Acute Paediatrics — MCQs
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A 2-year-old boy with known viral-induced wheeze attends the emergency department with breathlessness and wheeze. He has received 3 doses of salbutamol via spacer in the last hour. On examination, he is alert, speaking in short sentences, has widespread expiratory wheeze, respiratory rate 38/min, heart rate 128/min, and oxygen saturation 94% on air. What is the most appropriate next step in acute management?
A 9-month-old infant with a 2-day history of coryzal symptoms and cough now presents with increased work of breathing. On examination, respiratory rate is 58/min, heart rate 148/min, oxygen saturation 93% on air, temperature 38.1°C. There is subcostal recession, nasal flaring, and widespread fine inspiratory crepitations with expiratory wheeze. What is the most likely diagnosis?
A 4-year-old girl presents to the emergency department with a 2-hour history of fever to 39.8°C, lethargy, and a non-blanching purpuric rash on her legs. She is pale, has cool peripheries, capillary refill time of 4 seconds, heart rate 165/min, blood pressure 85/50 mmHg, and respiratory rate 38/min. She has received one fluid bolus of 20 ml/kg 0.9% saline. What is the most appropriate next immediate step?
What is the most appropriate interval for follow-up echocardiography in a child diagnosed with Kawasaki disease who had normal coronary arteries at presentation and received timely treatment with IVIG?
A 13-month-old girl presents with a 6-day history of fever ranging from 38.8°C to 40.1°C. She is irritable with bilateral non-exudative conjunctivitis and a polymorphous rash on her trunk. Her lips are dry and cracked. Cervical lymphadenopathy is present. Blood tests show: WCC 18.5 × 10⁹/L, neutrophils 14.2 × 10⁹/L, CRP 145 mg/L, albumin 25 g/L, ALT 78 U/L, and platelets 498 × 10⁹/L. Echocardiography shows normal coronary arteries. She weighs 10 kg. What is the most appropriate definitive treatment?
A 6-year-old boy with known asthma on beclometasone 200 micrograms twice daily presents to the emergency department. He is drowsy, has absent breath sounds bilaterally, silent chest on auscultation, oxygen saturation 88% on 15L oxygen via non-rebreather mask, heart rate 145/min, and respiratory rate 8/min. What is the most appropriate immediate next step in management?
An 11-month-old infant presents with fever of 39.2°C for 3 hours. She is alert, interactive, and feeding normally. Examination reveals a red, bulging right tympanic membrane. There are no other abnormal findings. Her immunisations are up to date. What is the most appropriate initial management?
A 5-year-old girl presents with fever of 39.4°C for 48 hours. She has a widespread maculopapular rash, bilateral non-purulent conjunctivitis, cracked red lips, and cervical lymphadenopathy. Her hands and feet appear edematous and erythematous. Blood tests show: WCC 16.2 × 10⁹/L, CRP 112 mg/L, ESR 58 mm/hr, platelets 542 × 10⁹/L, and albumin 28 g/L. What is the single most important immediate investigation to guide management?
A 7-year-old boy with asthma is assessed in the emergency department. He is sitting upright, speaking in short phrases, has a respiratory rate of 32/min, heart rate 128/min, and oxygen saturation 91% on air. Widespread expiratory wheeze is audible. After initial bronchodilator therapy, what is the most appropriate immediate treatment to prevent admission to intensive care?
A 9-year-old boy with poorly controlled asthma is currently on fluticasone 250 micrograms twice daily and salbutamol as needed. He uses his salbutamol inhaler daily, wakes with cough twice per week, and has had three courses of oral prednisolone in the past year for acute exacerbations. His parents report that despite prescriptions being collected, they sometimes forget to give the evening dose of preventer. Inhaler technique check shows he uses his metered-dose inhaler without a spacer, taking shallow breaths without breath-holding. What factor is most likely contributing significantly to his poor asthma control?
Acute Paediatrics UK Medical PG Practice Questions and MCQs
Question 31: A 2-year-old boy with known viral-induced wheeze attends the emergency department with breathlessness and wheeze. He has received 3 doses of salbutamol via spacer in the last hour. On examination, he is alert, speaking in short sentences, has widespread expiratory wheeze, respiratory rate 38/min, heart rate 128/min, and oxygen saturation 94% on air. What is the most appropriate next step in acute management?
- A. Admit for observation and continue salbutamol via spacer every 4 hours
- B. Give oral prednisolone 20 mg and observe for response (Correct Answer)
- C. Administer salbutamol nebuliser driven by oxygen
- D. Add ipratropium bromide nebuliser with salbutamol
- E. Discharge with increased frequency of salbutamol inhaler at home
Explanation: ***Give oral prednisolone 20 mg and observe for response*** - This patient presents with a **moderate exacerbation** of viral-induced wheeze, characterized by breathlessness, speaking in short sentences, and inadequate response to three doses of **salbutamol** via spacer within an hour. - **Oral corticosteroids**, such as prednisolone, are indicated in children with moderate acute wheeze exacerbations who do not respond adequately to initial bronchodilator therapy to reduce **airway inflammation** and improve outcomes. *Admit for observation and continue salbutamol via spacer every 4 hours* - Continuing salbutamol every 4 hours is insufficient for a child who has already shown inadequate response to three doses in a shorter period, indicating the need for more intensive management. - While admission for observation may be necessary, this step alone does not address the underlying **airway inflammation** and is not the most appropriate immediate pharmacological intervention. *Administer salbutamol nebuliser driven by oxygen* - For mild-to-moderate wheeze in children, **salbutamol via spacer and mask** is equally effective and often preferred over nebulizers, especially when the child is alert. - Nebulisers driven by oxygen are typically reserved for **severe exacerbations** or when the child is unable to use a spacer effectively, which is not the primary issue here given the 94% saturation. *Add ipratropium bromide nebuliser with salbutamol* - **Ipratropium bromide** is primarily indicated as an adjunct therapy in the management of **acute severe asthma** or wheeze, or in cases of very poor response to high-dose beta-agonists. - While it can be considered in severe cases, the priority in a moderate exacerbation failing initial bronchodilators is the addition of **systemic corticosteroids** to target inflammation. *Discharge with increased frequency of salbutamol inhaler at home* - Discharge is inappropriate as the child is still symptomatic, showing signs of respiratory distress (e.g., speaking in short sentences, elevated respiratory rate, oxygen saturation 94%). - Clinical stability, significant symptom improvement, and maintenance of **oxygen saturations** without distress are prerequisites for safe discharge, which are not met here.
Question 32: A 9-month-old infant with a 2-day history of coryzal symptoms and cough now presents with increased work of breathing. On examination, respiratory rate is 58/min, heart rate 148/min, oxygen saturation 93% on air, temperature 38.1°C. There is subcostal recession, nasal flaring, and widespread fine inspiratory crepitations with expiratory wheeze. What is the most likely diagnosis?
- A. Bronchiolitis (Correct Answer)
- B. Viral-induced wheeze
- C. Pneumonia
- D. First presentation of asthma
- E. Foreign body aspiration
Explanation: ***Bronchiolitis*** - This infant presents with the classic clinical triad of a **coryzal prodrome**, increased **work of breathing**, and **widespread fine inspiratory crepitations** with an expiratory wheeze. - It is most commonly caused by **Respiratory Syncytial Virus (RSV)** and primarily affects infants **under 12 months** of age, peaking between 3-6 months. *Viral-induced wheeze* - Typically occurs in children **older than 12 months** and is characterized by wheezing without the prominent **fine crepitations** seen in bronchiolitis. - It often presents with a more **recurrent pattern** in response to viral infections rather than the distinct seasonal presentation of bronchiolitis. *Pneumonia* - Usually presents with a **higher fever**, focal (rather than widespread) chest signs, and **coarse crepitations**. - While respiratory distress is present, the presence of a **diffuse expiratory wheeze** makes pneumonia less likely than bronchiolitis in this age group. *First presentation of asthma* - Asthma is rarely diagnosed as a first presentation in an infant **under 1 year** of age and typically requires a pattern of **reversibility** and recurrence. - The clinical picture of fine crepitations and a first-time wheeze during a coryzal illness in an infant strongly favors **bronchiolitis** over asthma. *Foreign body aspiration* - Classically presents with a **sudden onset** of choking or respiratory distress, usually without the **coryzal prodrome** or fever. - On examination, it typically results in **unilateral** or focal findings like localized wheeze or reduced breath sounds, rather than **widespread crepitations**.
Question 33: A 4-year-old girl presents to the emergency department with a 2-hour history of fever to 39.8°C, lethargy, and a non-blanching purpuric rash on her legs. She is pale, has cool peripheries, capillary refill time of 4 seconds, heart rate 165/min, blood pressure 85/50 mmHg, and respiratory rate 38/min. She has received one fluid bolus of 20 ml/kg 0.9% saline. What is the most appropriate next immediate step?
- A. Administer a second fluid bolus of 20 ml/kg 0.9% saline
- B. Give intravenous ceftriaxone 80 mg/kg immediately (Correct Answer)
- C. Arrange urgent transfer to paediatric intensive care unit
- D. Perform blood cultures, FBC, CRP, coagulation screen, and blood gas
- E. Commence inotropic support with dopamine infusion
Explanation: ***Give intravenous ceftriaxone 80 mg/kg immediately*** - The combination of **fever, lethargy, non-blanching purpuric rash**, and signs of **shock** (pale, cool peripheries, prolonged CRT, hypotension, tachycardia) is highly indicative of **meningococcal septicaemia**, a medical emergency requiring immediate antibiotic treatment. - **Intravenous ceftriaxone (or cefotaxime)** must be administered without delay, as prompt antibiotic therapy is critical for improving outcomes and reducing mortality in suspected **bacterial sepsis** and **meningococcal disease**. *Administer a second fluid bolus of 20 ml/kg 0.9% saline* - While the child is still in **shock** and will likely require further fluid resuscitation (having received only one bolus), the **immediate administration of antibiotics** for suspected meningococcal disease takes precedence to target the infection. - **Fluid boluses** help manage circulatory compromise, but they do not address the underlying **bacterial infection**, which is the primary cause of rapid deterioration in this life-threatening condition. *Arrange urgent transfer to paediatric intensive care unit* - **Urgent PICU transfer** is necessary for ongoing advanced management of **septicaemic shock**, but **initial stabilization** and **life-saving interventions**, such as immediate antibiotic administration, must occur first in the emergency department. - Transfer arrangements should never delay the most critical early treatments for **airway, breathing, and circulation**, especially controlling the source of infection. *Perform blood cultures, FBC, CRP, coagulation screen, and blood gas* - Although these **diagnostic investigations** are essential for confirming the diagnosis and guiding management, they must **never delay the immediate administration of antibiotics** in a child with suspected meningococcal septicaemia. - If intravenous access is established, blood for cultures should be drawn **simultaneously or immediately prior** to antibiotic administration, but the antibiotic should not be withheld pending these results. *Commence inotropic support with dopamine infusion* - **Inotropic support** is indicated for **fluid-refractory shock**, typically after multiple fluid boluses (e.g., 40-60 ml/kg) have failed to restore adequate circulation, and it is not the immediate first step. - Furthermore, current pediatric guidelines often recommend **adrenaline or noradrenaline** as the preferred first-line vasopressors for septic shock, rather than dopamine.
Question 34: What is the most appropriate interval for follow-up echocardiography in a child diagnosed with Kawasaki disease who had normal coronary arteries at presentation and received timely treatment with IVIG?
- A. At 1-2 weeks and 6-8 weeks after treatment (Correct Answer)
- B. At 48 hours, 1 week, and 1 month after treatment
- C. Daily for 5 days then weekly for 1 month
- D. At 1 week and 3 months after treatment
- E. At 1 month and 6 months after treatment
Explanation: ***At 1-2 weeks and 6-8 weeks after treatment***- For patients with **uncomplicated Kawasaki disease** and normal coronary arteries, standard guidelines recommend repeat echocardiography at **1-2 weeks** and **6-8 weeks** post-acute phase.- This timeline captures the window when **coronary artery aneurysms** most commonly develop; if results remain normal at 8 weeks, **low-dose aspirin** therapy can typically be discontinued.*At 48 hours, 1 week, and 1 month after treatment*- This schedule is not standard for patients with **normal coronary arteries** at baseline; the 48-hour follow-up is generally unnecessary for outpatient monitoring.- A **6-8 week** scan is crucial for secondary prevention and risk stratification, making the 1-month interval less ideal for the final determination.*Daily for 5 days then weekly for 1 month*- **Daily echocardiography** is excessive and not indicated for a child showing normal baseline coronary morphology and rapid response to treatment.- This intensive level of monitoring is reserved for hemodynamically unstable patients or those with rapidly expanding **giant aneurysms**.*At 1 week and 3 months after treatment*- Waiting until **3 months** for the second scan is too late, as medical decisions regarding aspirin therapy are typically made at the **6-8 week** mark.- A 1-week scan alone is insufficient to confirm that delayed **coronary dilation** will not occur during the subacute phase.*At 1 month and 6 months after treatment*- This protocol ignores the critical **1-2 week** window where early changes associated with **vasculitis** may first appear on imaging.- A **6-month** interval is only indicated for patients who have already demonstrated persistent coronary abnormalities, not for those with **normal baseline** studies.
Question 35: A 13-month-old girl presents with a 6-day history of fever ranging from 38.8°C to 40.1°C. She is irritable with bilateral non-exudative conjunctivitis and a polymorphous rash on her trunk. Her lips are dry and cracked. Cervical lymphadenopathy is present. Blood tests show: WCC 18.5 × 10⁹/L, neutrophils 14.2 × 10⁹/L, CRP 145 mg/L, albumin 25 g/L, ALT 78 U/L, and platelets 498 × 10⁹/L. Echocardiography shows normal coronary arteries. She weighs 10 kg. What is the most appropriate definitive treatment?
- A. Intravenous immunoglobulin 2 g/kg as a single infusion plus high-dose aspirin 80-100 mg/kg/day (Correct Answer)
- B. Intravenous methylprednisolone 10 mg/kg/day for 3 days plus aspirin
- C. Oral prednisolone 2 mg/kg/day plus low-dose aspirin 3-5 mg/kg/day
- D. Intravenous ceftriaxone 80 mg/kg/day and supportive care
- E. Infliximab 5 mg/kg as a single infusion plus aspirin
Explanation: ***Intravenous immunoglobulin 2 g/kg as a single infusion plus high-dose aspirin 80-100 mg/kg/day***- The patient's presentation with prolonged fever, non-exudative conjunctivitis, polymorphous rash, dry cracked lips, and cervical lymphadenopathy is classic for **Kawasaki disease**.- The definitive first-line treatment for acute Kawasaki disease is a single infusion of **IVIG (2 g/kg)** to reduce inflammation and prevent **coronary artery aneurysms**, along with high-dose **aspirin** for its anti-inflammatory effects.*Intravenous methylprednisolone 10 mg/kg/day for 3 days plus aspirin*- Pulse **corticosteroids** are typically considered for patients who are **refractory** to initial IVIG therapy, or in conjunction with IVIG in very high-risk cases.- They are not the standard single definitive first-line therapy for a classic presentation of Kawasaki disease.*Oral prednisolone 2 mg/kg/day plus low-dose aspirin 3-5 mg/kg/day*- Oral steroids are not the primary treatment for acute Kawasaki disease and do not replace the crucial role of **IVIG** in preventing cardiac complications.- **Low-dose aspirin** is used for its antiplatelet effect during the convalescent phase, after the acute febrile period has resolved, not as the primary anti-inflammatory dose.*Intravenous ceftriaxone 80 mg/kg/day and supportive care*- **Ceftriaxone** is an antibiotic, used for bacterial infections, but it is not effective against the underlying **vasculitis** of Kawasaki disease.- Treating Kawasaki disease with antibiotics alone would delay appropriate therapy, significantly increasing the risk of severe **coronary artery damage**.*Infliximab 5 mg/kg as a single infusion plus aspirin*- **Infliximab**, a TNF-alpha inhibitor, is a second-line or adjunctive therapy for Kawasaki disease, primarily used in patients who are **refractory to IVIG**.- It is not the initial definitive treatment and is used in conjunction with or after initial IVIG failure, not as a replacement for the primary IVIG/aspirin protocol.
Question 36: A 6-year-old boy with known asthma on beclometasone 200 micrograms twice daily presents to the emergency department. He is drowsy, has absent breath sounds bilaterally, silent chest on auscultation, oxygen saturation 88% on 15L oxygen via non-rebreather mask, heart rate 145/min, and respiratory rate 8/min. What is the most appropriate immediate next step in management?
- A. Start non-invasive ventilation with continuous positive airway pressure
- B. Immediate senior anaesthetic review for intubation and ventilation (Correct Answer)
- C. Administer intravenous magnesium sulphate 40 mg/kg over 20 minutes
- D. Give back-to-back salbutamol nebulisers with ipratropium
- E. Commence intravenous aminophylline bolus and infusion
Explanation: ***Immediate senior anaesthetic review for intubation and ventilation*** - The patient presents with classic signs of **life-threatening asthma** and **impending respiratory arrest**, including **drowsiness**, **silent chest** (absent breath sounds), severe **hypoxia** (SpO2 88% on 15L O2), and marked **bradypnea** (respiratory rate 8/min). - In this critical state, **securing the airway** and providing **mechanical ventilation** are the absolute priorities to ensure adequate oxygenation and ventilation, especially given the altered consciousness and respiratory exhaustion. *Start non-invasive ventilation with continuous positive airway pressure* - **Non-invasive ventilation (NIV)** is generally contraindicated in patients with **altered consciousness** or **drowsiness** due to the high risk of aspiration and inability to protect their airway. - This patient requires **invasive mechanical ventilation** to manage severe respiratory failure and prevent further deterioration safely. *Administer intravenous magnesium sulphate 40 mg/kg over 20 minutes* - While **intravenous magnesium sulphate** is a valuable adjunctive treatment for severe acute asthma, it is not the immediate life-saving intervention when the patient is in **impending respiratory arrest**. - Administering a drug over 20 minutes is too slow for a patient with such profound respiratory distress and **bradypnea** who needs immediate airway and ventilatory support. *Give back-to-back salbutamol nebulisers with ipratropium* - A **silent chest** indicates extremely poor airflow to the lungs, rendering nebulised medications largely **ineffective** as they cannot reach the lower airways. - The patient's **drowsiness** and **bradypnea** signify respiratory exhaustion and failure, requiring immediate **ventilatory support** rather than continued, likely ineffective, nebuliser therapy. *Commence intravenous aminophylline bolus and infusion* - **Intravenous aminophylline** is considered a second- or third-line bronchodilator for severe asthma but is insufficient and too slow for a patient exhibiting signs of **hypoventilation** and **reduced level of consciousness**. - Prioritizing pharmacological infusions over immediate **airway management** and **mechanical ventilation** in a patient with impending respiratory arrest would be a dangerous delay in essential care.
Question 37: An 11-month-old infant presents with fever of 39.2°C for 3 hours. She is alert, interactive, and feeding normally. Examination reveals a red, bulging right tympanic membrane. There are no other abnormal findings. Her immunisations are up to date. What is the most appropriate initial management?
- A. Arrange same-day paediatric assessment for potential sepsis
- B. Prescribe amoxicillin 40 mg/kg/day in three divided doses (Correct Answer)
- C. Provide advice on antipyretic use and safety-netting with delayed antibiotic prescription
- D. Perform urine dipstick and culture before deciding on antibiotics
- E. Prescribe co-amoxiclav 40 mg/kg/day in three divided doses
Explanation: ***Prescribe amoxicillin 40 mg/kg/day in three divided doses*** - For an infant **under 2 years** of age with symptoms of **acute otitis media (AOM)**, specifically a **red, bulging tympanic membrane**, immediate antibiotic therapy is recommended. - **Amoxicillin** is the first-line treatment for uncomplicated pediatric AOM due to its effectiveness against common pathogens like *Streptococcus pneumoniae*. *Arrange same-day paediatric assessment for potential sepsis* - The infant is described as **alert, interactive, and feeding normally**, indicating clinical stability and an absence of **red-flag features** for sepsis. - A clear source of infection (AOM) has been identified, making an urgent **paediatric assessment** for sepsis unnecessary at this point. *Provide advice on antipyretic use and safety-netting with delayed antibiotic prescription* - **Delayed prescribing** is generally reserved for children older than 2 years who are systemically well or those with mild, unilateral AOM without severe features. - Guidelines advise **immediate antibiotics** for infants under 2 years with a definitive diagnosis of AOM and a **bulging tympanic membrane** to reduce the risk of complications. *Perform urine dipstick and culture before deciding on antibiotics* - While urinary tract infections (UTIs) can cause fever in infants, the presence of a **red, bulging tympanic membrane** strongly points to **acute otitis media** as the source of fever. - Prioritizing **urinalysis** before addressing the clear signs of AOM is not the most appropriate initial step in a non-toxic appearing infant. *Prescribe co-amoxiclav 40 mg/kg/day in three divided doses* - **Co-amoxiclav** (amoxicillin-clavulanate) is a broader-spectrum antibiotic and is typically reserved for **treatment failure** with amoxicillin or in cases with specific risk factors for resistant organisms. - Using it as first-line therapy for uncomplicated AOM increases the risk of **antibiotic resistance** and potential side effects such as diarrhea.
Question 38: A 5-year-old girl presents with fever of 39.4°C for 48 hours. She has a widespread maculopapular rash, bilateral non-purulent conjunctivitis, cracked red lips, and cervical lymphadenopathy. Her hands and feet appear edematous and erythematous. Blood tests show: WCC 16.2 × 10⁹/L, CRP 112 mg/L, ESR 58 mm/hr, platelets 542 × 10⁹/L, and albumin 28 g/L. What is the single most important immediate investigation to guide management?
- A. Echocardiography to assess for coronary artery abnormalities (Correct Answer)
- B. Blood cultures before starting antibiotics
- C. Lumbar puncture to exclude meningitis
- D. Throat swab for Group A Streptococcus
- E. Autoantibody screen including ANA and ANCA
Explanation: ***Echocardiography to assess for coronary artery abnormalities*** - This patient presents with the classic features of **Kawasaki disease**, including prolonged fever, **maculopapular rash**, **bilateral non-purulent conjunctivitis**, **cracked red lips**, **cervical lymphadenopathy**, and **edematous, erythematous hands and feet**, along with elevated inflammatory markers. - **Echocardiography** is the most critical immediate investigation to detect **coronary artery aneurysms**, a life-threatening complication, which guides urgent initiation of **IVIG** and **aspirin** therapy. *Blood cultures before starting antibiotics* - While fever of unknown origin often warrants **blood cultures**, the specific constellation of signs (mucosal changes, extremity edema) makes **Kawasaki disease** a more likely diagnosis than typical bacterial sepsis. - Although generally performed, blood cultures would not provide the most critical information for guiding immediate, disease-specific management in this suspected **vasculitis**. *Lumbar puncture to exclude meningitis* - Although **aseptic meningitis** can rarely occur in **Kawasaki disease**, the primary clinical picture is dominated by features of a systemic **vasculitis**, not central nervous system infection. - A **lumbar puncture** is an invasive procedure and is not the most immediate or important investigation for guiding therapy aimed at preventing **cardiac complications** in this scenario. *Throat swab for Group A Streptococcus* - **Scarlet fever** (due to Group A Streptococcus) can cause fever and rash but typically lacks the prominent **conjunctivitis**, **cracked lips**, and distinct **extremity edema** seen in this patient. - A **throat swab** result would not be available immediately to guide urgent management decisions for **Kawasaki disease** and its potential **cardiac sequelae**. *Autoantibody screen including ANA and ANCA* - **Kawasaki disease** is a **clinical diagnosis** supported by inflammatory markers, not by specific autoantibodies like **ANA** or **ANCA**. - These autoantibody screens are more relevant for diagnosing chronic autoimmune or systemic vasculitic conditions and would not guide the acute, time-sensitive management of suspected **Kawasaki disease**.
Question 39: A 7-year-old boy with asthma is assessed in the emergency department. He is sitting upright, speaking in short phrases, has a respiratory rate of 32/min, heart rate 128/min, and oxygen saturation 91% on air. Widespread expiratory wheeze is audible. After initial bronchodilator therapy, what is the most appropriate immediate treatment to prevent admission to intensive care?
- A. Intravenous magnesium sulphate 40 mg/kg over 20 minutes (Correct Answer)
- B. Oral prednisolone 30 mg once daily for 3 days
- C. Intravenous salbutamol infusion
- D. Intravenous aminophylline bolus followed by infusion
- E. Non-invasive ventilation with bilevel positive airway pressure
Explanation: ***Intravenous magnesium sulphate 40 mg/kg over 20 minutes***- This patient exhibits features of **acute severe asthma** (SpO2 91%, HR 128/min, RR 32/min); intravenous magnesium sulphate is the recommended next step for those not responding to initial **bronchodilators**.- Magnesium acts as a **smooth muscle relaxant** and has been shown to improve lung function and significantly reduce the need for **ITU admission**.*Oral prednisolone 30 mg once daily for 3 days*- While **corticosteroids** are essential in asthma management, they should be administered as part of the **initial therapy** and take several hours to take effect.- In the acute setting where there is poor response to initial bronchodilators, more **rapid-acting intravenous interventions** are required to prevent clinical deterioration.*Intravenous salbutamol infusion*- This is generally considered a **second-line** intravenous treatment and is often reserved for those who remain refractory to **IV magnesium sulphate**.- It carries a higher risk of side effects like **tachycardia** and **hypokalemia**, necessitating closer cardiac monitoring than magnesium.*Intravenous aminophylline bolus followed by infusion*- Aminophylline is typically used in cases of **life-threatening asthma** or when there is an inadequate response to both magnesium and salbutamol.- It has a **narrow therapeutic index** and requires drug level monitoring due to the risk of significant toxicity.*Non-invasive ventilation with bilevel positive airway pressure*- **NIV** is not a routine part of the management of acute asthma in children and is rarely used outside of a **critical care** environment.- Management focuses on pharmacological reversal of **bronchospasm**; if this fails, more invasive measures like **intubation** are usually preferred over BiPAP.
Question 40: A 9-year-old boy with poorly controlled asthma is currently on fluticasone 250 micrograms twice daily and salbutamol as needed. He uses his salbutamol inhaler daily, wakes with cough twice per week, and has had three courses of oral prednisolone in the past year for acute exacerbations. His parents report that despite prescriptions being collected, they sometimes forget to give the evening dose of preventer. Inhaler technique check shows he uses his metered-dose inhaler without a spacer, taking shallow breaths without breath-holding. What factor is most likely contributing significantly to his poor asthma control?
- A. Suboptimal inhaler technique leading to poor drug delivery to the airways (Correct Answer)
- B. Inadequate dose of inhaled corticosteroid requiring step-up to high-dose therapy
- C. Undiagnosed environmental triggers such as house dust mite or pet allergen exposure
- D. Poor treatment adherence with missed doses of regular preventer medication
- E. Development of steroid resistance requiring alternative immunomodulatory therapy
Explanation: ***Suboptimal inhaler technique leading to poor drug delivery to the airways*** - The patient's use of a **metered-dose inhaler (MDI)** without a **spacer**, along with shallow breaths and no **breath-hold**, critically impairs the delivery of medication to the lungs. - For children, ensuring correct **inhaler technique** is a fundamental first step in addressing uncontrolled asthma, as even adequate doses are ineffective if not properly delivered. *Inadequate dose of inhaled corticosteroid requiring step-up to high-dose therapy* - **Escalating the dose** is premature when fundamental issues like **inhaler technique** and **adherence** are unaddressed, especially since his current fluticasone dose is already considered medium. - Increasing the dose would not improve control if the medication does not reach the **lower airways** due to improper technique. *Undiagnosed environmental triggers such as house dust mite or pet allergen exposure* - While **environmental triggers** can exacerbate asthma, the documented **poor inhaler technique** represents a more direct and immediately addressable cause of poor control. - Investigating environmental triggers is typically considered after optimizing **medication delivery** and **adherence**. *Poor treatment adherence with missed doses of regular preventer medication* - Although parents report occasional **missed doses**, the problem with **inhaler technique** during the doses that *are* taken is a constant barrier to effective treatment. - Both **adherence** and **technique** are important, but the detailed description of incorrect MDI use points to drug delivery as the most significant primary issue. *Development of steroid resistance requiring alternative immunomodulatory therapy* - **Steroid resistance** is a rare diagnosis, usually considered only after meticulous confirmation of **adherence**, **correct inhaler technique**, and exclusion of other comorbidities. - It would be clinically inappropriate to consider **immunomodulatory therapy** before rectifying basic, modifiable factors like **inhaler technique**.
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