Respiratory Diseases Practice Questions

Q: A child presents with high grade fever, inspiratory stridor and develops swallowing difficulty with drooling of saliva since last 4-6 hours. Which of the following treatment is recommended apart from general airway management?

IV ceftriaxone. ***IV ceftriaxone*** - The symptoms (high-grade fever, inspiratory stridor, swallowing difficulty with drooling, rapid onset) are highly suggestive of **acute epiglottitis**, a life-threatening emergency. - **Empiric intravenous antibiotics** like ceftriaxone are crucial for treating the bacterial infection (commonly *Haemophilus influenzae* type b or *Streptococcus pneumoniae*) causing epiglottitis. *Anti-diphtheria toxin* - This treatment is specific for **diphtheria**, which causes a pseudomembrane and can lead to airway obstruction, but the clinical picture here is more consistent with epiglottitis due to its rapid and severe presentation without mention of a pseudomembrane. - Diphtheria typically has a more gradual onset and is characterized by a **grayish pseudomembrane** in the throat, unmentioned in this case. *Corticosteroids* - While corticosteroids are used in other forms of upper airway obstruction (like **croup**), their role in acute epiglottitis is controversial and not a primary life-saving measure; antibiotics and airway management are paramount. - Their primary benefit lies in reducing inflammation, but they do not address the acute bacterial cause of epiglottitis directly and are secondary to antibiotics. *Nebulized racemic epinephrine* - This treatment is primarily used for **laryngotracheobronchitis (croup)**, which presents with a barking cough and stridor, but typically lacks the high fever and severe drooling seen in epiglottitis. - Nebulized racemic epinephrine helps to reduce subglottic edema in croup but would not be effective against the severe supraglottic swelling of epiglottitis, nor would it treat the underlying bacterial infection.

Q: A 3-year-old is diagnosed with severe acute asthma exacerbation. Which medication is given first?

Nebulized salbutamol. ***Nebulized salbutamol*** - **Salbutamol** (albuterol) is a **short-acting beta-2 agonist (SABA)** which provides rapid bronchodilation by relaxing smooth muscles in the airways. - It is the **first-line treatment** for acute asthma exacerbations due to its quick onset of action and effectiveness in relieving bronchospasm. *Inhaled ipratropium* - **Ipratropium**, an anticholinergic, is often added to bronchodilators like salbutamol in **severe exacerbations** but is not the primary initial bronchodilator. - It works by blocking muscarinic receptors, causing **bronchodilation**, but its onset of action is slower than salbutamol. *IV corticosteroids* - **Corticosteroids** reduce airway inflammation and are crucial for preventing relapse and shortening recovery in severe asthma, but their **onset of action is delayed** (several hours). - They are typically administered after initial bronchodilation with SABAs and are not the first medication given for immediate symptom relief. *IV magnesium sulfate* - **Magnesium sulfate** is a smooth muscle relaxant that can be used in **severe, life-threatening asthma exacerbations** that are refractory to standard therapy. - It is considered a **second or third-line treatment** rather than an initial intervention for immediate bronchodilation.

Q: An 8-year-old with cystic fibrosis on chronic macrolide therapy presents with a worsening productive cough, fever, and weight loss. Sputum culture shows Pseudomonas aeruginosa, which is multidrug-resistant. Evaluate the risks and benefits of the available treatment options.

Inhaled colistin + IV meropenem. ***Inhaled colistin + IV meropenem*** - This combination targets **multidrug-resistant (MDR) *Pseudomonas aeruginosa***, which is a common and challenging pathogen in cystic fibrosis (CF) patients. - **Inhaled colistin** delivers high concentrations of the antibiotic directly to the lungs, minimizing systemic toxicity, while **IV meropenem** provides systemic coverage for severe infections. *IV ceftazidime + aminoglycoside* - While typically used for *Pseudomonas* infections, this combination might be ineffective against **multi-drug resistant strains**, given the patient's history and the severity of the infection. - Aminoglycosides have significant **nephrotoxicity** and **ototoxicity** risks, especially with prolonged use, which may be contraindicated in a patient with chronic illness. *Long-term inhaled tobramycin* - **Long-term inhaled tobramycin** is a maintenance therapy to prevent exacerbations, not typically used for acute, severe, and MDR infections. - The *Pseudomonas* strain is already **multidrug-resistant**, suggesting tobramycin monotherapy would be insufficient. *Bronchial artery embolization* - This procedure is indicated for managing **massive hemoptysis** in CF patients, which is not described as the primary problem here. - It does not address the underlying **bacterial infection** or the patient's worsening cough, fever, and weight loss.

Q: A 12-year-old boy presents with recurrent episodes of wheezing, coughing, and shortness of breath, particularly at night. What is the most likely diagnosis?

Asthma. ***Asthma*** - This presentation of **recurrent wheezing, coughing**, and **shortness of breath**, especially at night in a 12-year-old boy, is highly characteristic of **asthma**. - **Nocturnal symptoms** are a classic feature of asthma, often due to circadian rhythms influencing airway inflammation and bronchoconstriction. *Chronic Bronchitis* - **Chronic bronchitis** is defined by a productive cough for at least 3 months in 2 consecutive years and is primarily seen in **adult smokers**. - It is highly unlikely in a 12-year-old boy without a significant smoking history. *Bronchiolitis* - **Bronchiolitis** primarily affects **infants and young children** (usually under 2 years old) and is typically caused by viral infections like **RSV**. - While it presents with wheezing and respiratory distress, it's rare in a 12-year-old and usually an acute rather than recurrent condition. *Pneumonia* - **Pneumonia** is an infection of the lungs, typically presenting with fever, cough with sputum, chest pain, and fatigue. - While it can cause shortness of breath and cough, the **recurrent nature** and improvement with treatment (implied by recurrence) are less typical of pneumonia and more indicative of a chronic reactive airway disease.

Q: An 8-year-old girl with asthma presents with wheezing and difficulty breathing despite using her inhaler. What is the next best step in management?

Administer a short-acting beta-agonist via nebulizer. ***Administer a short-acting beta-agonist via nebulizer*** - The immediate treatment for acute asthma exacerbations, characterized by wheezing and difficulty breathing despite regular inhaler use, is the administration of a **short-acting beta-agonist (SABA)** to quickly open the airways. - Using a **nebulizer** allows for the efficient delivery of a higher dose of medication directly to the lungs, which is crucial when symptoms are not relieved by a standard inhaler. *Administer a higher dose of inhaled corticosteroids* - While inhaled corticosteroids are important for **long-term asthma control** and reducing inflammation, they do not provide immediate relief during an acute asthma attack. - Increasing the dose will not address the rapid bronchodilation needed to alleviate severe wheezing and difficulty breathing. *Hospitalize and start intravenous corticosteroids* - **Hospitalization and intravenous corticosteroids** are reserved for severe asthma exacerbations that do not respond to initial outpatient management with bronchodilators, or if the patient shows signs of impending respiratory failure. - This step is premature without first attempting more immediate and less invasive treatments for acute symptom relief. *Schedule for allergy testing* - **Allergy testing** is part of identifying asthma triggers and developing a long-term management plan, but it has no role in the acute management of an asthma exacerbation. - Focusing on allergy testing during an acute attack would delay critical treatment for the patient's immediate breathing difficulties.

Q: What is the first-line treatment for croup in children?

Corticosteroids. **Corticosteroids** - **Corticosteroids** (e.g., **dexamethasone**) are the first-line treatment for croup, as they reduce **airway inflammation** and **edema**, improving symptoms. - Their anti-inflammatory effects help alleviate the characteristic **barking cough** and **stridor** associated with croup. *Antibiotics* - Croup is primarily caused by **viral infections**, typically **parainfluenza virus**, making antibiotics ineffective. - **Antibiotics** are only indicated if a **secondary bacterial infection** is suspected, which is rare. *Antihistamines* - **Antihistamines** are not effective in treating croup as they do not address the underlying **viral inflammation** and **airway swelling**. - They may cause **sedation**, which could mask signs of respiratory distress. *Cough suppressants* - **Cough suppressants** are generally not recommended for croup because the cough is a protective mechanism to clear the airways. - Suppressing the cough could potentially worsen **airway obstruction** in children with croup.

Q: In managing bronchiolitis in an infant, which treatment is most commonly tried but not recommended due to its ineffectiveness in improving clinical outcomes?

Nebulized albuterol. ***Nebulized albuterol*** - Bronchiolitis is primarily caused by **viral infections** (most commonly RSV), leading to inflammation and mucus production, not bronchoconstriction that responds to bronchodilators. - Despite being commonly attempted in clinical practice, studies have consistently shown that **albuterol** (a bronchodilator) does not improve clinical outcomes, reduce hospital stays, or decrease the need for respiratory support in infants with bronchiolitis. - **Key point**: Unlike asthma (where bronchodilators are effective), bronchiolitis involves small airway obstruction from mucus and inflammation, not reversible bronchospasm. *High-flow oxygen* - **High-flow nasal cannula (HFNC) oxygen therapy** is recommended for infants with bronchiolitis experiencing respiratory distress and hypoxemia. - It provides humidified oxygen at a high flow rate, which reduces work of breathing and improves oxygenation, making it an **effective supportive treatment**. *Systemic corticosteroids* - While systemic corticosteroids are also not routinely recommended for bronchiolitis, they are less commonly tried compared to bronchodilators. - The inflammatory response in viral bronchiolitis is less responsive to steroids, and their use has not shown consistent benefit. *Antibiotics* - Bronchiolitis is predominantly a **viral illness**, making antibiotics unnecessary. - Antibiotics are indicated only when there is strong evidence of a **secondary bacterial infection**, not for routine bronchiolitis management.

Q: An 18-month-old child presents with fever, cough, and wheezing. A chest X-ray shows hyperinflation and patchy infiltrates. What is the most likely diagnosis?

Bronchiolitis. ***Bronchiolitis*** - **Bronchiolitis** is the most common lower respiratory tract infection in children under 2 years old and presents with **fever**, **cough**, and **wheezing**, often following a viral upper respiratory infection (most commonly RSV). - Chest X-ray findings typically include **hyperinflation** (due to air trapping from small airway obstruction) and **patchy infiltrates** or peribronchial thickening, which are characteristic of this condition. - The age group (18 months) and clinical presentation are classic for bronchiolitis. *Asthma* - While asthma can present with **wheezing** and **cough**, it is less common in children under 2 years old as the first presentation. - Asthma typically lacks fever and is more episodic with identifiable triggers (allergens, exercise, cold air). - Chest X-ray in asthma may show hyperinflation but usually lacks the patchy infiltrates seen here. *Pneumonia* - Pneumonia typically presents with **high fever**, **productive cough**, and **localized infiltrates or consolidation** on chest X-ray rather than diffuse patchy infiltrates. - While bacterial pneumonia can cause cough and fever, the prominent **wheezing** and **hyperinflation** are more characteristic of bronchiolitis. - The diffuse nature of findings favors bronchiolitis over focal pneumonia. *Cystic fibrosis* - Cystic fibrosis is a **genetic disorder** that typically presents with **recurrent respiratory infections**, **failure to thrive**, and **malabsorption** with steatorrhea. - While it can cause chronic cough and wheezing, an acute presentation as described without prior history of recurrent infections, poor growth, or gastrointestinal symptoms makes this less likely. - CF is a chronic progressive condition rather than an acute illness.

Q: A 6-year-old boy presents with fever, cough, and difficulty breathing. On examination, there are decreased breath sounds on the right side and dullness to percussion. Chest X-ray shows blunting of the costophrenic angle. What is the most likely diagnosis?

Pleural Effusion. ***Pleural Effusion*** - The combination of **decreased breath sounds** and **dullness to percussion** with **blunting of the costophrenic angle** on chest X-ray is diagnostic of pleural effusion. - Pleural effusion represents fluid accumulation in the pleural space, commonly seen as a **parapneumonic effusion** in pediatric respiratory infections. - The physical exam finding of **dullness to percussion** is the key distinguishing feature that indicates fluid rather than air-trapping or simple consolidation. *Pneumonia* - Pneumonia is likely the **underlying cause** and often presents with similar symptoms (fever, cough, difficulty breathing). - However, when **dullness to percussion** and **costophrenic angle blunting** are specifically noted, this indicates the presence of **pleural effusion** (often parapneumonic). - Pure pneumonia with consolidation may show **bronchial breath sounds** and **increased tactile fremitus**, but the marked dullness and imaging findings point to fluid collection. *Asthma* - Asthma typically presents with **wheezing** and **hyperresonance** to percussion due to air trapping, not dullness. - The primary pathophysiology in asthma is **bronchoconstriction**, which does not cause fluid accumulation or dullness to percussion. *Pneumothorax* - Pneumothorax involves air in the pleural space, leading to **hyperresonance** to percussion (not dullness) and severely **diminished breath sounds**. - The finding of **dullness** specifically rules out pneumothorax in favor of fluid or solid mass.

Q: A 10-month-old infant presents with a history of recurrent chest infections and has a sweat chloride level of 70 mmol/L. What is the most likely diagnosis?

Cystic fibrosis. ***Cystic fibrosis*** - A **high sweat chloride level** (typically > 60 mmol/L) is the hallmark diagnostic criterion for cystic fibrosis (CF). - Recurrent chest infections are common in CF due to thick, sticky mucus obstructing airways and promoting **bacterial growth**. *Primary ciliary dyskinesia* - Characterized by **defects in ciliary structure or function**, leading to impaired mucus clearance and recurrent respiratory infections. - However, it is not associated with elevated sweat chloride levels. *Bronchopulmonary dysplasia* - A chronic lung disease that affects premature infants who received oxygen therapy or mechanical ventilation. - It involves **abnormal lung development** and persistent respiratory symptoms, but not high sweat chloride. *Asthma* - A chronic inflammatory disease of the airways, often characterized by **reversible airway obstruction** and hyperresponsiveness. - It presents with wheezing, coughing, and shortness of breath, but does not involve elevated sweat chloride or recurrent severe infections in infancy to this degree.

Question 1

A child presents with high grade fever, inspiratory stridor and develops swallowing difficulty with drooling of saliva since last 4-6 hours. Which of the following treatment is recommended apart from general airway management?

Accepted Answer

IV ceftriaxone

Answer

Anti-diphtheria toxin

Answer

Corticosteroids

Answer

Nebulized racemic epinephrine

Question 2

A 3-year-old is diagnosed with severe acute asthma exacerbation. Which medication is given first?

Accepted Answer

Nebulized salbutamol

Answer

Inhaled ipratropium

Answer

IV corticosteroids

Answer

IV magnesium sulfate

Question 3

An 8-year-old with cystic fibrosis on chronic macrolide therapy presents with a worsening productive cough, fever, and weight loss. Sputum culture shows Pseudomonas aeruginosa, which is multidrug-resistant. Evaluate the risks and benefits of the available treatment options.

Accepted Answer

Inhaled colistin + IV meropenem

Answer

IV ceftazidime + aminoglycoside

Answer

Long-term inhaled tobramycin

Answer

Bronchial artery embolization

Question 4

A 12-year-old boy presents with recurrent episodes of wheezing, coughing, and shortness of breath, particularly at night. What is the most likely diagnosis?

Accepted Answer

Asthma

Answer

Chronic Bronchitis

Answer

Bronchiolitis

Answer

Pneumonia

Question 5

An 8-year-old girl with asthma presents with wheezing and difficulty breathing despite using her inhaler. What is the next best step in management?

Accepted Answer

Administer a short-acting beta-agonist via nebulizer

Answer

Administer a higher dose of inhaled corticosteroids

Answer

Hospitalize and start intravenous corticosteroids

Answer

Schedule for allergy testing

Question 6

What is the first-line treatment for croup in children?

Accepted Answer

Corticosteroids

Answer

Antibiotics

Answer

Antihistamines

Answer

Cough suppressants

Question 7

In managing bronchiolitis in an infant, which treatment is most commonly tried but not recommended due to its ineffectiveness in improving clinical outcomes?

Accepted Answer

Nebulized albuterol

Answer

High-flow oxygen

Answer

Antibiotics

Answer

Systemic corticosteroids

Question 8

An 18-month-old child presents with fever, cough, and wheezing. A chest X-ray shows hyperinflation and patchy infiltrates. What is the most likely diagnosis?

Accepted Answer

Bronchiolitis

Answer

Asthma

Answer

Pneumonia

Answer

Cystic fibrosis

Question 9

A 6-year-old boy presents with fever, cough, and difficulty breathing. On examination, there are decreased breath sounds on the right side and dullness to percussion. Chest X-ray shows blunting of the costophrenic angle. What is the most likely diagnosis?

Accepted Answer

Pleural Effusion

Answer

Asthma

Answer

Pneumonia

Answer

Pneumothorax

Question 10

A 10-month-old infant presents with a history of recurrent chest infections and has a sweat chloride level of 70 mmol/L. What is the most likely diagnosis?

Accepted Answer

Cystic fibrosis

Answer

Primary ciliary dyskinesia

Answer

Bronchopulmonary dysplasia

Answer

Asthma

Respiratory Diseases — MCQs

Respiratory Diseases — MCQs

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