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  Respiratory distress is a common presenting complaint in

 young children. In assessing this, it is important to take an

organized approach. We recommend beginning with the vital

& audio-visual signs (outside) and working inward to the

quality of aeration and breath sounds (see above).

   Vital Signs.  It is tough to interpret a single vital sign in

isolation. For example, what diagnoses could explain an SpO2

of 75%? Pneumonia...FBA...? What about - SpO2 75% &

RR 2? Now, I bet you’re thinking more along the lines of

overdose or a neurologic cause! So in reviewing vital signs,

remember to obtain and report all the ones that pertain to the

area you are assessing, whether it be respiratory (RR/O2),

cardiovascular (HR/BP), or all five (Temp, RR/O2, HR/BP).

   Audio Signs. The audio signs of respiratory distress are

the the sounds you hear without a stethoscope. Stridor, thesound of upper airway turbulent airflow, can be heard with

 your ear alone (and sometimes from across the room!).

Additionally, you may hear sonorous respiratory sounds that

are nasopharyngeal in origin (e.g. congestion, snorting, or

stertor) when patients are stuffy or sleeping soundly.

   Visual Signs.  The visual signs of respiration can be hard

to describe and vary by age. Young children, when distressed,

usually breathe faster, harder, and louder. The best place to see

these visual signs are in the face (nasal flaring), neck (tracheal

tugging), and chest (suprasternal, intercostal, subcostal

retractions). Additionally, you might find that some older

children purse their lips a little as they breathe to auto-PEEP

their expiratory phase. In this case, their breathing could be

described as deliberate, as breathing this way takes a great deal of

concentration! Aeration. Aeration is meant to describe the loudness,

location, and quality of breaths heard when auscultating the

chest. Think of aeration as a comparison between what you’d

expect to hear with what you actually hear. For people with

thicker chest walls, you may expect to hear softer breath

sounds. However, if it is hard to auscultate breaths on a thin

toddler, that’s a problem! Ask yourself, is this softer/louder

than I expected? Are breath sounds missing in areas? Do they

sound qualitatively different?

  Breath Sounds.  When describing the pulmonary exam

on a patient, try to close with the auscultatory exam. Be

definitive in describing the location (e.g. diffusely, throughout,left/right, L lower lobe, bilateral bases, right apex, anteriorly,

posteriorly...etc) and quality of the sound (e.g. wheezing, coarse

wheezes, crackles, wet/coarse crackles, fine crackles...etc).

Here are a couple examples:

Moderate bronchiolitis (lower airway infection):

“...breathing 54, satting 90%, tachypneic with suprasternal retractions

and nasal flaring, mostly fair aeration, poor at the bases, with coarse wet

breath sounds and occasional end-expiratory wheezes...” 

Foreign body aspiration (upper airway process):

“...breathing 42, satting 86%, loud biphasic stridor, anxious and

tachypneic with nasal flaring and deep subcostal retractions, poor aeration,

with transmitted upper airway sounds...”

Respiratory Assessment

RESPIRATORY EXAM Consider upper vs lower 

adapted from Dieckmann R, ed. Pediatric Education for Prehospital Professionals.

2nd ed. Sudbury, MA: Jones & Bartlett Publishers, American Academy of Pediatrics; 2006.

RESPIRATORY EXAM

ORGANIZATION

1. VITAL SIGNS

a. RR & SpO2

2. AUDIO/VISUAL SIGNS (appearance)

a. Comfortable

b. Comfortably tachypneic

c. Tachypneic with suprasternal

retractions (in mild distress)

d. Tachypneic, flaring, head-

bobbing, and severely

retracting (in mod-severe

distress)

e. Could include audible stridor

or grunting - as these are

 heard without a stethoscope! 

3. AERATION

a. Good (hearing the volume of

breath sounds you expect)

b. Fair (lower than expected)

c. Poor (far lower than expected)

4. BREATH SOUNDS

a. Description + Location

i. Ex: Wheezing throughout

ii. Ex: Crackles in the LLL

   R   E   S   P   I   R   A   T   O   R   Y   A   S   S   E   S   S   M   E   N   T   A   N   D   D   I   S   T

   R   E   S   S   V  e  r  s   i  o  n

   2   0   1   2

SOUNDUPPER

vs

LOWER

EXAMPLES

STRIDOR(High-pitched sound made by turbulent

airflow through a partially obstructed

large, extrathoracic airway, generated

around the level of the glottis)

UPPER Croup, Foreign Body Aspiration (lodged in the

upper airway), Retropharyngeal Abscess,

 Anaphylaxis (upper airway swelling), Vascular

Ring/Sling, Laryngo/tracheomalacia, Subglottic

stenosis, Vocal cord paralysis, Tumor

STERTOR

(Lower-pitched, snoring sound that

comes from obstructions mainly in the

oronasopharynx)

UPPER Nasopharyngeal secretions, Tracheostomy noises

(when needing suctioning), Upper airway mucous,

Snoring, Obstructive sleep apnea

DIMINISHED/ABSENT BREATH

SOUNDS

UPPER or

LOWER

Completely obstructing FBA, SEVERE asthma,

Pleural effusion, Pneumonia

WHEEZING(High-pitched whistling sound made

from partial obstruction of the lowerairways, usually occurs on exhalation.)

LOWER  Asthma, Foreign Body Aspiration (to a lower

airway), Bronchiolitis, Anaphylaxis (lower airway

swelling), Cystic Fibrosis, Pneumonitis (inhalation

injury), Aspiration (via GER or other)

CRACKLES LOWER Pneumonia, Bronchiolitis, Fluid/mucous/blood in

lower airways, Heart Failure

HEAR Stridor with your EAR. Auscultate Wheezing with a Stethoscope