Respiratory Distress vs Respiratory Failure in Children

Respiratory problems are the commonest route to cardiac arrest in children, so the first question in every PALS respiratory case is how severe it is. The PALS course divides it into distress, where the child is compensating, and failure, where they no longer can.

Signs of respiratory distress

• Fast breathing for age — see vital signs by age.
• Increased effort: nasal flaring, retractions, use of accessory muscles.
• Abnormal sounds: stridor, wheeze, grunting.
• A child who is still alert, responsive and a good colour.

Signs of respiratory failure

• Breathing that becomes very fast and then slows, or becomes irregular.
• Reduced effort as the child tires — a dangerous “improvement”.
• Falling oxygen saturation despite oxygen, cyanosis.
• Drowsiness, reduced response or agitation.
• Bradycardia — a late, ominous sign.

What changes in treatment

Distress: position of comfort, oxygen, treat the cause and monitor closely. Failure: support ventilation with a bag-mask — see bag-mask ventilation — call for advanced help and prepare for an advanced airway.

Then identify the type

Severity is half the categorisation; the other half is type: upper airway obstruction, lower airway obstruction, or lung tissue disease and disordered control of breathing. See the systematic approach.

This guide summarises what the PALS course teaches, for education only. It is not a clinical protocol: follow the current American Heart Association guidelines, linked below, and your institution’s paediatric policies.

More PALS guides: PALS assessment, algorithms and skills

• PALS Course in Abu Dhabi — dates, format and booking
• The PALS Systematic Approach: Assess, Categorise and Treat a Sick Child
• Upper Airway Obstruction in Children: Croup, Foreign Bodies and Anaphylaxis
• Lower Airway Obstruction in Children: Asthma and Bronchiolitis
• Lung Tissue Disease and Disordered Control of Breathing in PALS
• Shock in Children: The Four Types Taught in PALS
• Septic Shock in Children: Recognition and the First Hour
• Fluid Resuscitation in Children: Boluses and Reassessment
• PALS Bradycardia Algorithm: Oxygen First, Then CPR and Drugs
• PALS Tachycardia: Sinus Tachycardia vs SVT in Children
• PALS Cardiac Arrest Algorithm: Shockable and Non-Shockable Rhythms
• PALS Post-Cardiac Arrest Care: After ROSC in Children
• PALS Drugs: Adrenaline, Adenosine, Amiodarone, Atropine and More
• Weight-Based Dosing in PALS: Estimating Weight and Avoiding Errors
• Intraosseous (IO) Access in PALS: When and How It Is Used
• Paediatric Vital Signs by Age: Heart Rate, Breathing and Blood Pressure
• PALS Defibrillation and Cardioversion: Energies per Kilogram
• All PALS guides, by topic

Other life support and first aid courses: BLS Course · ACLS Course · First Aid Course · Training calendar

Frequently asked questions

What is the difference between respiratory distress and failure?

In distress the child compensates and maintains oxygenation and ventilation; in failure they can no longer do so.

Why is a tiring child dangerous?

Reducing effort can mean the child is exhausted and heading into respiratory failure.

Is bradycardia a sign of respiratory failure?

It can be a late sign of hypoxia and imminent arrest.

What is the treatment for respiratory failure?

Assisted ventilation, oxygen, treating the cause and advanced help.

Is this tested in PALS?

Yes, in case scenarios and the written test.

Sources and further reading

What we teach follows the awarding body and the UAE health authorities. For the definitive position on a course or licensing question, these are the places to check.

• CPR and ECC Guidelines — American Heart Association
• PALS course options — American Heart Association

Last reviewed 21 September 2026 by the training team at Safety First Medical Services, an American Heart Association training centre at Addax Office Tower, Al Reem Island, Abu Dhabi. Call +971 55 761 9841 or email training@safetyfirstmed.ae.