PALS Algorithm for Respiratory Distress vs. Failure

Pediatric fluid resuscitation can help children in breathing emergencies, but only when their respiratory distress or failure is recognised quickly and accurately. In the United States, each year, about 75,000 children are hospitalized for acute respiratory failure, with a mortality rate of around 7%. Therefore, you should be aware of the difference between when a child is breathing hard (distress) versus when they’re no longer getting enough air (failure). It allows you, as a caregiver, parent, or responder, to act quickly and get professional help while the child still has reserves. Whether at home, in school, or even at the clinic, early action matters. This guide shows you what the signs look like, why they happen, and how everyday helpers can spot warning signs and give children timely, potentially life-saving care.

Understanding Respiratory Distress, Respiratory Failure, and Paediatric Fluid Resuscitation

Respiratory distress means a child’s breathing is becoming difficult and the body is working harder to get enough air. You might see fast breathing, nasal flaring, retractions, or the use of neck and chest muscles. Oxygen is still getting through, but the effort is increased, and early support—such as oxygen or inhaled medications—can help prevent the situation from worsening.

Respiratory failure occurs when the child can no longer breathe well enough to maintain normal oxygen or carbon dioxide levels. Breathing may slow, weaken, or stop altogether. This is a medical emergency that requires immediate advanced support, such as assisted ventilation.

Paediatric fluid resuscitation involves giving fluids, usually through an IV, to restore blood volume and improve circulation in cases of shock, dehydration, or poor perfusion. While it does not directly treat breathing problems, it becomes essential when conditions like sepsis or dehydration worsen a child’s ability to breathe effectively or deliver oxygen to tissues.

How Do Respiratory Distress vs. Respiratory Failure Differ?

In the framework of the PALS respiratory algorithm (used by healthcare professionals), a child can move from respiratory distress to respiratory failure if the breathing work gets too heavy and the body’s compensation breaks down. Knowing the difference helps you recognize when to act quickly (for example, calling 911, giving oxygen if directed) rather than waiting.
Below is a table that lays out the key differences between the two stages.

Feature	Respiratory Distress	Respiratory Failure
Definition	The child is breathing harder or faster; the body is still trying to keep up.	The child’s breathing can no longer get enough oxygen or remove enough carbon dioxide; compensation fails.
Work of Breathing	Increased effort (retractions, nasal flaring, accessory muscle use)	Effort decreases or becomes ineffective (shallow, slow, or absent breaths)
Skin / Colour / Alertness	Usually alert, may show anxiety or unrest; skin may be pale or show mild cyanosis around lips/fingers	Confused, drowsy, or unresponsive; widespread cyanosis (bluish-grey) or mottled skin
Vital Signs / Compensation	Tachypnea (rapid breathing), tachycardia (fast heart rate), while the body compensates	Bradycardia (slow heart rate) or irregular breathing, slows or ceases; the body fails to compensate
Oxygen / Gas Exchange	Oxygen levels may be near normal; carbon dioxide only slightly elevated	Significant hypoxemia (low oxygen) and hypercapnia (high carbon dioxide) when measurable
When to Call for Emergency Help	You should call if distress worsens quickly, breathing looks very hard, or the child’s color/alertness changes	Call 911 immediately — this is a full medical emergency; breathing is failing, and collapse is possible
Typical Causes (common in children)	Asthma flare, croup, bronchiolitis, pneumonia, airway obstruction	Progression of those same causes plus neuromuscular weakness, severe infections, lung injury, and airway compromise

 

What Are the Right Steps to Manage Respiratory Distress?

After the 2023–24 viral surge, U.S. pediatric ER visits for breathing problems rose by over 71%, especially among children. Most cases respond to early oxygen or inhaled medications when treated quickly.

If you spot these signs, follow the steps for respiratory distress below: 

1. Call For Help Early: If you’re a lay responder and the child’s breathing is hard, noisy, with flaring nostrils, retractions under the ribs, start: call 911 or seek immediate care.
2. Position the Child: Keep them in the most comfortable breathing position (usually upright for older children, semi-upright or neutral head for infants) to ease the work of breathing.
3. Apply Prescribed Rescue Medication: If the child has an asthma plan, use the rescue inhaler (e.g., albuterol with spacer) as directed. For suspected croup, follow the plan or seek care.
4. Support Breathing Effort: Loosen tight clothing around chest/neck; keep the environment calm; give supplemental oxygen if available and you are trained, but do not delay calling for help.
5. Monitor Changes: Watch for worsening signs, such as slower or shallower breathing, blue lips/fingertips, drowsiness. If any of these appear, treat as escalating toward failure.
6. Prepare for Escalation: Lay responders should stay with the child, maintain airway patency, and be ready to give CPR if breathing stops.

Steps to Manage Respiratory Failure

During respiratory failure, the muscles tire, oxygen drops, and the brain and heart begin to suffer. At this point, advanced help is critical. Recognizing this shift quickly can save a child’s life. If breathing slows or stops, follow the respiratory failure steps below and call 911 immediately: 

1. Call 911 Immediately & Alert EMS: At the point of respiratory failure, the situation is critical. The child may be gasping, have very shallow breathing, or be unresponsive; advanced airway and ventilation are needed per PALS.
2. Ensure Airway is Open: For trained respondents/clinicians: assess for obstruction, clear visible secretions, consider airway adjuncts (or endotracheal intubation) per the PALS respiratory algorithm.
3. Provide Assisted Ventilation: Use bag-valve-mask (BVM) ventilation with 100% oxygen if available; for professionals, this may escalate to mechanical ventilation.
4. Supplement Oxygen and Monitor Saturation: Aim to correct hypoxemia; for professionals, monitor blood gases. For lay responders, focus on visibly improved color and alertness.
5. Correct Circulatory Problems (Clinical Use Only): In hospital settings, providers may use pediatric fluid resuscitation if breathing failure is linked to shock or poor circulation. 
6. Address Underlying Cause: In a hospital, treat status asthmaticus (see PALS asthma algorithm), severe croup, pneumonitis, or airway obstruction. Fluids, medications, and ventilation support as required.
7. Continuous Reassessment: Professionals follow the PALS loop: airway → breathing → circulation → definitive care. Lay responders must stay with the child, keep the airway open, and monitor until help arrives.
8. Prepare for Cardiac Arrest: In PALS, children in respiratory failure are at high risk of arrest. Once breathing fails and circulation falls, high-quality CPR and advanced life support follow.

Read More: How to Manage a Respiratory Arrest

Key Pediatric-Specific Considerations for Airway Management

Infants and children have unique airway anatomy and structure that requires more attention during respiratory support.  As per the 2020 AHA PALS Guideline, precise ventilation, airway positioning, and monitoring are essential. 

• Avoid excessive neck extension in infants. 
• Keep an infant’s airway neutral. 
• Use appropriately sized masks or oral/nasal airways and a tight bag-mask seal. 
• Ventilate with an advanced airway at 1 breath every 2-3 seconds. 
• Keep an eye out for signs of exhaustion, retractions, bradypnea, or cyanosis, and respond quickly to provide oxygen, airway support, or advanced airway management.

Why Continuous Learning is Important for Mastering PALS 

Respiratory emergencies are unexpected and require immediate, informed action. Online certification courses, such as PALS, enable healthcare providers to remain current with evidence-based guidelines with no constraints based on classroom scheduling or travel.

With online PALS certification, you are able to:

• Understand updated AHA guidelines in compliance with respiratory and cardiac emergencies. Apply PALS respiratory algorithms to manage distress and failure.
• Learn at your own convenience through interactive modules and graphic simulations.
• Strengthen your understanding and application of the respiratory distress and failure algorithms.
• Master management of asthma and croup through PALS croup treatment and treatment for moderate asthma (PALS) modules.
• Earn an accredited certification from home.

Online course promotes active learning through real-life scenarios that help in clinical decision-making, critical thinking, and appropriate steps to life-support interventions.

Read More: Importance of PALS Certification: An Introduction to Online Learning

Master Pediatric Emergency Response with the Right Training!

Effective management of respiratory distress and respiratory failure requires quick identification, systematic evaluation, and evidence-based care. Through advanced PALS training, healthcare providers learn essential interventions like airway management, oxygen therapy, and pediatric fluid resuscitation. By keeping these processes in check, healthcare professionals can stabilize the person and prevent further worsening.

With a flexible, accredited, and self-paced program, the online certification of PALS allows you to refine these life-saving skills and keep up with current clinical guidelines. Invest in your professional growth and be prepared to respond effectively during a respiratory crisis.

Frequently Asked Questions 

1. Can respiratory distress become failure rapidly?

Yes, once the reserves of the body are used up, deterioration can be rapid, particularly in the child. Early identification is of utmost importance.

2. How does PALS direct management of respiratory emergencies?

PALS offers a systematic “Evaluate → Identify → Intervene” algorithm with emphasis on airway, breathing, and circulation. It stresses identification of upper/lower airway issues, lung disease, or control of breathing abnormality, and general plus specific intervention.

3. Can a child recover completely after respiratory failure?

Yes, with immediate and proper intervention, complete recovery can occur. Delays, however, enhance the danger of permanent organ injury, neurological damage, or death.