An 8-year-old female is admitted to the hospital for an exacerbation of asthma. She has recently moved to this area and has not seen a primary care provider in more than six months. She reports complaints of dyspnea, cough and wheeze intermittently for the last four months. Initially the symptoms were only related to exercise which forced her to stop playing actively with her friends. Now she has symptoms almost daily and awakens several times each week with wheezing. She lives in a non-smoking environment. She and her parents deny any known environmental factors which contribute to her difficulty in breathing. Prior to the last several months, she has had no respiratory problems. Since admission, she has been stabilized with frequent albuterol treatments and is feeling much better. She is alert and conversive, able to speak and play without restriction when you see her in the emergency room.Physical examination is significant for an only mildly elevated respiratory rate and mild expiratory wheezing with no accessory muscle use/WOB at this time. Spirometry done at this time reveals a reduced FEV1 and FEV1/FVC at 60% of predicted for age. You consider asthma education needs for this patient and begin thinking about appropriate medication regimens for her condition upon hospital discharge. WHICH of the following is the MOST APPROPRIATE choice of medication(s) to recommend to her and her parents for long-term maintenance therapy of her condition?

Inhaled corticosteroid twice daily, plus short-acting beta-2 agonist (albuterol) treatment as needed

Inhaled short-acting beta-2 agonist medication (albuterol), every 4-6 hours, as symptoms warrant

Inhaled long-acting beta-2 agonist medication (salmeterol), twice daily

Inhaled corticosteroid twice daily, plus short-acting beta-2 agonist (albuterol) treatment as needed

Oral prednisone tablets, twice daily

Montelukast (Singulair) tablets, once daily

A 10-month-old child is brought in for urgent evaluation by her worried parents. She has been ill with low-grade fever, cough, and nasal congestion for several days. Last night, her cough sounded "barky" like a seal and her parents are worried about her ability to breathe. She seems to have more difficulty breathing when she becomes upset. On examination, you note the child who is fussy but consolable. She appears well hydrated and in no acute respiratory distress, although audible breath sounds are noted when she begins to cry. You note her high-pitched barking cough. What clinical finding would you expect to hear upon auscultation?

Prominent inspiratory sounds caused by subglottic airway narrowing

Decreased breath sounds over the right lung field

Prominent expiratory sounds caused by bronchospasm and inflammation of small airways

Prominent inspiratory and expiratory sounds caused by mucous deposition in both large and small airways

Prominent inspiratory sounds caused by re-expansion of collapsed of alveolar air spaces

Prominent inspiratory sounds caused by subglottic airway narrowing

An 18-month-old girl is seen in the emergency department for sudden onset of respiratory distress during a family picnic. She is afebrile and has otherwise been well. Physical examination demonstrates unilateral wheezing in the right lung field. What is the MOST LIKELY finding you will see on her chest x-ray?

Hyperinflation of the right lung with mediastinal shift to the left

A consolidation of the right lower lobe with mediastinal shift to the right

A foreign body in the right mainstem bronchus

A consolidation of the right lower lobe with no mediastinal shift

Hyperinflation of the right lung with mediastinal shift to the left

A 3-week-old infant is brought to the emergency room by his parents. They report that he seems to be breathing hard and had a couple of episodes where it looked like he stopped breathing. They deny cyanosis or fever. When you ask his mother about her pregnancy, she reports that it was uneventful. She had prenatal care. She had no perinatal infections, and she was GBS negative. The patient was born at full term via spontaneous vaginal delivery. His nursery course was uneventful and he went home at approximately 36 hours of life. He established care with his pediatrician at 2 weeks of life, and his mother proudly reports that he had already surpassed his birth weight. He received his first vaccination, and his mother reports that his pediatrician said he was in excellent health. He is exclusively breast fed, and had been eating well (approximately 15 minutes per breast every 1-2 hours) until today. Of note, the patient s 4-year-old brother has a cold. Physical examination reveals the following: Temperature: 37.7 C (100 F), respiratory rate 65, blood pressure 73/45, heart rate 168, oxygen saturation is 90% on room air. The infant appears to be in respiratory distress. There are deep subcostal retractions with inspiration. Exam of the lungs reveals diffuse wheezing and poor air movement. Cardiovascular exam reveals tachycardia, but no murmurs. Capillary refill is normal. After placing the infant on supplemental oxygen, he appears much more comfortable and O2 sat increases to 95%. You obtain a PA and lateral CXR which reveals hyperinflation and interstitial infiltrates. You obtain appropriate laboratory studies to hopefully identify the organism causing this infant s distress. Based upon the MOST LIKELY etiology for this infant s respiratory difficulty, initial management should include WHICH of the following measures:

Supportive care, including oxygen, hydration and bulb syringe suction as needed

Broad spectrum antibiotic therapy to cover most likely organisms

Inhaled corticosteroid therapy along with antibiotics

Systemic corticosteroid therapy along with antibiotics

Supportive care, including oxygen, hydration and bulb syringe suction as needed

Ventilatory management as the infant is in significant respiratory distress

A 16-month-old child is evaluated for respiratory distress in the middle of winter. His anxious mother reports that he has had a few days of nasal congestion and drainage. She also reports that the child has has felt warm to her, although she did not measure his temperature. He started coughing earlier today and his mother reports that the quality of his cough has recently changed, in that it is now becoming more high-pitched and "barky" in nature. He has been otherwise healthy and has no chronic illness. His mother thinks that his breathing has become much more labored over the past several hours. Your examination reveals a child who appears to be in mild respiratory distress with an elevated respiratory rate of 36. Other vital signs, including oxygen saturation, are within normal parameters. There is no accessory muscle use or work of breathing noted. The child is not posturing in an unusual position and has a non-toxic appearance. You note that most of the child's work of breathing appears to be upon inspiration. WHICH of the following findings are you MOST likely to appreciate upon auscultation of this child's lung fields?

Fine crackles in bilateral lung fields

Rhonchi in bilateral lung fields

A 15-year-old girl with cystic fibrosis presents to the emergency room with fever and worsening dyspnea. She has been admitted to the hospital several times this year with pneumonia, and she just completed a course of antibiotics as an outpatient about 2 weeks ago. She admits she may not have taken all the doses as prescribed. In addition to bronchodilator therapy, she reports she had been on inhaled tobramycin, but admits she hasn t taken it for awhile. She says she has been having cough productive of yellowish-green sputum. Physical examination is notable for vital signs as follows: temperature 38.5 C (101.3 F), respiratory rate 28, blood pressure 105/67, heart rate 92, and oxygen saturation 92% on 2L via nasal cannula. She is very thin and appears younger than her stated age. She is barrel-chested (increased AP diameter of the thorax). There is diffuse wheezing on auscultation of the lungs, and a markedly prolonged expiratory phase. A CXR shows marked hyperinflation and lobar consolidation in the right middle lobe. WHICH of following statements regarding cystic fibrosis is true?

Maintenance therapy of cystic fibrosis includes bronchodilators, airway clearance and DNAse

A finding of bronchiectasis is inconsistent with a diagnosis of cystic fibrosis

Cystic fibrosis is an autosomal recessive condition inherited through gene expression on chromosome number 5

Exacerbation of illness due to serious infection (as in the vignette above) is most often caused by gram positive organisms

Maintenance therapy of cystic fibrosis includes bronchodilators, airway clearance and DNAse

The underlying defect of cystic fibrosis is in sodium and potassium transport channels in the lungs and other organs

Pediatric Pulmonology

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| Written by Liborio

Liborio

Community Contributor

Total Contribution - 3 | Total attempts - 7,106

Questions: 8 | Attempts: 1,613 | Updated: Mar 21, 2023

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