PE25.1-6 | Respiratory System — Graded Quiz

Correct. Watchful waiting for 48–72 hours is appropriate in children ≥2 years with mild-moderate AOM (unilateral, no severe otalgia, temperature <39°C) without complications. If symptoms worsen or fail to improve, high-dose amoxicillin (80–90 mg/kg/day) is initiated. Children <6 months, children with bilateral AOM, or those with otorrhoea need immediate antibiotics.

AOM watchful waiting: appropriate only in children ≥2 years, mild symptoms, unilateral disease. Antibiotic: amoxicillin 80–90 mg/kg/day. Always treat immediately: age <6 months, bilateral AOM, perforation/otorrhoea, immunocompromised, severe pain/fever ≥39°C.

The correct answer is B. Watchful waiting applies to children ≥2 years with mild uncomplicated AOM. It is NOT appropriate for infants <6 months, bilateral AOM, or severe disease. When antibiotics are needed, high-dose amoxicillin is first-line — not azithromycin.

Correct. After securing the airway, the antibiotic of choice for Hib epiglottitis is IV ceftriaxone (a third-generation cephalosporin). It covers beta-lactamase-producing H. influenzae strains that are ampicillin-resistant. Note that this child is immunised but can still develop Hib disease — vaccine failure occurs, especially with incomplete series.

Epiglottitis management: DO NOT examine throat → secure airway in theatre → IV ceftriaxone (third-generation cephalosporin). The Hib vaccine has nearly eliminated epiglottitis in fully immunised populations. Hib vaccine schedule in India: at 6, 10, 14 weeks (with pentavalent vaccine) + booster at 18 months.

The correct answer is B. IV ceftriaxone is first-line for epiglottitis as it covers beta-lactamase-producing Hib strains. Ampicillin alone may fail (30–40% of H. influenzae are beta-lactamase producers). Oral antibiotics are inappropriate for severe infection. Metronidazole covers anaerobes, not Hib.

Correct. For mild-moderate croup (Westley score 1–7), a single dose of oral dexamethasone 0.15–0.6 mg/kg is the evidence-based treatment of choice. It reduces inflammation, decreases hospitalisation rates and the need for intubation. Humidified mist therapy is NOT evidence-based. Nebulised salbutamol is for asthma/bronchospasm, not croup. Intubation is only for severe croup with impending respiratory failure.

Westley Croup Score: 0 = no symptoms; 1–2 = mild; 3–7 = moderate; 8–11 = severe; >11 = extreme. Treatment: ALL severities benefit from dexamethasone 0.15–0.6 mg/kg single dose. Add nebulised adrenaline for moderate-severe (score ≥4). Observe for 4 hours post-adrenaline (rebound effect).

The correct answer is B. Dexamethasone is the cornerstone treatment for all severities of croup. Humidified mist is no longer recommended (RCTs show no benefit). Salbutamol treats bronchospasm, not supraglottic/subglottic oedema. Intubation is reserved for Westley score >11 with impending failure.

Correct. In mild-moderate laryngomalacia with adequate weight gain, the management is conservative (reassurance, positional advice, anti-reflux measures if GERD is present). Most cases of laryngomalacia resolve spontaneously by 18–24 months as laryngeal cartilage matures. Surgery (supraglottoplasty) is reserved for severe cases with failure to thrive, cyanosis, or recurrent apnoea.

Laryngomalacia: the most common cause of infant stridor. Management stratification: mild (normal growth, no cyanosis) = expectant; moderate (feeding difficulty, mild growth impact) = anti-reflux ± positional; severe (FTT, cyanosis, apnoea) = supraglottoplasty. Resolves spontaneously in >90% by 18–24 months.

The correct answer is B. Mild laryngomalacia with normal growth requires only reassurance and follow-up. Supraglottoplasty is reserved for severe cases with failure to thrive or cyanotic episodes. Tracheostomy is a last resort. Systemic steroids have no role in laryngomalacia.

Correct. If the child has EFFECTIVE COUGH (can cry, cough forcefully, breathe), do NOT interfere with back blows or thrusts — let the child dislodge the object naturally. Intervene only if the cough becomes ineffective (silent cough, cyanosis, decreasing consciousness). At age 15 months (>1 year), if intervention needed: abdominal thrusts (not chest thrusts). Blind finger sweeps are NEVER performed.

Foreign body BLS algorithm: Effective cough → encourage coughing only. Ineffective cough (or unconscious): <1 year = 5 back blows + 5 chest thrusts; >1 year = 5 back blows + 5 abdominal thrusts. NEVER blind finger sweep. Definitive = rigid bronchoscopy. Right main bronchus is most commonly affected.

The correct answer is B. An effective cough generates more airway pressure than any external manoeuvre. When the child is conscious with effective cough: encourage coughing, do not intervene physically. Blind finger sweeps are dangerous at any age. Bronchoscopy is needed if obstruction persists, not as an immediate first step.

Correct. Management of bronchiolitis is supportive. Core treatments are supplemental oxygen (target SpO2 ≥94%), hydration (NG/IV if unable to feed), and nasal suctioning. Bronchodilators, corticosteroids, antibiotics, and ribavirin are NOT routinely recommended. Hypertonic saline may reduce length of hospital stay but has no proven mortality benefit.

Bronchiolitis management: SUPPORTIVE only. O2 target SpO2 ≥94%, hydration (NG > IV), nasal suctioning. DO NOT use: bronchodilators, corticosteroids, antibiotics (unless secondary bacterial infection), ribavirin (except immunocompromised). Admission criteria: SpO2 <92%, unable to feed (>50% normal intake), severe retractions, age <6 weeks.

The correct answer is B. Bronchiolitis management is supportive only — O2, hydration, suctioning. Bronchodilators and steroids are NOT recommended (multiple RCTs show no benefit). Ribavirin is used only in severely immunocompromised patients. Hypertonic saline reduces LOS modestly but has no mortality benefit.

Correct. IMNCI classification for a 3-year-old (12m–5yr age group): fast breathing = ≥40/min. This child's RR is 36/min, which is BELOW threshold, with no chest indrawing and no danger signs. Classification: NO PNEUMONIA (cough or cold). Treatment: soothing remedies, advise to return if worsens (unable to drink, worsening, fever persists >2 days, breathing worsens).

IMNCI triage: No pneumonia (RR below threshold, no indrawing, no danger signs) → soothing remedy + safety net. Pneumonia (fast breathing or chest indrawing) → amoxicillin 40 mg/kg/day ×5 days + follow up. Severe pneumonia (chest indrawing) → refer. Very severe (danger signs) → refer + pre-referral antibiotics.

The correct answer is B. The IMNCI fast-breathing threshold for a 1–5 year old is ≥40 breaths/min. RR 36/min is below this, so the child does NOT have 'pneumonia' classification. Without chest indrawing or danger signs, this is classified as 'No pneumonia — cough or cold.'

Correct. A foreign body acting as a check valve allows air in during inspiration but traps it on expiration. This causes ipsilateral hyperinflation with the mediastinum shifting AWAY from the obstructed side (to the LEFT in right-sided obstruction) on expiration. This is the 'obstructive emphysema' pattern. Decubitus X-ray (lateral decubitus, affected side down) accentuates the finding.

Foreign body aspiration CXR patterns: (1) Check-valve partial obstruction = hyperinflation + mediastinal shift AWAY on expiration. (2) Complete obstruction = atelectasis + mediastinal shift TOWARDS. Decubitus X-ray: normal lung deflates when dependent; hyperinflated lung stays expanded = positive sign for FBA. Gold standard: rigid bronchoscopy.

The correct answer is B. Check-valve partial obstruction → ipsilateral hyperinflation (air goes in, can't come out) → mediastinal shift to CONTRALATERAL side on expiration. Complete obstruction causes atelectasis with ipsilateral shift. Bilateral opacities suggest pneumonia/pulmonary oedema, not FBA.

Correct. Wheeze-associated LRTI (WALRI) is triggered by viral infections and is characterised by fever + viral prodrome (URTI) preceding the wheeze. Asthma exacerbations can also be triggered by viral URTIs, but in pure WALRI there is no pre-existing atopic history and the wheezing is episodic with viral illness. Bilateral wheeze, bronchodilator response, and eosinophilia can occur in both conditions.

WALRI vs Asthma: WALRI = wheeze only with viral URTI, no wheeze between episodes, often outgrows by age 5–6. Asthma = episodic wheeze with multiple triggers (exercise, allergens, cold), personal/family atopy, persistent pattern. Diagnosis of asthma in <5 years is clinical; spirometry not reliable. Both treated with bronchodilators acutely; ICS for recurrent/persistent asthma.

The correct answer is B. The key distinguishing feature of virus-triggered WALRI is a clear fever and URTI prodrome directly preceding wheeze onset. Bronchodilator response, bilateral wheeze, and eosinophilia can be found in both asthma and WALRI. The clinical context (age, atopic history, episodic pattern without viral trigger) differentiates them.

Correct. A Westley Croup Score >11 represents extreme/life-threatening croup. When nebulised adrenaline and corticosteroids fail to maintain oxygenation and consciousness, airway intubation is indicated. This should be done in a controlled environment with anaesthesia and ENT/paediatric surgical backup for emergency cricothyrotomy/tracheostomy if intubation fails.

Extreme croup (Westley >11): alert anaesthesia + ENT before patient deteriorates. Use tube 0.5–1 mm smaller than calculated size (subglottic oedema narrows the lumen). Post-extubation: continue dexamethasone, monitor for post-intubation subglottic oedema. Nebulised adrenaline rebound after 2–4 hours — observe in hospital for minimum 4 hours after last dose.

The correct answer is B. Westley score 13 = extreme croup with impending respiratory failure. When maximal medical therapy fails, intubation is mandatory. Heliox reduces work of breathing but does not clear obstruction. Flexible laryngoscopy risks precipitating total obstruction in a critically ill child — not appropriate here.