Respiratory distress and failure in children — viva

Opening (must-hit)

"I treat respiratory distress and failure as one continuum. I clear the pre-arrest threat gate first, give oxygen, and then read the trend in the child's effort — rising effort means they are compensating, falling effort with a quieter chest and a drowsier child means they are failing. I localise the cause to the upper airway, lower airway, lung tissue, or the pump and drive, and I escalate support in steps while treating the cause." [1] [6] [8]

Branch A — Distress versus failure

Examiner: How do you tell respiratory distress from respiratory failure at the bedside? Candidate: Distress is high but effective work of breathing — tachypnoea, recession, flaring, grunting — with maintained saturations and a normal conscious state. Failure is when that effort no longer succeeds: hypoxaemia despite oxygen, carbon dioxide retention, a falling respiratory rate, a quieter chest, and altered alertness. The direction of the effort matters more than any single number. [1] [8]

Branch B — The quiet, tiring child

Examiner: A child who was working hard now looks calmer with a slower rate. Reassuring? Candidate: No — this is the most dangerous trap in the topic. A falling rate with reducing recession but no real improvement, a quieter chest, and drowsiness signal exhaustion and impending arrest. I call for help, deliver bag-mask ventilation with oxygen, and prepare to intubate rather than interpret the calmer picture as recovery. [1] [8]

Branch C — Localising by sound

Examiner: How does the character of the breathing help you? Candidate: Stridor points to the upper airway, wheeze with prolonged expiration to the lower airways, crackles and focal signs to the lung tissue, and poor, shallow, irregular effort to the pump or central drive. A silent chest in a struggling child means too little air is moving to make a sound. Localising the compartment directs the specific treatment. [6]

Branch D — Escalating support

Examiner: A hypoxaemic infant with bronchiolitis is not improving on low-flow oxygen. What next? Candidate: I escalate to heated humidified high-flow nasal cannula, which reduces escalation of care in bronchiolitis, then to CPAP if high-flow fails, and to intubation and lung-protective ventilation if non-invasive support fails or the infant tires. The FIRST-ABC evidence informs how I choose between high-flow and CPAP rather than mandating one mode. [2] [5]

Branch E — Oxygen that does not work

Examiner: A child with pneumonia stays hypoxaemic despite high-concentration oxygen. Why? Candidate: This is shunt — blood passing lung units that are consolidated or collapsed and cannot oxygenate it. More oxygen alone will not fix it; positive airway pressure recruits lung and improves oxygenation. If this is evolving paediatric acute respiratory distress syndrome, I apply the PALICC-2 approach and involve intensive care. [6]

Branch F — Not primarily the lungs

Examiner: A febrile toddler is tachypnoeic but the chest is clear. What are you thinking? Candidate: Fast breathing without lung signs may be compensatory — sepsis, metabolic acidosis such as diabetic ketoacidosis, or shock. I run the sepsis pathway in parallel, since respiratory dysfunction is a core organ-failure domain in the paediatric sepsis criteria, and I look for the underlying cause rather than assuming primary lung disease. [8]

Branch G — Listening to the parent

Examiner: The parent insists the child is worse than the observations suggest. Your response? Candidate: Caregiver concern is independently associated with critical illness, so I treat it as data. I reassess the child fully, escalate my level of concern and monitoring rather than reassure on a single normal reading, and I keep the child under close observation. [12]