Respiratory distress assessment and management — MCQs

An 8-year-old girl is brought to the emergency department by her parents with severe difficulty in breathing for an hour. She is struggling to breathe. She was playing outside with her friends, when she suddenly fell to the ground, out of breath. She was diagnosed with asthma one year before and has since been on treatment for it. At present, she is sitting leaning forward with severe retractions of the intercostal muscles. She is unable to lie down. Her parents mentioned that she has already taken several puffs of her inhaler since this episode began but without response. On physical examination, her lungs are hyperresonant to percussion and there is decreased air entry in both of her lungs. Her vital signs show: blood pressure 110/60 mm Hg, pulse 110/min, respirations 22/min, and a peak expiratory flow rate (PEFR) of 50%. She is having difficulty in communicating with the physician. Her blood is sent for evaluation and a chest X-ray is ordered. Her arterial blood gas reports are as follows: PaO2 50 mm Hg pH 7.38 PaCO2 47 mm Hg HCO3 27 mEq/L Which of the following is the most appropriate next step in management?

A 16-month-old male patient, with no significant past medical history, is brought into the emergency department for the second time in 5 days with tachypnea, expiratory wheezes and hypoxia. The patient presented to the emergency department initially due to rhinorrhea, fever and cough. He was treated with nasal suctioning and discharged home. The mother states that, over the past 5 days, the patient has started breathing faster with chest retractions. His vital signs are significant for a temperature of 100.7 F, respiratory rate of 45 and oxygen saturation of 90%. What is the most appropriate treatment for this patient?

A 26-year-old G1P0 female who is 39 weeks pregnant presents to the emergency department in labor. She reports following her primary care physician’s recommendations throughout her pregnancy and has not had any complications. During delivery, the baby’s head turtled back into the vaginal canal and did not advance any further. The neonatal intensivist was called for shoulder dystocia and a baby girl was able to be delivered vaginally 6 minutes later. Upon initial assessment, the baby appeared pale throughout, had her arms and legs flexed without active motion, and had some flexion of extremities when stimulated. Her pulse is 120/min and had irregular respirations. What is this baby’s initial APGAR score?

Thirty minutes after delivery, a 1780-g (3-lb 15-oz) male newborn develops respiratory distress. He was born at 30 weeks' gestation via vaginal delivery. His temperature is 36.8C (98.2F), pulse is 140/min, respirations are 64/min, and blood pressure is 61/32 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 90%. Examination shows pale extremities. Grunting and moderate subcostal retractions are present. Pulmonary examination shows decreased breath sounds bilaterally. Supplemental oxygen is administered. Ten minutes later, his pulse is 148/min and respirations are 66/min. Pulse oximetry on 60% oxygen shows an oxygen saturation of 90%. Which of the following is the most likely diagnosis?

A 3-year-old girl is brought to the physician for a well-child examination. She was born at term and has been healthy since. She can climb up and down the stairs and can pedal a tricycle. She has difficulty using a spoon to feed herself but can copy a line. She speaks in 2- to 3-word sentences that can be understood by most people. She is selfish while playing with children her age and throws tantrums quite often. She cannot put on her own shoes and socks. She does not tolerate separation from her parents. She is at 60th percentile for height and weight. Physical examination including neurologic examination reveals no abnormalities. Which of the following is the most appropriate assessment of her development?

A 5-year-old is brought into the emergency department for trouble breathing. He was at a family picnic playing when his symptoms began. The patient is currently struggling to breathe and has red, warm extremities. The patient has an unknown medical history and his only medications include herbs that his parents give him. His temperature is 99.5°F (37.5°C), pulse is 112/min, blood pressure is 70/40 mmHg, respirations are 18/min, and oxygen saturation is 82% on 100% O2. Which of the following is the best initial step in management?

A mother brings her 6-month-old boy to the emergency department. She reports that her son has been breathing faster than usual for the past 2 days, and she has noted occasional wheezing. She states that prior to the difficulty breathing, she noticed some clear nasal discharge for several days. The infant was born full-term, with no complications, and no significant medical history. His temperature is 100°F (37.8°C), blood pressure is 60/30 mmHg, pulse is 120/min, respirations are 40/min, and oxygen saturation is 95% on room air. Physical exam reveals expiratory wheezing, crackles diffusely, and intercostal retractions. The child is currently playing with toys. Which of the following is the most appropriate next step in management?

A 3-year-old boy is brought to the emergency department by his mother because of a cough and mild shortness of breath for the past 12 hours. He has not had fever. He has been to the emergency department 4 times during the past 6 months for treatment of asthma exacerbations. His 9-month-old sister was treated for bronchiolitis a week ago. His father has allergic rhinitis. Current medications include an albuterol inhaler and a formoterol-fluticasone inhaler. He appears in mild distress. His temperature is 37.5°C (99.5°F), pulse is 101/min, respirations are 28/min, and blood pressure is 86/60 mm Hg. Examination shows mild intercostal and subcostal retractions. Pulmonary examination shows decreased breath sounds and mild expiratory wheezing throughout the right lung field. Cardiac examination shows no abnormalities. An x-ray of the chest shows hyperlucency of the right lung field with decreased pulmonary markings. Which of the following is the next best step in management?

Five weeks after delivery, a 1350-g (3-lb 0-oz) male newborn has respiratory distress. He was born at 26 weeks' gestation. He required intubation and mechanical ventilation for a month following delivery and has been on noninvasive pressure ventilation for 5 days. His temperature is 36.8°C (98.2°F), pulse is 148/min, respirations are 63/min, and blood pressure is 60/32 mm Hg. Pulse oximetry on 40% oxygen shows an oxygen saturation of 91%. Examination shows moderate intercostal and subcostal retractions. Scattered crackles are heard in the thorax. An x-ray of the chest shows diffuse granular densities and basal atelectasis. Which of the following is the most likely diagnosis?

A 4-year-old girl is brought to the emergency department by her parents with a sudden onset of breathlessness. She has been having similar episodes over the past few months with a progressive increase in frequency over the past week. They have noticed that the difficulty in breathing is more prominent during the day when she plays in the garden with her siblings. She gets better once she comes indoors. During the episodes, she complains of an inability to breathe and her parents say that she is gasping for breath. Sometimes they hear a noisy wheeze while she breathes. The breathlessness does not disrupt her sleep. On examination, she seems to be in distress with noticeable intercostal retractions. Auscultation reveals a slight expiratory wheeze. According to her history and physical findings, which of the following mechanisms is most likely responsible for this child’s difficulty in breathing?