Respiratory Emergencies practice questions

Answer: D) Brief resolved unexplained event (BRUE)

An infant under 1 year who has a brief, self-resolved episode of pallor and irregular breathing, with no cause found on history and exam, meets the definition of a BRUE. BRUE replaced the older term ALTE in 2016.

• AIncorrect. ALTE is the older term. The 2016 American Academy of Pediatrics guideline replaced it with BRUE and added risk stratification.
• BIncorrect. A febrile seizure needs a fever, and this infant is afebrile. Febrile seizures also usually occur in children older than 6 months.
• CIncorrect. Breath-holding spells are triggered by crying or being upset. This event happened during sleep with no crying beforehand, and an identifiable trigger would not fit an 'unexplained' event.
• DCorrect. A BRUE is a sudden, brief (under 1 minute), now-resolved episode in an infant younger than 1 year. It involves color change (cyanosis or pallor), abnormal breathing, a marked change in tone, or altered responsiveness, with no cause found after an appropriate history and exam.

Answer: B) Pleural effusion

• AIncorrect. This causes hyperresonance.
• BCorrect. Fluid in the pleural space dampens sounds.
• CIncorrect. This causes wheezing.
• DIncorrect. This causes stridor.

Answer: D) Epinephrine 0.5 mg IM in the anterolateral thigh

Intramuscular epinephrine in the anterolateral thigh is given first in anaphylaxis. Bronchodilators, antihistamines, steroids, and fluids are add-ons.

• AIncorrect. Albuterol helps bronchospasm that persists, but it's an add-on. It doesn't reverse airway swelling or low blood pressure, and it shouldn't delay epinephrine.
• BIncorrect. Antihistamines may help hives and itching, but they haven't been shown to help in anaphylaxis and don't treat airway or circulatory compromise. They come after epinephrine.
• CIncorrect. Steroids are given to shorten the reaction or reduce a biphasic reaction. They act slowly and aren't first-line.
• DCorrect. IM epinephrine 0.3–0.5 mg (1 mg/mL) is the first-line treatment for anaphylaxis. The thigh is preferred over the deltoid.

Answer: B) Give supplemental oxygen to keep SpO2 at about 95% or higher, repeated inhaled albuterol, and early systemic corticosteroids

An acute asthma exacerbation in pregnancy is treated as aggressively as in any adult: oxygen to keep SpO2 at about 95% or higher, inhaled short-acting beta-agonists, and early systemic corticosteroids. Maternal hypoxia from undertreated asthma is a greater risk to the fetus than these medications.

• AIncorrect. Systemic corticosteroids should not be withheld in pregnancy when they are indicated. An undertreated exacerbation, and the maternal hypoxia it causes, puts the fetus at greater risk than the medication does.
• BCorrect. Acute asthma in pregnancy is managed the same way as in other adults. Oxygen is titrated to an SpO2 of about 95% or higher, and inhaled short-acting beta-agonists and early systemic corticosteroids are given promptly, because maternal hypoxia is the main threat to the fetus.
• CIncorrect. Beta-blockers, including cardioselective ones at higher doses, can worsen bronchospasm. They are inappropriate during an acute asthma exacerbation.
• DIncorrect. During an exacerbation, maternal oxygen saturation should be kept at about 95% or higher to prevent fetal hypoxia. A saturation of 90%–92% is not acceptable in this setting.

Answer: D) Thrombolytic therapy

• AIncorrect. The patient is unstable.
• BIncorrect. That isn't enough.
• CIncorrect. They worsen hypotension.
• DCorrect. It can dissolve the clot quickly.

Answer: A) Single dose of oral dexamethasone

Barking cough, hoarseness, low-grade fever and stridor in a toddler indicate croup. Mild cases are treated with a corticosteroid such as dexamethasone, with nebulized epinephrine added for more significant stridor.

• ACorrect. This is mild viral croup. A corticosteroid reduces airway inflammation and is the main treatment. Nebulized epinephrine is reserved for more significant stridor, such as stridor at rest.
• BIncorrect. Croup is a clinical diagnosis, and a throat culture adds nothing. Agitating a child with upper airway narrowing can worsen stridor.
• CIncorrect. Croup is usually viral. Antibiotics are used only if a bacterial infection is present, and nothing here suggests one.
• DIncorrect. Albuterol treats lower airway bronchospasm. The obstruction in croup is subglottic swelling, which responds to steroids and, when severe, nebulized epinephrine.

Answer: A) Nebulized albuterol and ipratropium, systemic corticosteroids, an antibiotic, and oxygen titrated to SpO2 88% to 92%

A COPD exacerbation is treated with short-acting bronchodilators (albuterol/ipratropium), systemic corticosteroids, and antibiotics when infection is likely. Oxygen is titrated to SpO2 88% to 92%, and NIV is used for hypercapnic respiratory failure.

• ACorrect. Short-acting bronchodilators, systemic corticosteroids, and antibiotics when infection is suggested (purulent sputum) are the core of exacerbation treatment. Controlled oxygen targets SpO2 88% to 92%. Noninvasive ventilation is added for hypercapnic respiratory failure.
• BIncorrect. Uncontrolled high-flow oxygen can worsen ventilation-perfusion mismatch and hypercapnia in COPD. Oxygen should be titrated to 88% to 92%. This plan also omits an antibiotic despite purulent sputum.
• CIncorrect. Nothing here suggests heart failure that would call for diuresis. Antibiotics for an exacerbation with purulent sputum are started empirically, not held for culture results. Steroids are also missing.
• DIncorrect. Acute exacerbations are treated with short-acting nebulized bronchodilators and systemic corticosteroids right away. Spirometry is not performed during an acute exacerbation to decide on steroids.

Answer: B) An air leak

• AIncorrect. Intermittent bubbling with breathing can be normal; continuous is not.
• BCorrect. Check connections and the insertion site.
• CIncorrect. A blocked tube stops fluctuation.
• DIncorrect. This doesn't show healing.

Answer: B) Impending respiratory failure from fatigue and rising CO2

In severe asthma, a silent chest with decreasing consciousness and a slowing respiratory rate means minimal air movement and hypercapnia. This is impending respiratory failure, not improvement, and calls for immediate escalation of care.

• AIncorrect. Real improvement brings better alertness and oxygenation. Here the patient is drowsier and hypoxic, so the loss of wheezing reflects very little air movement, not open airways.
• BCorrect. A silent chest, slowing respirations and decreasing consciousness signal exhaustion and hypercapnia. The patient needs immediate escalation and preparation for ventilatory support.
• CIncorrect. Hyperventilation from anxiety does not cause hypoxemia or obtundation. Drowsiness with a falling respiratory rate points to CO2 retention, not anxiety resolving.
• DIncorrect. Vocal cord dysfunction typically causes inspiratory stridor and throat tightness, usually with preserved oxygenation. It does not explain progressive lethargy and a silent chest.

Answer: B) Foreign body aspiration

• AIncorrect. Unilateral findings suggest aspiration.
• BCorrect. Bronchoscopy may be needed.
• CIncorrect. That causes stridor and a barking cough.
• DIncorrect. The sudden onset suggests aspiration.