Bronchiolitis — MCQs
2 months old child having birth weight 2kg, with poor feeding, very sleepy and wheezing. The diagnosis is?
A child with recent onset of upper respiratory tract infection after 2 days presents with acute onset of breathlessness, cough, and fever. Which of the following treatments is contraindicated?
A 6-month-old female infant is brought to the physician with a 2-day history of severe cough, wheezing, and respiratory distress. Physical examination shows rhinitis, mild cyanosis, and fever. Which of the following is the most likely etiology of this child's pulmonary infection?
A 3-month-old infant with no chest indrawing and a respiratory rate of 52/minute. The diagnosis is:
A 2 year child presented with low grade fever and stridor. What is the likely diagnosis?
Prophylaxis with cotrimoxazole is recommended in all situations except for which of the following?
A 4-year-old boy presents with low-grade fever, inspiratory stridor, and barking cough for the past 5 days. Examination reveals a hoarse voice, a moderately inflamed pharynx, and a slightly increased respiratory rate. His chest x-ray showed subglottic narrowing appearing like a steeple. Which among the following is not indicated in the treatment of this condition?
Which of the following conditions is most associated with digital clubbing in children?
A 2-month-old child with a birth weight of 2 kg presents with poor feeding, excessive sleepiness, and wheezing. What is the most likely diagnosis?
Which one of the following conditions does not typically present with inspiratory stridor in children?
Bronchiolitis Indian Medical PG Practice Questions and MCQs
Question 1: 2 months old child having birth weight 2kg, with poor feeding, very sleepy and wheezing. The diagnosis is?
- A. Very severe disease (Correct Answer)
- B. No evidence of pneumonia
- C. Severe respiratory infection
- D. No diagnosis
Explanation: ***Very severe disease*** - According to **WHO/IMNCI (Integrated Management of Neonatal and Childhood Illness) classification** for young infants (0-2 months), the presence of **danger signs** automatically classifies the condition as "Very severe disease" - This infant presents with two critical danger signs: **poor feeding** and **lethargy (very sleepy)**, along with respiratory symptoms (wheezing) - In young infants, any danger sign (poor feeding, lethargic/unconscious, convulsions, severe chest indrawing, central cyanosis) requires immediate classification as "Very severe disease" and **urgent referral** to higher center - This is a specific diagnostic classification used in pediatric emergency protocols, not a general term *Severe respiratory infection* - While the child has respiratory symptoms (wheezing), this classification would only be appropriate if respiratory distress was present **without danger signs** - The presence of danger signs (poor feeding, lethargy) escalates the classification to "Very severe disease" in the WHO/IMNCI protocol - In young infants (0-2 months), the classification system prioritizes danger signs over organ-specific diagnoses *No evidence of pneumonia* - This is incorrect as the infant clearly presents with respiratory symptoms (wheezing) and systemic signs of illness - The presence of wheezing, poor feeding, and lethargy indicates serious illness requiring urgent evaluation and treatment - This option contradicts the clinical presentation *No diagnosis* - This is incorrect as the WHO/IMNCI classification provides a clear diagnostic framework - The presence of danger signs in a young infant mandates classification as "Very severe disease" - A working diagnosis is essential for guiding appropriate management and urgent referral
Question 2: A child with recent onset of upper respiratory tract infection after 2 days presents with acute onset of breathlessness, cough, and fever. Which of the following treatments is contraindicated?
- A. Antipyretics
- B. Morphine (Correct Answer)
- C. Antibiotics
- D. O2 inhalation
Explanation: ***Morphine (CONTRAINDICATED)*** - Morphine is a **potent respiratory depressant** and is **absolutely contraindicated** in a child with acute breathlessness and respiratory infection. - It suppresses the respiratory drive, worsening hypoxia and potentially leading to **respiratory failure**. - The sedative effects mask crucial clinical signs of deteriorating respiratory status, delaying life-saving interventions. - **Opioids should never be used** in acute respiratory distress in children. *Antipyretics (NOT contraindicated)* - **Paracetamol** or **ibuprofen** are safe and appropriate for fever management in children with respiratory infections. - They improve patient comfort without adversely affecting respiratory function. - Fever reduction helps decrease metabolic demand and oxygen consumption. *Antibiotics (NOT contraindicated)* - Indicated when **bacterial pneumonia** or bacterial superinfection complicates the viral URI. - Choice depends on clinical assessment, chest X-ray findings, and laboratory markers (elevated WBC, CRP). - Common organisms include *Streptococcus pneumoniae* and *Haemophilus influenzae*. *O2 inhalation (NOT contraindicated)* - **Essential treatment** for hypoxia (SpO2 <92-94%) in acute respiratory distress. - Delivered via nasal prongs, face mask, or high-flow nasal cannula depending on severity. - Oxygen therapy is a **life-saving intervention** and should never be withheld.
Question 3: A 6-month-old female infant is brought to the physician with a 2-day history of severe cough, wheezing, and respiratory distress. Physical examination shows rhinitis, mild cyanosis, and fever. Which of the following is the most likely etiology of this child's pulmonary infection?
- A. Respiratory syncytial virus (Correct Answer)
- B. Cytomegalovirus
- C. Parainfluenza virus
- D. Adenovirus
Explanation: ***Respiratory syncytial virus*** - **Respiratory syncytial virus (RSV)** is the most common cause of **bronchiolitis** in infants and young children, characterized by cough, wheezing, and respiratory distress. - The age of the patient (6-month-old infant) and the clinical presentation, including rhinitis, cyanosis, and fever, are highly consistent with an RSV infection. *Cytomegalovirus* - **Cytomegalovirus (CMV)** infection primarily affects immunocompromised individuals or can cause congenital infections. - While CMV can cause respiratory symptoms, it typically manifests as **pneumonitis** in infants, often without the prominent wheezing seen in this case. *Parainfluenza virus* - **Parainfluenza virus (PIV)** is a common cause of **croup** (laryngotracheobronchitis) in infants and young children, characterized by a barking cough and stridor. - While PIV can rarely cause bronchiolitis, the typical presentation described, especially with prominent wheezing, is less characteristic of PIV compared to RSV. *Adenovirus* - **Adenovirus** can cause a variety of respiratory illnesses, including pneumonia, bronchitis, and pharyngitis. - While adenovirus can cause severe respiratory infections in infants, RSV is more frequently associated with the specific constellation of severe cough, wheezing, and respiratory distress in this age group.
Question 4: A 3-month-old infant with no chest indrawing and a respiratory rate of 52/minute. The diagnosis is:
- A. Severe pneumonia
- B. Pneumonia (Correct Answer)
- C. No pneumonia
- D. Very severe disease
Explanation: ***Pneumonia*** - A respiratory rate of 52/minute in a 3-month-old infant **meets the age-specific threshold for tachypnea** (respiratory rate ≥ 50 breaths/minute for infants 2-12 months according to IMCI guidelines). - In the **absence of chest indrawing**, the presence of fast breathing (tachypnea) alone classifies this as **pneumonia** per IMCI classification. - This requires **outpatient management with oral antibiotics** and close follow-up. *No pneumonia* - This diagnosis would apply if the respiratory rate was **< 50 breaths/minute** for this age group with no chest indrawing. - Since the respiratory rate is 52/minute (≥ 50/minute), this rules out "no pneumonia." *Severe pneumonia* - This diagnosis requires the presence of **chest indrawing** in addition to fast breathing. - The question explicitly states **"no chest indrawing,"** which excludes severe pneumonia. - Severe pneumonia would require **hospitalization and parenteral antibiotics**. *Very severe disease* - This diagnosis involves **danger signs** such as inability to drink or breastfeed, persistent vomiting, convulsions, lethargy, unconsciousness, or severe malnutrition. - None of these critical signs are mentioned in the clinical scenario. - Very severe disease requires **urgent hospitalization and injectable antibiotics**.
Question 5: A 2 year child presented with low grade fever and stridor. What is the likely diagnosis?
- A. Acute Laryngotracheobronchitis (Correct Answer)
- B. Acute Bacterial Tracheitis
- C. Acute Epiglottitis
- D. Foreign Body aspiration
Explanation: ***Acute Laryngotracheobronchitis*** - The combination of **low-grade fever** and **stridor** in a 2-year-old child strongly suggests **croup**, which is medically known as acute laryngotracheobronchitis. - Croup is characterized by **inflammation** of the larynx, trachea, and bronchi, often presenting with a **barking cough** and inspiratory stridor. The X-ray image would show the characteristic **steeple sign**. *Acute Bacterial Tracheitis* - This is a more severe bacterial infection that can present with stridor but typically shows **higher fever**, **toxic appearance**, and rapid clinical deterioration. - Unlike croup, bacterial tracheitis patients appear **more ill** and may have **purulent secretions** requiring more aggressive management. *Acute Epiglottitis* - A serious condition characterized by **rapid onset of high fever**, **dysphagia**, drooling, and a **"tripod" position**, which are not indicated by the given symptoms. - The stridor in epiglottitis is typically quieter and may indicate more severe airway obstruction compared to the characteristic stridor of croup. *Foreign Body aspiration* - While foreign body aspiration can cause stridor, it is typically an **acute event** with a sudden onset of choking, coughing, and respiratory distress. - There is no mention of a choking episode or sudden onset, and a low-grade fever is less typical for an uncomplicated foreign body aspiration.
Question 6: Prophylaxis with cotrimoxazole is recommended in all situations except for which of the following?
- A. All symptomatic HIV infected children > 5 years of age irrespective of CD4 (Correct Answer)
- B. All HIV infected infants less than 1 year age irrespective of symptoms or CD4 counts
- C. All HIV exposed infants till HIV infection can be ruled out
- D. As secondary prophylaxis after initial treatment for Pneumocystis jirovecii pneumonia
Explanation: ***All symptomatic HIV infected children > 5 years of age irrespective of CD4*** - Cotrimoxazole prophylaxis is generally recommended for HIV-infected children with **CD4 counts below certain thresholds** or **specific clinical scenarios**, not just based on age and symptoms alone for those > 5 years. - The guidelines often focus on preventing **Pneumocystis jirovecii pneumonia (PJP)** and other opportunistic infections in pediatric HIV, with a nuanced approach to older children based on immune status. *All HIV exposed infants till HIV infection can be ruled out* - **Cotrimoxazole prophylaxis** is strongly recommended for **all HIV-exposed infants** from 4-6 weeks of age until HIV infection is definitively ruled out. - This prevents **P. jirovecii pneumonia**, which has a high mortality rate in this vulnerable population. *All HIV infected infants less than 1 year age irrespective of symptoms or CD4 counts* - **Cotrimoxazole prophylaxis** is indicated for **all HIV-infected infants younger than 1 year of age**, regardless of their clinical symptoms or CD4 counts. - This is due to their **immature immune system** and high risk of **opportunistic infections**, especially PJP. *As secondary prophylaxis after initial treatment for pneumocystis carini pneumonia* - **Cotrimoxazole** is the **standard drug** used for **secondary prophylaxis** following successful treatment of **Pneumocystis jirovecii pneumonia (PJP)**. - This prevents recurrence of PJP, which can be life-threatening in immunocompromised individuals.
Question 7: A 4-year-old boy presents with low-grade fever, inspiratory stridor, and barking cough for the past 5 days. Examination reveals a hoarse voice, a moderately inflamed pharynx, and a slightly increased respiratory rate. His chest x-ray showed subglottic narrowing appearing like a steeple. Which among the following is not indicated in the treatment of this condition?
- A. Nebulized racemic epinephrine
- B. Intramuscular dexamethasone
- C. Helium oxygen mixture
- D. Parenteral cefotaxime (Correct Answer)
- E. Nebulized budesonide
Explanation: ***Parenteral cefotaxime*** - The clinical presentation (low-grade fever, inspiratory stridor, barking cough, hoarse voice) and the **steeple sign** on chest X-ray are classic for **croup (laryngotracheobronchitis)**, which is predominantly caused by **viral infections**, not bacterial. Therefore, antibiotics like parenteral cefotaxime are generally **not indicated**. - **Cefotaxime** is a broad-spectrum antibiotic used for serious bacterial infections; its use in viral croup would be inappropriate and could contribute to antibiotic resistance. *Nebulized racemic epinephrine* - **Nebulized racemic epinephrine** is a common and effective treatment for moderate to severe croup, as it helps to **vasoconstrict** the subglottic mucosa, reducing edema and improving airflow. - It provides temporary relief from symptoms, especially stridor, by reducing swelling in the airway. *Intramuscular dexamethasone* - **Dexamethasone**, a corticosteroid, is a cornerstone of croup treatment as it reduces inflammation and edema in the airway, improving respiratory symptoms. - It can be administered orally, intravenously, or intramuscularly, and provides sustained relief, typically for 24-48 hours. *Nebulized budesonide* - **Nebulized budesonide** is an alternative corticosteroid treatment for croup that delivers anti-inflammatory medication directly to the airway. - Studies show it is equally effective to dexamethasone for mild to moderate croup, though dexamethasone is often preferred due to ease of administration and longer duration of action. *Helium oxygen mixture* - A **helium-oxygen mixture (heliox)** is a therapeutic gas that is less dense than air, which can reduce the work of breathing in patients with severe airway obstruction, such as refractory croup. - By decreasing airway turbulence, heliox can temporarily improve air movement past the narrowed subglottic area.
Question 8: Which of the following conditions is most associated with digital clubbing in children?
- A. Croup
- B. Bronchiolitis
- C. Asthma
- D. Cystic fibrosis (Correct Answer)
Explanation: ***Cystic fibrosis*** - **Cystic fibrosis** is a common cause of **digital clubbing** in children due to chronic hypoxemia and lung disease, leading to abnormal growth of connective tissue at the nail beds. - The chronic lung infections, bronchiectasis, and airway obstruction characteristic of cystic fibrosis contribute to persistent **tissue hypoxia**, which is a primary driver of clubbing. *Croup* - Croup is an acute viral infection of the upper airway, primarily characterized by a **barking cough** and **stridor**, and generally resolves within a week without chronic complications like clubbing. - It does not cause chronic hypoxemia necessary for the development of digital clubbing. *Bronchiolitis* - **Bronchiolitis** is an acute viral infection of the lower respiratory tract, most common in infants, causing wheezing and respiratory distress, but it is typically a **short-lived illness** without chronic sequelae leading to clubbing. - This condition does not cause prolonged enough or severe enough **hypoxia** to result in clubbing. *Asthma* - While severe, uncontrolled **asthma** can cause intermittent hypoxia, it is typically not associated with chronic digital clubbing, especially in children, unless there are other coincident chronic lung conditions. - Digital clubbing is rare in asthma and often suggests an alternate or co-existing pathology, such as **bronchiectasis** or **cystic fibrosis**.
Question 9: A 2-month-old child with a birth weight of 2 kg presents with poor feeding, excessive sleepiness, and wheezing. What is the most likely diagnosis?
- A. Viral upper respiratory tract infection
- B. Severe pneumonia
- C. Bronchiolitis (Correct Answer)
- D. Congestive heart failure
Explanation: ***Bronchiolitis*** - This presentation in a 2-month-old, especially with a history of **low birth weight**, points to bronchiolitis, characterized by **poor feeding**, **excessive sleepiness**, and **wheezing**. - **Bronchiolitis** primarily affects infants under 2 years (peak 2-6 months) and presents with signs of **lower respiratory tract involvement** including wheezing, tachypnea, and respiratory distress, which can lead to fatigue and feeding difficulties. - The **wheezing** is the key distinguishing feature indicating **small airway inflammation** typical of bronchiolitis. *Incorrect: Viral upper respiratory tract infection* - While viral URTI can cause nasal congestion and rhinorrhea, it typically affects the **upper airways** (nose, pharynx). - **Wheezing** indicates **lower airway involvement**, making bronchiolitis more likely than simple URTI. - The combination of systemic symptoms (poor feeding, excessive sleepiness) with wheezing suggests more significant lower respiratory disease. *Incorrect: Severe pneumonia* - Though severe pneumonia can cause similar systemic symptoms, **crackles or rales** are more characteristic than **wheezing**. - Pneumonia typically presents with **fever**, **cough**, and **focal consolidation** on examination. - The predominant **wheezing** in this case points more toward bronchiolitis with its diffuse small airway involvement. *Incorrect: Congestive heart failure* - CHF is an important differential in low birth weight infants with poor feeding and respiratory distress. - However, CHF typically presents with **tachycardia**, **hepatomegaly**, **gallop rhythm**, and **bilateral crackles** rather than prominent wheezing. - The **wheezing** without cardiac signs makes bronchiolitis more likely than a primary cardiac cause.
Question 10: Which one of the following conditions does not typically present with inspiratory stridor in children?
- A. Laryngomalacia
- B. Acute epiglottitis
- C. Bronchiolitis (Correct Answer)
- D. Croup
Explanation: ***Bronchiolitis*** - This condition primarily affects the **small airways** (bronchioles) and is caused by inflammation and swelling, leading to **expiratory wheezing** and difficulty breathing, rather than inspiratory stridor. - While it can cause respiratory distress, the narrowing of the lower airways typically manifests as **wheezing and crackles**, not the harsh, high-pitched sound of inspiratory stridor associated with upper airway obstruction. *Laryngomalacia* - This is a common congenital condition characterized by the collapse of **supraglottic structures** during inspiration, leading to intermittent **inspiratory stridor** that is often worse when the infant is feeding, agitated, or supine. - The stridor is typically **soft and musical**, and usually improves spontaneously as the child grows. *Acute epiglottitis* - This is a severe and rapidly progressive bacterial infection of the **epiglottis**, which can cause significant **upper airway obstruction** and life-threatening inspiratory stridor. - Children with epiglottitis often present with a **sudden onset of high fever**, sore throat, **drooling**, and a **"tripod" position** (leaning forward with neck extended). *Croup* - This condition, typically caused by a viral infection, leads to **subglottic inflammation** and swelling, resulting in the characteristic **"barking" cough** and **inspiratory stridor**. - The stridor is due to the narrowing of the trachea below the vocal cords.
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