Respiratory distress and failure in children — OSCE

Station brief (candidate)

• Assess the severity of this child's respiratory distress using work, efficacy, and effect of breathing.
• Interpret the observations against age-normal ranges and identify features of impending failure.
• Outline an initial management and stepwise escalation plan.
• Update the anxious parent clearly, take their concern seriously, and agree what happens next. [1] [12]

Role-player notes

You are the parent of a 2-year-old who has been breathing harder all day and has now "gone a bit floppy and quiet." You are frightened and feel the staff are not moving fast enough. You settle when the doctor examines the child promptly, explains what the fast breathing and low oxygen mean in plain language, and tells you the plan and what to watch for. You become distressed if the doctor dismisses your worry or delays giving oxygen. [12]

Expected candidate performance

1. First impression and threat gate: State immediately whether the child is pre-arrest — apnoea, silent chest, bradycardia, exhaustion, or hypoxaemia unresponsive to oxygen — and act on it. A quiet, floppy child after a day of hard breathing is high-risk. [8]
2. Structured assessment: Assess work (rate against age-normal ranges, recession, flaring, grunting), efficacy (air entry, chest expansion, saturations), and effect (heart rate, colour, conscious state). [1]
3. Recognise failure: Name the danger signs — a falling respiratory rate, reducing effort without improvement, a quiet chest, and drowsiness — as the shift from distress to failure. [8]
4. Management and escalation: Give oxygen first, treat the likely cause, and escalate through high-flow nasal cannula and non-invasive support to intubation if the child does not improve, calling for senior and intensive-care help early. [2]
5. Safe monitoring: Use structured observations and clear escalation triggers, and set explicit review points on the ward. [11]
6. Communication: Explain the meaning of the observations in plain language, validate the parent's concern as useful information, and agree the plan and warning signs with teach-back. [12]

Marking domains

• Threat gate applied before anything else.
• Severity graded on work, efficacy, and effect, interpreted against age-normal ranges.
• Danger signs of failure named explicitly.
• Stepwise escalation plan with early senior involvement.
• Respectful, concern-validating communication with a clear plan. [1] [12]

Common fails

• Delaying oxygen while completing history or investigations. [8]
• Interpreting a falling respiratory rate as improvement. [1]
• No structured escalation plan or review trigger. [11]
• Dismissing the parent's concern that the child is worse. [12]