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SOB…not what you think it means! A short list of respiratory distress signs that you should know.

It’s always hard to say goodbye to summer isn’t it?— But I really like September. The weather is still warm and nice enough to feel good, and I don’t know about you but by the end of August I’m ready (as are my kids, even though they won’t admit it) for my kids to go back to school, so by mid-September everyone is sort of getting back to a regular routine. I’m not gonna lie…I very much appreciate a quiet house at 9am and the chance to drink some coffee peacefully and have a little alone time. So that’s the good part.

The “less good” part is that by mid-September children have been in enclosed spaces like classrooms long enough to allow viruses to really live their best lives and circulate like crazy, and the ragweeds and other allergens are flying through the air with the greatest of ease. What that means for primary, acute, urgent care, and emergency clinicians is that the numbers of children with asthma and wheezing and croup and other respiratory illnesses starts to increase. It’s like clockwork: sometime around 3 weeks into the school year we start seeing an uptick in kids coming in with respiratory distress. We often shorten it to ‘SOB’: shortness of breath.

I’m sure it won’t surprise you to hear that kids arrive for medical care with varying degrees of sickness. One tough thing about breathing difficulty is that it can turn south in the blink of an eye, so since I’ve talked about pneumonia and specific issues related to asthma in other blog entries, today I want to review some signs of respiratory distress so that should you encounter someone experiencing this you’ll recognize it on the earlier side, which is always handy given the “turn south in the blink of an eye” phrase used above.

Most people look for rapid breathing as the primary sign of respiratory distress.

This makes sense since it is indeed one of the primary signs, but it’s important to understand that what’s normal and what isn’t for kids depends on their age. For example, babies breathe quite comfortably at a rate of 40 breaths per minute but a 15 year old with a similar respiratory rate would be in significant distress. So we must incorporate AGE into our assessment of breathing rate.

Color change is another sign that is brought up often.

Fair enough, it’s an obvious one that someone turning blue or pale is sick and isn’t oxygenating properly, so likely is in respiratory distress. I want to emphasize here that color change can be a serious late finding, so when I hear about this sign I get concerned that the breathing problems has been going on for longer than anyone thought or has progressed more rapidly than anyone realized. Turning blue and even a persistent pale hue needs to be assessed immediately.

It definitely helps to know some more subtle signs of respiratory distress that might trigger earlier medical intervention, so let’s review them now in the spirit of identifying respiratory distress as early as possible, potentially preventing a situation from becoming critical.

Nasal flaring.

This is fairly self-explanatory, but when the nostrils flare or move in and out this is a sign that the body is working harder than normal to get oxygen into the lungs.


Again, this word says it all, but this is more common in babies with shortness of breath. They actually make a grunting noise at the end of expiration, and this noise is the body’s effort to increase pressure in the lungs to help keep them open to optimize oxygen exchange.


Retractions are often described as “pulling” between the muscles in the chest. These can occur above the sternum, between the ribs, or just below the ribcage, and another way of maximizing oxygen delivery into the body.

Noisy Breathing.

Breathing should be quiet, so any extra sound, whether it’s wheezing or stridor or a bark-like cough, needs to be investigated. Not all wheezing means asthma, for example, as an inhaled foreign body can mimic wheezing sounds, albeit usually only on one side. But this needs assessment to determine cause.

Mental Status.

A late and ominous finding, but as respiratory distress progresses to respiratory failure, increased confusion and/or somnolence can occur as oxygenation to the brain decreases.

Hope this helps a little. In my opinion, this short list is a manageable summary of key elements to be familiar with to recognize respiratory distress, hopefully on the early side, so you can get back to enjoying your quiet time in September.