Pediatric Respiratory Disorders

An 18-month-old boy is brought to the pediatric pulmonology clinic due to persistent respiratory difficulties. Three months ago, he was hospitalized in the pediatric intensive care unit for a severe lower respiratory tract infection caused by *Adenovirus*, which required mechanical ventilation for seven days. Since discharge, he has exhibited continuous tachypnea, a daily wet cough, and audible wheezing. The patient has had no recent fever or rhinorrhea. Two separate five-day courses of oral prednisolone and regular administration of nebulized albuterol have provided no symptomatic relief. On physical examination, his temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), heart rate is $130/\text{min}$, respiratory rate is $52/\text{min}$, and oxygen saturation is $91\%$ on room air. Pulmonary auscultation reveals diffuse, bilateral expiratory wheezes and coarse crackles. A chest radiograph demonstrates bilateral hyperinflation without focal consolidation. Which of the following is the most appropriate next step in the evaluation or management of this patient?

In early February, the parents of an 18-month-old girl bring her to the emergency department because she has been breathing rapidly and feeding poorly for the past 24 hours. The parents note that her symptoms began four days ago with a runny nose, mild nasal congestion, and a "tight" cough. She has a past medical history of atopic dermatitis managed with emollients. Her immunizations are up to date. Her temperature is 37.9°C (100.2°F), pulse is 158/min, respirations are 58/min, and oxygen saturation is 89% on room air. Physical examination reveals an irritable but consolable toddler with prominent nasal flaring and subcostal retractions. Lung auscultation demonstrates a prolonged expiratory phase, diffuse polyphonic wheezing, and bilateral coarse crackles. A chest radiograph displays bilateral hyperinflation, flattened hemidiaphragms, and a focal, wedge-shaped area of increased opacity in the right middle lobe. Which of the following is the most appropriate next step in management?

During a mid-winter surge of respiratory illnesses, an $8$-month-old girl is evaluated in the pediatric emergency department for severe difficulty breathing. Her symptoms began three days ago with a runny nose, mild cough, and a maximum temperature of $38.0^\circ\text{C}$ ($100.4^\circ\text{F}$). Today, she became increasingly fussy, had two episodes of post-tussive emesis, and refused her last three bottle feeds. Her medical history is notable for delivery at $35$ weeks gestation and a family history of severe asthma in her father. Vital signs show a heart rate of $165$/min, respiratory rate of $68$/min, and oxygen saturation of $87\%$ on room air. Examination reveals an irritable infant with significant head bobbing, nasal flaring, and subcostal retractions. Lung auscultation is remarkable for a prolonged expiratory phase, diffuse polyphonic wheezing, and coarse bilateral crackles. A chest radiograph shows increased anterior-posterior diameter, flattened hemidiaphragms, and prominent perihilar markings but no focal opacities. Which of the following is the most appropriate next step in management?

A 4-year-old boy is brought to the emergency department due to a sudden onset of high fever, severe sore throat, and difficulty breathing that began 4 hours ago. He has not received any childhood immunizations due to parental preference. On examination, the patient appears toxic, anxious, and is sitting in a tripod position while drooling. He has marked inspiratory stridor and intercostal retractions. Oxygen saturation is 93% on room air.

Arrange the following steps in the most appropriate chronological order for the management of this patient's condition.

During a busy winter shift at an urgent care clinic, a 15-month-old girl is evaluated for three days of progressive rhinorrhea, mild cough, and a tactile fever. Over the last 12 hours, she has developed noisy breathing and decreased her solid food intake, though she continues to drink liquids from a sippy cup. She was born at 39 weeks gestation and has no significant past medical history. Her temperature is 37.7°C (99.9°F), pulse is 135/min, respirations are 48/min, and blood pressure is 90/55 mm Hg. Pulse oximetry shows 94% on room air. On examination, the patient is well-perfused and interactive. Lung auscultation reveals diffuse bilateral expiratory wheezes, scattered crackles, and mild subcostal retractions. A trial of a nebulized bronchodilator is administered in the clinic, but reassessment 30 minutes later shows no clinical change in her respiratory rate or auscultatory findings. Which of the following is the most appropriate next step in management?

A $3$-year-old girl is brought to the emergency department by her parents, who state they have declined all childhood vaccinations due to personal beliefs. She developed a sudden-onset high fever and severe sore throat $4$ hours ago. The patient is currently sitting upright on her father's lap, leaning forward with her chin thrust outward. She is drooling profusely and her voice sounds thick and muffled when she attempts to speak. Vital signs show a temperature of $39.8^\circ\text{C}$ ($103.6^\circ\text{F}$), heart rate of $155 \text{ /min}$, and respiratory rate of $48 \text{ /min}$. Marked inspiratory stridor is audible without a stethoscope.

Arrange the following management steps in the most appropriate sequential order for this patient, from first step to final step.

A 10-year-old girl with a known diagnosis of cystic fibrosis is admitted to the pediatric ward for an acute pulmonary exacerbation. She presents with an increased productive cough, decreased exercise tolerance, and a 12% drop in her forced expiratory volume in 1 second ($FEV_1$) from baseline. She is started on intravenous antipseudomonal antibiotics. The respiratory therapist is preparing her daily airway clearance regimen, which involves multiple inhaled medications and physical modalities.

Arrange the following therapies in the correct physiological sequence they should be administered during a single treatment session to maximize airway clearance and drug deposition.

A $7$-month-old boy is evaluated in the urgent care center in early January. His mother reports a $3$-day history of copious nasal discharge, low-grade fever, and a progressively worsening cough. Today, he developed difficulty breathing and has been feeding poorly. His $5$-year-old sister has a history of atopic dermatitis and allergic rhinitis, and she recently recovered from a mild upper respiratory infection. Temperature is $37.8^{\circ}\text{C}$ ($100.0^{\circ}\text{F}$), pulse is $155$ /min, respiratory rate is $62$ /min, and oxygen saturation is $91\%$ on room air. Examination reveals a tachypneic infant with nasal flaring and moderate subcostal retractions. Auscultation of the lungs demonstrates diffuse, bilateral expiratory wheezes and scattered crackles. An empiric nebulized albuterol treatment is administered in the clinic; however, a reassessment $30$ minutes later shows no clinical improvement in his respiratory effort or oxygenation. Which of the following best describes the primary pathophysiologic mechanism responsible for this patient's current respiratory distress and lack of response to the administered therapy?

Emergency medical services transport a 14-month-old male toddler to the hospital following an acute episode of respiratory distress. The parents report that two hours prior to arrival, the child experienced an abrupt, violent choking spell while playing unsupervised in his older sibling's bedroom. The initial severe coughing subsided, but a persistent, noisy breathing pattern developed immediately afterward. He has been previously healthy with no recent history of fever, rhinorrhea, or diagnosed pulmonary conditions. Vital signs upon arrival include a temperature of 37.0°C (98.6°F), a heart rate of 142/min, a respiratory rate of 48/min, and an oxygen saturation of 94% on ambient air. Physical examination shows a conscious, alert child with mild subcostal retractions. Chest auscultation identifies noticeably decreased air entry over the right hemithorax, accompanied by a focal monophonic wheeze during expiration. An expiratory chest radiograph reveals asymmetric hyperlucency of the right lung alongside a leftward deviation of the mediastinum. Which of the following is the most appropriate next step in the management of this patient?

Emergency medical services transport a 15-month-old girl to the emergency department following a sudden episode of severe choking and coughing. The babysitter reports the child was playing near a coffee table with a bowl of mixed nuts when the event occurred. The acute coughing fit has now subsided. Her vital signs show a temperature of 37.0°C (98.6°F), a heart rate of 128/min, a respiratory rate of 34/min, and an oxygen saturation of 97% on room air. Auscultation of the lungs reveals noticeably decreased air entry and a distinct expiratory wheeze localized to the right lower lung field. An expiratory chest radiograph displays hyperinflation of the right lung alongside a mild shift of the mediastinum toward the left. Which of the following is the most appropriate next step in the management of this patient?

An 8-year-old girl is evaluated in the emergency department due to rapidly worsening shortness of breath. She has a known history of moderate persistent asthma. Two days ago, she developed rhinorrhea, a mild cough, and a low-grade fever. Over the past hour in the emergency department, she has received three consecutive nebulized albuterol-ipratropium treatments and a dose of intravenous methylprednisolone, but her work of breathing continues to increase. She is up to date on all childhood immunizations. Vital signs show a temperature of $37.4^\circ\text{C}$ ($99.3^\circ\text{F}$), a heart rate of $152/\text{min}$, a respiratory rate of $44/\text{min}$, and an oxygen saturation of $89\%$ on $4\text{ L/min}$ supplemental oxygen via nasal cannula. On physical examination, she is diaphoretic, visibly fatigued, and sitting forward. There are prominent supraclavicular and intercostal retractions. Lung auscultation reveals markedly diminished air entry bilaterally without audible wheezing. Which of the following interventions are indicated as part of the immediate management bundle for this patient? (Select all that apply)

An 11-year-old boy is brought to the pediatric emergency department due to severe, worsening shortness of breath over the past 24 hours. He has a known history of moderate persistent asthma and has been using his albuterol inhaler every 2 hours at home without relief. On arrival, the patient appears lethargic and diaphoretic. He is only able to speak in single syllables. His temperature is $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), pulse is $155/\text{min}$, respirations are $14/\text{min}$, and blood pressure is $112/68\text{ mm Hg}$. Pulse oximetry is $87\%$ on room air. Lung auscultation reveals a "silent chest" with profoundly diminished air entry bilaterally and minimal wheezing.

Which of the following is the most appropriate next step in management?

A 15-month-old male toddler is evaluated in the pediatric emergency center due to worsening respiratory effort and poor oral intake over the last 24 hours. The parents note that he developed a profuse runny nose, mild fever, and a paroxysmal cough three days ago. His birth history is notable for delivery at 34 weeks gestation. He has no history of atopy or prior wheezing episodes. On physical examination, the patient's temperature is $38.2^\circ\text{C}$ ($100.8^\circ\text{F}$), heart rate is $165/\text{min}$, respiratory rate is $72/\text{min}$, and oxygen saturation is $87\%$ on room air. The child appears lethargic but is easily arousable. He exhibits pronounced nasal flaring, intercostal retractions, and expiratory grunting. Auscultation of the chest reveals widespread coarse crackles and high-pitched expiratory polyphonic wheezing. Which of the following interventions are indicated as part of the most appropriate management bundle for this patient? (Select all that apply)

A $6$-month-old boy is brought to the pediatric clinic by his parents for evaluation of chronic noisy breathing. The parents report the noise started around $2$ months of age and has progressively worsened. It is described as a harsh, high-pitched sound heard during both inspiration and expiration. The parents also report that he frequently regurgitates his formula and has been resisting the recent introduction of pureed solid foods, often coughing when swallowing. They note that the infant's breathing seems to improve when he sleeps with his neck hyper-extended. He is at the $15$ th percentile for weight and $50$ th percentile for length. Vital signs are within normal limits for age. Physical examination reveals a prominent biphasic stridor that does not improve with the administration of nebulized racemic epinephrine. Which of the following is the most likely underlying mechanism of this patient's condition?

A 9-year-old boy with a history of mild persistent asthma presents to the emergency department with a 24-hour history of worsening cough, shortness of breath, and chest tightness. He recently had symptoms of a mild viral upper respiratory tract infection. Vital signs show a temperature of $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), heart rate of $115/\text{min}$, respiratory rate of $28/\text{min}$, and oxygen saturation of $94\%$ on room air. Physical examination reveals mild intercostal retractions and diffuse expiratory wheezing bilaterally. Which of the following are appropriate initial steps in the management of this patient's condition? (Select all that apply)

An 11-month-old boy is brought to the pediatric clinic by his parents due to a 4-day history of nasal congestion, low-grade fever, and noisy breathing. His parents note a new, "tight" cough that worsened last night. The patient has a history of mild atopic dermatitis. His father has moderate persistent asthma. The parents also express concern because the boy's 14-month-old cousin is already running, whereas this patient only pulls to stand and cruises along furniture but does not walk independently.

Temperature is 37.9°C (100.2°F), pulse is 138/min, respirations are 46/min, and pulse oximetry is 96% on room air. The patient appears comfortable and is drinking fluids well. Examination shows clear rhinorrhea. Tympanic membranes are slightly erythematous bilaterally, but there is no bulging and mobility is normal on pneumatic otoscopy. Lung auscultation reveals prolonged expiration, diffuse bilateral wheezes, and scattered coarse crackles, accompanied by mild intercostal retractions.

Which of the following is the most appropriate next step in management?

A 4-year-old boy, who recently immigrated and has an unknown immunization history, is brought to the emergency department by his parents. Over the last 6 hours, he has developed a high fever, a muffled voice, and significant difficulty breathing. On physical examination, the child appears toxic and highly anxious. He is sitting upright, leaning forward with his neck extended, and drooling. His temperature is 39.5°C (103.1°F), heart rate is 150/min, respiratory rate is 42/min, and oxygen saturation is 93% on room air. Severe inspiratory stridor and marked intercostal retractions are noted visually. Arrange the following acute management steps in the most appropriate chronological sequence for this patient.

A 4-year-old girl is evaluated in the emergency department for severe shortness of breath and wheezing. Her mother reports that the child developed a runny nose and a low-grade fever two days ago, which progressed to a persistent, tight cough and difficulty breathing this morning. The patient's medical history includes atopic dermatitis and allergic rhinitis, for which she uses emollients and as-needed oral antihistamines. Her immunizations are up-to-date. On arrival, her temperature is 37.3°C (99.1°F), pulse is 138/min, respirations are 44/min, and blood pressure is 95/60 mm Hg. Pulse oximetry shows 91% on room air. Physical examination reveals a distressed, tachypneic child sitting upright. There are prominent intercostal and subcostal retractions. Lung auscultation demonstrates a prolonged expiratory phase with diffuse, bilateral polyphonic wheezing. Which of the following is the most appropriate next step in management?

While playing unsupervised in a playroom, a 22-month-old toddler experiences a sudden onset of choking and spasmodic coughing. His caregiver reports that the intense coughing resolved after several minutes, but the child has since been breathing rapidly. He has been previously healthy with no recent fever or nasal congestion. Current vital signs include a temperature of 36.9°C (98.4°F), blood pressure of 96/58 mm Hg, pulse of 128/min, and a respiratory rate of 42/min. Pulse oximetry indicates 95% on room air. Physical examination demonstrates an alert child with mild subcostal retractions. Lung auscultation is notable for decreased air entry and a persistent, localized monophonic wheeze over the right hemithorax. A chest radiograph demonstrates hyperinflation of the right lung field with leftward mediastinal deviation that is accentuated on expiration. Which of the following is the most appropriate next step in management?

A 15-year-old adolescent with cystic fibrosis and pancreatic insufficiency is evaluated in the outpatient pulmonary clinic for a 4-week history of worsening productive cough, malaise, and subjective low-grade fevers. He reports expectorating thick, brownish, plug-like sputum. His daily maintenance regimen of dornase alfa, hypertonic saline, and chest physiotherapy has not alleviated the symptoms. Pulmonary function testing performed today shows a forced expiratory volume in 1 second (FEV1) of 60% of predicted, a significant decline from his baseline of 84% recorded two months ago. Vital signs show an oxygen saturation of 95% on ambient air. Lung auscultation reveals prominent bilateral expiratory wheezes and coarse upper lobe crackles. A complete blood count is notable for an absolute eosinophil count of 1,250/mm³. Total serum IgE is markedly elevated at 1,650 IU/mL. High-resolution computed tomography of the chest demonstrates new upper lobe central bronchiectasis with scattered mucous plugging and fleeting infiltrates. Which of the following are indicated in the initial pharmacological management of this patient's current condition? (Select all that apply)