dysphagia suggest partial airway obstruction Children with abnormal auscultatory findings (i.e., wheeze, rales, rhonchi, and/or asymmetric breath sounds) and fever are likely to have infectious etiologies (e.g., pneumonia or bronchiolitis) Patients can be further categorized on the basis of tachypnea ( Fig 71.1B ) Children with rapid respirations and fever may have pneumonia, even in the absence of rales; empyema, pulmonary embolism, and encephalitis are also important considerations Tachypnea without fever points to trauma, cardiac disease, metabolic disturbances, toxic ingestions, or exposures Febrile children without tachypnea may have apnea or bradypnea as late manifestations of CNS infection In afebrile patients, considerations include CNS depression, spinal cord injury, neuromuscular disease, and neonatal apnea Diagnostic tests should be performed selectively to evaluate for diagnoses suggested by history and physical examination ( Table 71.9 ) Laboratory tests can inform respiratory status and diagnosis Airway and chest radiographs can be helpful in determining the site and often the etiology of respiratory distress, and may provide insights into the likely clinical course Flexible nasopharyngoscopy can help identify some etiologies of upper airway obstruction, as indicated Ultrasound may also provide information on diagnosis, as well as guide the management ( Table 71.10 ) Pulmonary ultrasound can be used to evaluate for pneumonia, pleural effusion, pneumothorax, and hemothorax Cardiac ultrasound can be used to detect presence of a pericardial effusion and assess overall cardiac function As appropriate, ultrasound findings can then be confirmed with chest x-ray or formal echocardiogram For complete details on pulmonary and cardiac ultrasound technique and findings, please refer to Chapter 131 Ultrasound Treatment Regardless of the cause of respiratory distress, aggressive treatment must be initiated immediately to rapidly address airway patency, oxygenation and ventilation ( Table 71.6 ) In the alert patient, establish and maintain the position that maximizes respiratory function Every effort should be made to avoid agitating the child Supplemental oxygen can be administered using nasal cannula, high-flow nasal canula, and simple or nonrebreather mask Noninvasive positive pressure ventilation, in the form of CPAP or BPAP may be trialed to decrease work of breathing and improve respiratory status In the patient with decreased sensorium, positioning the airway by chin lift (contraindicated if neck injury is suspected) or jaw thrust may relieve soft tissue obstruction of the airway The oral cavity should be cleared of secretions, vomitus, blood, and visible