing is failing, consider high-flow nasal cannula or CPAP/NIV per local protocol. It buys time while the advanced airway is prepared.
4. Advanced airway: intubate for failing effort, falling consciousness, or no response to noninvasive support. Once it is in place, give a breath every 2–3 seconds with continuous capnography. In severe asthma, slow the rate and lengthen the expiratory time to avoid air trapping.
5. Naloxone for opioid depression: give it to support breathing. Restoring alertness is not the goal.

Pre-Arrest: Bradycardia With Cardiopulmonary Compromise

1. Confirm: heart rate below 60/min with cardiopulmonary compromise (acutely altered mental status, signs of shock or hypotension) that persists despite effective oxygen and ventilation (2025 AHA Guidelines for CPR and ECC, Part 8, PALS Bradycardia With a Pulse algorithm).
2. Start CPR: if the heart rate stays below 60/min with cardiopulmonary compromise despite effective oxygenation and ventilation, start chest compressions and follow the pediatric cardiac arrest page (2025 AHA Guidelines for CPR and ECC, Part 8, COR 1, LOE C-EO).
3. Epinephrine: 0.01 mg/kg IV/IO (0.1 mL/kg of 0.1 mg/mL; max 1 mg), repeated every 3–5 minutes, when bradycardia with cardiopulmonary compromise persists after correction of other factors such as hypoxia (2025 AHA Guidelines for CPR and ECC, Part 8, COR 1, LOE C-EO). AHA 2025 prefers IV/IO over the endotracheal route. The endotracheal dose (0.1 mg/kg of 1 mg/mL, the Korean 2025 guideline (reference 2)) is only for the intubated child whose IV/IO access is difficult or unavailable.
4. Atropine: 0.02 mg/kg IV/IO (minimum 0.1 mg, maximum 0.5 mg per dose; may repeat once) only for bradycardia with cardiopulmonary compromise due to increased vagal tone or atrioventricular block, not due to hypoxia (2025 AHA Guidelines for CPR and ECC, Part 8, COR 1, LOE C-LD).
5. Pacing is a later option: emergency transcutaneous pacing may be considered (2025 AHA Guidelines for CPR and ECC, Part 8, COR 2b, LOE C-EO) for complete heart block or sinus node dysfunction that does not respond to CPR. Pacing does not replace oxygen, ventilation or CPR.

Respiratory and Croup

Bradycardia and Resuscitation

Doses vary by protocol; follow local protocols and medical direction. When severe asthma does not respond to first-line treatment, magnesium sulfate is an EPR-3 adjunct (Evidence B). Its dose is on the magnesium sulfate page. For asthma steroid courses, use the prednisone and dexamethasone pages.

• Reassess after each intervention: work of breathing, SpO₂, mental status and perfusion.
• Croup after nebulized epinephrine: the child needs 2–4 hours of observation. Discharge only if symptoms have stayed away for that period (CPS).
• Asthma: once the child is admitted, stop ipratropium. It adds nothing (EPR-3). Keep albuterol going.
• Escalate: call for PICU or critical-care transport when failure does not respond to the first steps above.

Neonates and Young Infants

• Premature babies drift into respiratory distress from mild causes.
• For neonatal resuscitation and the neonatal airway, follow the Neonatal Resuscitation Program (2025 AHA Part 5). You won't find neonatal doses or tube sizes on this page.
• Infants have less collateral ventilation. A small obstruction can cause atelectasis fast.

Adolescents (8–18 Years)

• With an advanced airway in a healthcare setting, ventilate at 10–20/min at clinical discretion.
• Switch to adult drug doses at the threshold your local protocol sets.

Opioid Exposure

• In opioid-dependent children, full-dose naloxone can trigger acute withdrawal. Titrate lower doses to effect.
• For respiratory depression from therapeutic opioids, go low: titrated naloxone at 1–5 mcg/kg, to effect.
• Keep supporting breathing while naloxone takes effect.

• Preparation: pre-drawn or colour-coded syringes, each labeled with drug, mg, mL and concentration. Check the epinephrine concentration on every syringe.
• Destination: a pediatric-ready ED. Go to a PICU when the child needs ventilation or vasoactive support.
• Restraint and caregivers: the child goes in a restraint on the stretcher, never on a caregiver's lap. Keep the caregiver close when protocol allows.
• Handoff: use a structured report such as IMIST-AMBO or MIST. Include the weight in kg and each drug's time, dose and route.

Transport and treatment depend on the cause, so use the croup and bronchiolitis pages.