A 2-year-old boy with viral-induced wheeze is brought to hospital with increased work of breathing. His respiratory rate is 45/min, oxygen saturations 91% on air, and he has moderate subcostal recession. He has had three similar episodes in the past 6 months, all associated with viral infections. His growth is normal and there is no family history of atopy. He receives salbutamol nebuliser with oxygen and shows good response with saturations improving to 96%. What is the most appropriate ongoing management plan?
Q122
A 4-year-old girl presents with a 3-day history of fever up to 39.6°C, sore throat, and reduced oral intake. On examination, she appears unwell with temperature 39.2°C, heart rate 140 bpm, respiratory rate 28/min, and oxygen saturations 97% on air. She is drooling, has marked tender bilateral cervical lymphadenopathy, and examination of the throat reveals bilateral tonsillar enlargement with exudate. She has trismus and is unable to open her mouth fully. What is the most appropriate immediate management?
Q123
What is the recommended oxygen saturation target for children with acute asthma exacerbation receiving supplemental oxygen therapy?
Q124
A 16-month-old child presents to the emergency department with a temperature of 39.4°C for 18 hours. On examination, there is bilateral conjunctival injection without exudate, a polymorphous rash on the trunk, bilateral cervical lymphadenopathy with one node measuring 1.8 cm, cracked red lips, and swollen hands. Blood tests show: WBC 16.2 × 10⁹/L, CRP 85 mg/L, ESR 62 mm/hr, platelets 420 × 10⁹/L. What is the most important investigation to arrange urgently?
Q125
A 7-year-old boy with known asthma is brought to the emergency department with acute breathlessness. He is using accessory muscles, has oxygen saturations of 92% on air, heart rate 130 bpm, and peak expiratory flow rate (PEFR) 45% of predicted. Despite receiving three back-to-back salbutamol nebulisers with oxygen and ipratropium bromide, his clinical condition shows minimal improvement. What is the most appropriate next step in management?
Q126
A 9-year-old girl with poorly controlled asthma presents with wheeze and breathlessness. She uses salbutamol frequently and beclometasone 200 micrograms twice daily. Review of her technique shows she uses her MDI without a spacer and doesn't hold her breath after inhaling. Peak flow is 60% of her predicted best. After correcting inhaler technique and optimizing current therapy, what would be the most appropriate step in her management plan according to BTS/SIGN guidelines?
Q127
A 22-month-old child is brought to the emergency department following a brief seizure at home. The parents report the child had been unwell for several hours with fever (measured as 38.9°C at home). The seizure lasted approximately 3 minutes, was generalised tonic-clonic, and self-terminated. The child is now alert, responsive, and interactive. Temperature is now 37.6°C after paracetamol. Neurological examination is normal. The child had a similar episode 8 months ago. What is the most appropriate management?
Q128
A 13-month-old girl presents to the emergency department with a 4-day history of fever up to 40°C. Her parents report she has been more irritable than usual and has developed a rash today. On examination, she has temperature 38.9°C, heart rate 160/min, and a maculopapular rash predominantly on the trunk. Cardiovascular, respiratory, and abdominal examinations are normal. Blood tests show: Hb 105 g/L, WCC 19.5 × 10⁹/L (neutrophils 14.2), platelets 580 × 10⁹/L, CRP 168 mg/L, ESR 72 mm/hr, sodium 132 mmol/L, albumin 26 g/L. An echocardiogram is performed showing normal coronary arteries. What is the most appropriate management?
Q129
A 5-year-old boy with known asthma is brought to hospital by ambulance. He is receiving nebulised salbutamol via oxygen. On arrival, he has a respiratory rate of 50/min, heart rate 145/min, and oxygen saturations of 88% on 15L oxygen via nebuliser mask. He is drowsy, has silent chest on auscultation, and weak respiratory effort. An arterial blood gas shows: pH 7.18, PaCO2 8.9 kPa, PaO2 7.2 kPa, HCO3 24 mmol/L. What is the most critical next management step?
Q130
A 10-month-old infant presents with a 3-day history of coryzal symptoms followed by increasing respiratory distress. On examination, he has subcostal and intercostal recession, respiratory rate 65/min, oxygen saturations 91% on air, and fine inspiratory crackles bilaterally. He is taking only 50% of normal feeds. A chest X-ray shows hyperinflation with patchy infiltrates. What is the most appropriate initial management?
Acute Paediatrics UK Medical PG Practice Questions and MCQs
Question 121: A 2-year-old boy with viral-induced wheeze is brought to hospital with increased work of breathing. His respiratory rate is 45/min, oxygen saturations 91% on air, and he has moderate subcostal recession. He has had three similar episodes in the past 6 months, all associated with viral infections. His growth is normal and there is no family history of atopy. He receives salbutamol nebuliser with oxygen and shows good response with saturations improving to 96%. What is the most appropriate ongoing management plan?
A. Prescribe salbutamol inhaler via spacer to use as needed for wheeze episodes (Correct Answer)
B. Start regular inhaled corticosteroid (beclometasone) twice daily
C. Prescribe montelukast daily as maintenance therapy
D. Arrange skin prick allergy testing to identify triggers
E. Start regular long-acting beta-agonist (salmeterol) therapy
Explanation: ***Prescribe salbutamol inhaler via spacer to use as needed for wheeze episodes***
- This child presents with **episodic viral wheeze**, characterized by recurrent wheezing episodes exclusively triggered by viral infections, with no symptoms between episodes and no features of atopy.
- For **episodic viral wheeze**, the most appropriate management is a **short-acting beta-agonist (SABA)** like salbutamol, delivered via a spacer, to be used only as needed for acute symptoms, given his good response.
*Start regular inhaled corticosteroid (beclometasone) twice daily*
- **Inhaled corticosteroids (ICS)** are primarily indicated for children with **multi-trigger wheeze** or asthma, especially those with interval symptoms or atopy, indicating chronic airway inflammation.
- In this case, the wheeze is purely **viral-induced** and episodic, meaning there is no ongoing inflammation to target with daily ICS.
*Prescribe montelukast daily as maintenance therapy*
- **Montelukast**, a leukotriene receptor antagonist, might be considered in some cases of frequent or severe viral wheeze, but it is not typically the first-line discharge treatment for uncomplicated episodic viral wheeze without other indications.
- Given the child is well between episodes and responds acutely to salbutamol, continuous daily **maintenance therapy** with montelukast is generally not required.
*Arrange skin prick allergy testing to identify triggers*
- **Allergy testing** is not indicated here, as the history clearly points to **viral infections** as the sole trigger for wheeze, and there are no features of atopy (e.g., eczema, family history, or other allergic symptoms).
- The absence of **atopic features** and the clear viral trigger make allergy testing unlikely to yield relevant management information in this specific scenario.
*Start regular long-acting beta-agonist (salmeterol) therapy*
- **Long-acting beta-agonists (LABAs)** are not recommended as **monotherapy** due to safety concerns and are typically used in combination with an **inhaled corticosteroid** for persistent asthma in older children or adults.
- LABAs are generally not appropriate for the management of **episodic viral wheeze** in young children, which requires on-demand relief of acute symptoms rather than daily control.
Question 122: A 4-year-old girl presents with a 3-day history of fever up to 39.6°C, sore throat, and reduced oral intake. On examination, she appears unwell with temperature 39.2°C, heart rate 140 bpm, respiratory rate 28/min, and oxygen saturations 97% on air. She is drooling, has marked tender bilateral cervical lymphadenopathy, and examination of the throat reveals bilateral tonsillar enlargement with exudate. She has trismus and is unable to open her mouth fully. What is the most appropriate immediate management?
A. Prescribe oral penicillin V and arrange outpatient follow-up
B. Arrange urgent ENT assessment for possible peritonsillar abscess (Correct Answer)
C. Perform lateral neck X-ray to exclude retropharyngeal abscess
D. Administer single dose intramuscular dexamethasone and discharge
E. Give oral ibuprofen for analgesia and observe for 2 hours
Explanation: ***Arrange urgent ENT assessment for possible peritonsillar abscess***
- The presence of **trismus** (difficulty opening the mouth) and **drooling** in a child with severe tonsillitis and systemic symptoms are classic signs of a **peritonsillar abscess (Quinsy)**.
- This condition is an emergency requiring prompt **ENT evaluation** for potential **drainage** (aspiration or incision) and initiation of intravenous antibiotics to prevent airway compromise.
*Prescribe oral penicillin V and arrange outpatient follow-up*
- Oral antibiotics are insufficient for a patient with signs of a deep space infection and systemic illness, especially with **trismus** and **drooling** indicating a potential abscess.
- The child's overall unwell appearance, high fever, and reduced oral intake necessitate **hospital admission** for intravenous fluids and parenteral antibiotics, not outpatient management.
*Perform lateral neck X-ray to exclude retropharyngeal abscess*
- While a **retropharyngeal abscess** is a differential, the prominent **tonsillar enlargement with exudate** and **trismus** point more strongly towards a peritonsillar abscess.
- Imaging, particularly X-rays, may not be definitive and should not delay urgent surgical consultation for a potentially life-threatening **airway emergency**. A **CT scan with contrast** is more appropriate if a deep space infection is suspected.
*Administer single dose intramuscular dexamethasone and discharge*
- Dexamethasone may reduce inflammation but does not address the underlying **bacterial infection** or the mechanical obstruction caused by a **peritonsillar abscess**.
- Discharging a child who is unwell, drooling, and has **trismus** is unsafe due to the significant risk of **airway obstruction** and worsening infection.
*Give oral ibuprofen for analgesia and observe for 2 hours*
- While analgesia is important for comfort, it does not treat the serious underlying pathology of a **deep space neck infection** and potential abscess.
- Observing a patient with these red flag symptoms for only 2 hours is inadequate and delays definitive **medical and surgical management** required for a rapidly progressing infection.
Question 123: What is the recommended oxygen saturation target for children with acute asthma exacerbation receiving supplemental oxygen therapy?
A. ≥88%
B. ≥90%
C. ≥92%
D. ≥94% (Correct Answer)
E. ≥98%
Explanation: ***≥94%***- According to **BTS/SIGN guidelines**, the recommended oxygen saturation target for children during an **acute asthma exacerbation** is **≥94%**.- Maintaining this level ensures adequate **tissue oxygenation** while primary treatments like **bronchodilators** and **corticosteroids** work to relieve the airway obstruction.*≥88%*- This lower threshold is generally reserved for patients at risk of **hypercapnic respiratory failure**, such as those with **COPD** or **cystic fibrosis**.- In **acute pediatric asthma**, targeting such a low saturation could lead to significant **hypoxemia** and end-organ stress.*≥90%*- While 90% is a common general threshold, it is generally considered too low for optimal management of **acute pediatric asthma exacerbations**.- Current guidelines advocate for a higher target to ensure better outcomes and prevent complications from **hypoxemia**.*≥92%*- Although closer to the recommended target, **≥92%** still falls slightly below the optimal saturation aim for children with **acute asthma**.- Achieving a higher saturation of ≥94% provides a better safety margin for **respiratory stability** and reduces the risk of **clinical deterioration**.*≥98%*- Aiming for **≥98%** oxygen saturation is generally unnecessary and can even be detrimental in some situations due to the risks of **hyperoxia**.- **Hyperoxia** can lead to **resorption atelectasis**, increased **oxidative stress**, and potentially compromise the patient's respiratory drive.
Question 124: A 16-month-old child presents to the emergency department with a temperature of 39.4°C for 18 hours. On examination, there is bilateral conjunctival injection without exudate, a polymorphous rash on the trunk, bilateral cervical lymphadenopathy with one node measuring 1.8 cm, cracked red lips, and swollen hands. Blood tests show: WBC 16.2 × 10⁹/L, CRP 85 mg/L, ESR 62 mm/hr, platelets 420 × 10⁹/L. What is the most important investigation to arrange urgently?
A. Blood cultures prior to antibiotic therapy
B. Echocardiography to assess coronary arteries (Correct Answer)
C. Throat swab for bacterial culture
D. Lumbar puncture to exclude meningitis
E. Abdominal ultrasound to assess for hydrops of gallbladder
Explanation: ***Echocardiography to assess coronary arteries***- The clinical presentation of fever, **bilateral conjunctival injection without exudate**, **polymorphous rash**, **bilateral cervical lymphadenopathy**, **cracked red lips**, and **swollen hands** is highly suggestive of **Kawasaki disease**.- Urgent echocardiography is essential as **coronary artery aneurysms** are the most serious complication of Kawasaki disease, requiring prompt identification to guide therapy and prevent long-term cardiac morbidity.*Blood cultures prior to antibiotic therapy*- While fever and elevated inflammatory markers (WBC, CRP, ESR) can indicate infection, the specific constellation of symptoms strongly points to **Kawasaki disease** rather than typical bacterial sepsis.- Although cultures are important in febrile children, they are not the *most urgent* investigation given the immediate risk of **coronary artery damage** in Kawasaki disease, which requires prompt cardiac assessment and treatment.*Throat swab for bacterial culture*- This investigation is typically performed to rule out **Group A Streptococcus** infections, such as **scarlet fever**, which can share features like rash and pharyngitis with Kawasaki disease.- However, a throat swab does not address the critical risk of **coronary artery pathology** inherent to Kawasaki disease, making it less urgent than cardiac imaging.*Lumbar puncture to exclude meningitis*- While high fever is present, the absence of clear meningeal signs and the prominent **mucocutaneous manifestations** divert suspicion away from primary bacterial meningitis.- Although Kawasaki disease can cause **aseptic meningitis**, performing a lumbar puncture is not the most urgent diagnostic step compared to evaluating for **cardiac complications**.*Abdominal ultrasound to assess for hydrops of gallbladder*- **Hydrops of the gallbladder** is a known, though less common, complication of Kawasaki disease, often presenting with right upper quadrant pain.- While it can be seen, it is usually self-limiting and rarely causes significant long-term morbidity, making it far less critical to assess urgently than the **coronary arteries**.
Question 125: A 7-year-old boy with known asthma is brought to the emergency department with acute breathlessness. He is using accessory muscles, has oxygen saturations of 92% on air, heart rate 130 bpm, and peak expiratory flow rate (PEFR) 45% of predicted. Despite receiving three back-to-back salbutamol nebulisers with oxygen and ipratropium bromide, his clinical condition shows minimal improvement. What is the most appropriate next step in management?
A. Administer intravenous magnesium sulphate (Correct Answer)
B. Arrange immediate transfer to paediatric intensive care unit
C. Give oral prednisolone 30 mg
D. Continue salbutamol nebulisers hourly
E. Request chest X-ray before further treatment
Explanation: ***Administer intravenous magnesium sulphate***- The patient's condition (PEFR 45% predicted, SpO2 92%, accessory muscle use, tachycardia) indicates **acute severe asthma** that is not responding to initial intensive nebulised bronchodilator therapy (three back-to-back salbutamol with ipratropium).- **Intravenous magnesium sulphate** is recommended as the next line of treatment in children with acute severe asthma who show poor response to initial inhaled bronchodilators, acting as a **bronchodilator** by relaxing bronchial smooth muscle.*Arrange immediate transfer to paediatric intensive care unit*- **PICU referral** is typically considered for patients with **life-threatening asthma** or those who fail to respond to maximal emergency department treatment, including intravenous bronchodilators.- While consultation with PICU may be initiated early in severe cases, administering the next crucial medical intervention like **IV magnesium** is the immediate priority to stabilize the patient.*Give oral prednisolone 30 mg*- **Systemic corticosteroids** (e.g., prednisolone) are a fundamental part of acute asthma management and should be administered early, ideally upon arrival, to reduce inflammation.- However, given the failure to respond to initial bronchodilators and ongoing severe symptoms, the most appropriate *next step* is to escalate **bronchodilatory therapy** intravenously, rather than solely relying on oral steroids at this stage of non-response.*Continue salbutamol nebulisers hourly*- The patient has already received **intensive back-to-back salbutamol** and ipratropium with minimal improvement, indicating refractoriness to this regimen.- Simply continuing hourly nebulisers is insufficient and delays the necessary escalation to more potent **intravenous bronchodilators**, risking further deterioration into respiratory failure.*Request chest X-ray before further treatment*- A **chest X-ray** is not routinely recommended in the management of acute asthma unless specific complications like **pneumothorax**, consolidation, or foreign body aspiration are suspected.- Prioritizing imaging over immediate medical interventions for **bronchoconstriction** in a severely unwell child can dangerously delay life-saving treatment.
Question 126: A 9-year-old girl with poorly controlled asthma presents with wheeze and breathlessness. She uses salbutamol frequently and beclometasone 200 micrograms twice daily. Review of her technique shows she uses her MDI without a spacer and doesn't hold her breath after inhaling. Peak flow is 60% of her predicted best. After correcting inhaler technique and optimizing current therapy, what would be the most appropriate step in her management plan according to BTS/SIGN guidelines?
A. Add montelukast as adjunct therapy
B. Increase beclometasone to 400 micrograms twice daily
C. Add long-acting beta-agonist (LABA) such as salmeterol (Correct Answer)
D. Add oral theophylline
E. Switch to combination inhaler containing ICS and LABA
Explanation: ***Add long-acting beta-agonist (LABA) such as salmeterol***
- According to **BTS/SIGN guidelines** for children aged 5–12 years, adding a **LABA** is the preferred next step (Step 3) for patients whose asthma is poorly controlled on **low-dose ICS** (400 mcg/day beclometasone equivalent).
- If the addition of a LABA provides some benefit but control remains inadequate, the **ICS dose** should then be increased or a **Leukotriene Receptor Antagonist (LTRA)** added.
*Add montelukast as adjunct therapy*
- **Montelukast (LTRA)** is typically considered at Step 3 only if there is no response to a **LABA** or as an alternative if LABA is not tolerated.
- Current guidelines prioritize the addition of a **long-acting bronchodilator** before moving to other adjunct therapies in this age group.
*Increase beclometasone to 400 micrograms twice daily*
- Increasing to a **medium-dose ICS** (e.g., 800 mcg/day beclometasone) is reserved for Step 4 if Step 3 therapies fail to achieve control.
- The guidelines emphasize adding a **LABA** first to avoid the potential side effects associated with higher doses of **inhaled corticosteroids** in children.
*Add oral theophylline*
- **Theophylline** is considered a Step 4 or Step 5 treatment option for **difficult-to-control asthma**.
- Due to its narrow **therapeutic index** and requiring blood level monitoring, it is only used after LABA and increased ICS doses have failed.
*Switch to combination inhaler containing ICS and LABA*
- While a **combination inhaler** is often used for convenience, the guidelines technically advise **adding a LABA** to existing therapy first to assess the clinical response to the specific drug.
- Switching to a combination inhaler usually occurs after the benefit of the **LABA component** has been established and the doses are being consolidated.
Question 127: A 22-month-old child is brought to the emergency department following a brief seizure at home. The parents report the child had been unwell for several hours with fever (measured as 38.9°C at home). The seizure lasted approximately 3 minutes, was generalised tonic-clonic, and self-terminated. The child is now alert, responsive, and interactive. Temperature is now 37.6°C after paracetamol. Neurological examination is normal. The child had a similar episode 8 months ago. What is the most appropriate management?
A. Discharge with safety netting advice and information about febrile seizures (Correct Answer)
B. Admit for lumbar puncture to exclude meningitis
C. Commence prophylactic anticonvulsant therapy
D. Perform urgent CT head to exclude structural abnormality
E. Admit for observation and EEG in the morning
Explanation: ***Discharge with safety netting advice and information about febrile seizures***
- This patient presents with a **simple febrile seizure**, defined as a generalized seizure lasting **less than 15 minutes** that does not recur within 24 hours in a neurologically normal child.
- Since the child is now **alert, interactive**, and has a normal clinical examination, they do not require admission and management focuses on **parental education** regarding recurrence risk and seizure first aid.
*Admit for lumbar puncture to exclude meningitis*
- **Lumbar puncture** is not indicated as the child is over 18 months, is currently **clinically well**, and lacks meningeal signs or bulging fontanelles.
- This procedure is generally reserved for cases where there is high clinical suspicion of **meningitis** or the child is persistently lethargic.
*Commence prophylactic anticonvulsant therapy*
- **Prophylactic anticonvulsants** are not recommended for simple febrile seizures because the potential **side effects** of the medications outweigh the benefits for a benign condition.
- These seizures do not cause brain damage, and long-term medication does not prevent the subsequent development of **epilepsy**.
*Perform urgent CT head to exclude structural abnormality*
- Neuroimaging like a **CT head** is not indicated for simple febrile seizures in the absence of **focal neurological deficits**, trauma, or signs of increased intracranial pressure.
- Exposure to **ionizing radiation** should be avoided in children unless there is a clear clinical necessity to rule out an acute intracranial process.
*Admit for observation and EEG in the morning*
- An **EEG** is not routinely recommended after a simple febrile seizure as it is not predictive of seizure recurrence or the future development of **afebrile seizures**.
- Admission is unnecessary for a child who has returned to **neurological baseline** and has a clear underlying source of fever or is otherwise clinically stable.
Question 128: A 13-month-old girl presents to the emergency department with a 4-day history of fever up to 40°C. Her parents report she has been more irritable than usual and has developed a rash today. On examination, she has temperature 38.9°C, heart rate 160/min, and a maculopapular rash predominantly on the trunk. Cardiovascular, respiratory, and abdominal examinations are normal. Blood tests show: Hb 105 g/L, WCC 19.5 × 10⁹/L (neutrophils 14.2), platelets 580 × 10⁹/L, CRP 168 mg/L, ESR 72 mm/hr, sodium 132 mmol/L, albumin 26 g/L. An echocardiogram is performed showing normal coronary arteries. What is the most appropriate management?
A. Intravenous immunoglobulin 2 g/kg as a single infusion
B. Observe for 24 hours and repeat echocardiogram if fever persists
C. Intravenous ceftriaxone for presumed bacterial sepsis
D. Oral prednisolone and follow-up in paediatric clinic
E. Intravenous immunoglobulin 2 g/kg plus high-dose aspirin (30-50 mg/kg/day) (Correct Answer)
Explanation: ***Intravenous immunoglobulin 2 g/kg plus high-dose aspirin (30-50 mg/kg/day)*** - The patient presents with prolonged fever, rash, and specific lab abnormalities (elevated CRP/ESR, leukocytosis, thrombocytosis, hypoalbuminemia, hyponatremia) consistent with **incomplete Kawasaki disease**, especially given the age. - This combination therapy is the **standard of care** for acute Kawasaki disease to reduce inflammation and prevent **coronary artery aneurysms**, the most serious complication. *Intravenous immunoglobulin 2 g/kg as a single infusion* - While **IVIG** is a critical component, it is typically administered in conjunction with **aspirin** to maximize anti-inflammatory and antiplatelet effects and ensure optimal outcomes. - **IVIG monotherapy** is not the recommended initial treatment for the acute phase of Kawasaki disease. *Observe for 24 hours and repeat echocardiogram if fever persists* - Delaying specific treatment for suspected **Kawasaki disease** significantly increases the risk of irreversible **coronary artery damage**, which early intervention aims to prevent. - A **normal echocardiogram** at presentation does not rule out Kawasaki disease, as aneurysms often develop later in the illness course, requiring repeat evaluations as part of follow-up. *Intravenous ceftriaxone for presumed bacterial sepsis* - While bacterial **sepsis** is a differential, the specific constellation of lab findings including **thrombocytosis**, **hypoalbuminemia**, and **hyponatremia**, along with high inflammatory markers, strongly points towards an inflammatory vasculitis rather than typical bacterial sepsis. - Antibiotics will not address the underlying systemic **vasculitis** or prevent the characteristic cardiovascular complications of Kawasaki disease. *Oral prednisolone and follow-up in paediatric clinic* - **Corticosteroids** are not first-line treatment for acute Kawasaki disease; they are generally reserved for cases that are **refractory to IVIG** or for very high-risk patients as adjunctive therapy. - Outpatient follow-up is inappropriate for a child in the acute phase of a systemic **vasculitis** that requires immediate inpatient treatment and monitoring to prevent serious cardiac morbidity.
Question 129: A 5-year-old boy with known asthma is brought to hospital by ambulance. He is receiving nebulised salbutamol via oxygen. On arrival, he has a respiratory rate of 50/min, heart rate 145/min, and oxygen saturations of 88% on 15L oxygen via nebuliser mask. He is drowsy, has silent chest on auscultation, and weak respiratory effort. An arterial blood gas shows: pH 7.18, PaCO2 8.9 kPa, PaO2 7.2 kPa, HCO3 24 mmol/L. What is the most critical next management step?
A. Immediate intravenous magnesium sulphate bolus
B. Urgent anaesthetic review for consideration of intubation and mechanical ventilation (Correct Answer)
C. Intravenous aminophylline loading dose followed by infusion
D. Continue back-to-back nebulised salbutamol and monitor closely
E. Commence non-invasive ventilation with BiPAP
Explanation: ***Urgent anaesthetic review for consideration of intubation and mechanical ventilation***
- This child presents with **near-fatal asthma**, characterized by **hypercapnia (PaCO2 8.9 kPa)**, **respiratory acidosis (pH 7.18)**, and altered consciousness (**drowsy**).
- The combination of a **silent chest**, weak respiratory effort, and severe hypoxia despite high-flow oxygen indicates **impending respiratory arrest**, necessitating immediate airway protection and invasive ventilation.
*Immediate intravenous magnesium sulphate bolus*
- While used in **life-threatening asthma**, this patient has progressed to **near-fatal** status where pharmacological bronchodilators alone are insufficient to reverse respiratory failure.
- Delaying definitive airway management to administer magnesium in a patient with a **failing respiratory drive** and high CO2 is unsafe.
*Intravenous aminophylline loading dose followed by infusion*
- **Aminophylline** is a second-line therapy for severe/life-threatening asthma but has a slow onset and narrow therapeutic index.
- In the presence of **type 2 respiratory failure** and exhaustion, it cannot replace the immediate need for **mechanical ventilation**.
*Continue back-to-back nebulised salbutamol and monitor closely*
- This approach is appropriate for **acute severe asthma**, but the presence of a **silent chest** suggests minimal air entry, meaning nebulized drugs will not reach the small airways.
- Monitoring alone is dangerous as the clinical and blood gas parameters indicate the child is already in **decompensated respiratory failure**.
*Commence non-invasive ventilation with BiPAP*
- **Non-invasive ventilation (BiPAP)** is not standard practice for pediatric acute asthma and can increase the risk of **pneumothorax** due to high pressures.
- It is contraindicated in a **drowsy patient** with a poor respiratory drive as it does not guarantee a secure airway or adequate minute ventilation.
Question 130: A 10-month-old infant presents with a 3-day history of coryzal symptoms followed by increasing respiratory distress. On examination, he has subcostal and intercostal recession, respiratory rate 65/min, oxygen saturations 91% on air, and fine inspiratory crackles bilaterally. He is taking only 50% of normal feeds. A chest X-ray shows hyperinflation with patchy infiltrates. What is the most appropriate initial management?
A. Oral amoxicillin and arrange outpatient follow-up
B. Admit for supportive care with supplemental oxygen and nasogastric feeding if required (Correct Answer)
C. Nebulised salbutamol and oral prednisolone
D. Intravenous co-amoxiclav and fluids
E. Chest physiotherapy and inhaled hypertonic saline
Explanation: ***Admit for supportive care with supplemental oxygen and nasogastric feeding if required***
- The infant's presentation with coryzal symptoms, increasing respiratory distress, subcostal/intercostal recession, tachypnoea (RR 65/min), hypoxia (SpO2 91%), and reduced feeding (<75%) are classic features of **severe bronchiolitis**, necessitating **hospital admission**.
- Management of bronchiolitis is primarily **supportive**, focusing on maintaining adequate **oxygenation** (supplemental oxygen) and **hydration** (nasogastric feeding if oral intake is insufficient).
*Oral amoxicillin and arrange outpatient follow-up*
- **Bronchiolitis** is a **viral infection**, predominantly caused by **RSV**, making **antibiotics** like amoxicillin ineffective and inappropriate unless there's a strong suspicion of secondary bacterial infection.
- The infant's significant **respiratory distress** and **hypoxia** preclude outpatient management, requiring immediate **hospitalization** for close monitoring and supportive care.
*Nebulised salbutamol and oral prednisolone*
- **Bronchodilators** (e.g., salbutamol) and **corticosteroids** (e.g., prednisolone) are **not recommended** for acute bronchiolitis as they have consistently shown **no significant benefit** in improving outcomes or reducing hospital stay.
- These medications are typically used for conditions like **asthma** or **viral-induced wheeze**, which differ in pathophysiology from bronchiolitis in infants.
*Intravenous co-amoxiclav and fluids*
- Routine **intravenous antibiotics** (like co-amoxiclav) are **not indicated** for bronchiolitis unless there is clear evidence of a **bacterial co-infection** or sepsis, which is not suggested by the initial presentation.
- While fluids are crucial, initial hydration can often be managed via **nasogastric feeding**, reserving intravenous fluids for cases where NG feeding is not tolerated or insufficient.
*Chest physiotherapy and inhaled hypertonic saline*
- **Chest physiotherapy** is **not routinely recommended** for bronchiolitis as it has not been shown to improve clinical outcomes and may cause **increased distress** and oxygen demand in infants.
- The use of **inhaled hypertonic saline** in acute bronchiolitis is **controversial**, and current UK guidelines **do not recommend** its routine use due to insufficient evidence of consistent benefit in the acute setting.
