Respiratory Emergencies: Croup, Epiglottitis, Bronchiolitis, Asthma, Foreign Bodies, and Distress vs Failure Practice Questions

25 multiple-choice questions on Respiratory emergencies: croup, epiglottitis, bronchiolitis, asthma, foreign bodies, and distress vs failure for paramedic and EMT students, from Chapter 44 (Pediatric Emergencies). Read each question, pick your answer, then tap Show answer to check it and read the explanation.

25 practice questions

1. A 2-year-old with croup has a barking cough but no stridor at rest. He is alert, playful, and pink. The best management is to:

   1. A. Give nebulized epinephrine right away
   2. B. Keep him calm and transport him in comfort
   3. C. Inspect his throat with a tongue blade
   4. D. Prepare for immediate intubation
   Show answer

   Answer: B. Keep him calm and transport him in comfort

   Mild croup without stridor at rest needs calm reassurance, a position of comfort, and monitoring; agitating the child worsens airway narrowing. Nebulized epinephrine is reserved for stridor at rest or significant distress.

2. The barking cough and stridor of croup are caused mainly by swelling of the:

   1. A. Subglottic airway
   2. B. Epiglottis
   3. C. Bronchioles
   4. D. Alveoli
   Show answer

   Answer: A. Subglottic airway

   Croup inflames the larynx and trachea, and swelling just below the vocal cords at the narrow subglottic region produces stridor and the seal-like bark. Swelling of the epiglottis is the hallmark of epiglottitis instead.

3. When nebulized L-epinephrine (1 mg/mL) is used for croup with stridor at rest, the usual dose is:

   1. A. 0.05 mL/kg, max 0.5 mL
   2. B. 5 mL/kg, max 50 mL
   3. C. 0.01 mL/kg, max 0.3 mL
   4. D. 0.5 mL/kg, max 5 mL
   Show answer

   Answer: D. 0.5 mL/kg, max 5 mL

   Nebulized L-epinephrine 1 mg/mL is given at 0.5 mL/kg up to 5 mL; racemic epinephrine 2.25% is given as 0.5 mL by nebulizer. The 0.01 mL/kg, 0.3-mL dose is the IM anaphylaxis dose, not the nebulized croup dose.

4. A parent asks whether to keep running a cool-mist humidifier for her toddler's croup. Current evidence shows that humidified air:

   1. A. Cures croup within 1 hour
   2. B. Replaces the need for steroids
   3. C. Does not improve croup symptoms
   4. D. Prevents stridor from returning
   Show answer

   Answer: C. Does not improve croup symptoms

   Randomized trials and a Cochrane review found that humidified air or mist does not improve croup scores, so it is not recommended; a single dose of dexamethasone is the mainstay, with nebulized epinephrine for stridor at rest. Mist does not cure croup. It does not replace steroids. It does not prevent stridor from returning. (Cochrane 2006; AAFP 2018 croup review.)

5. A toddler with croup has stridor at rest and retractions. Over 20 minutes the stridor gets quieter, but she becomes less responsive. This suggests:

   1. A. Tiring, near respiratory failure
   2. B. Improvement as the airway swelling eases
   3. C. Normal sleepiness after crying
   4. D. A response to cool night air
   Show answer

   Answer: A. Tiring, near respiratory failure

   Quieter stridor with declining responsiveness means she is moving less air and tiring, which is impending respiratory failure; prepare to assist ventilation and transport rapidly. True improvement comes with better air entry, less work of breathing and a more alert child. Sleepiness with ongoing retractions is not normal after crying. Cool air has no proven effect on croup. (AHA PALS provider manual; Caroline 9th ed.)

6. A 15-year-old with cystic fibrosis has sudden sharp chest pain and worsening shortness of breath. A complication to suspect is:

   1. A. Asthma exacerbation
   2. B. Spontaneous pneumothorax
   3. C. A CF pulmonary exacerbation
   4. D. Costochondritis
   Show answer

   Answer: B. Spontaneous pneumothorax

   Damaged, cystic lungs in cystic fibrosis make spontaneous pneumothorax a common complication in adolescents and young adults, presenting with sudden pleuritic pain and dyspnea; give oxygen, assess breath sounds, and watch for tension. A CF pulmonary exacerbation builds over days with more cough and sputum rather than sudden pleuritic pain, asthma causes wheeze without sharp one-sided pain, and costochondritis causes chest wall tenderness without worsening shortness of breath. (CF Foundation pneumothorax guideline 2010.)

7. A child with suspected epiglottitis suddenly obstructs completely and becomes apneic. Your first airway action should be to:

   1. A. Perform a needle cricothyrotomy
   2. B. Ventilate with a BVM and a tight seal
   3. C. Give back blows and chest thrusts
   4. D. Insert a nasopharyngeal airway
   Show answer

   Answer: B. Ventilate with a BVM and a tight seal

   Bag-valve-mask ventilation with a good two-person seal usually moves air past a swollen epiglottis and is the first step. Needle cricothyrotomy is a last resort when BVM ventilation and intubation fail.

8. Viral croup most commonly affects children in which age range?

   1. A. 6 months to 3 years
   2. B. Birth to 1 month of age
   3. C. 8 to 12 years of age
   4. D. 13 to 18 years of age
   Show answer

   Answer: A. 6 months to 3 years

   Croup peaks between about 6 months and 3 years, usually in fall and winter, with a barking cough and stridor that are often worse at night, because the young subglottic airway is narrow. Newborns rarely get croup. Children 8 and older and teenagers have wider airways, and new barky stridor at those ages should prompt thought of another cause. (AAFP 2018 croup review.)

9. In bacterial tracheitis, sudden airway obstruction is most often caused by:

   1. A. Swelling of the epiglottis
   2. B. Spasm of the small bronchioles
   3. C. Spasm of the vocal cords
   4. D. Thick, purulent tracheal secretions
   Show answer

   Answer: D. Thick, purulent tracheal secretions

   Bacterial tracheitis produces thick pus and sloughed membranes in the trachea that can suddenly plug the airway, so suction and be ready to ventilate. Epiglottic swelling is the mechanism in epiglottitis.

10. A 4-month-old in winter has nasal congestion, a cough, wheezing, and retractions. Her older brother has a cold. The most likely diagnosis is:

    1. A. Foreign-body aspiration
    2. B. Croup
    3. C. Bronchiolitis
    4. D. Epiglottitis
    Show answer

    Answer: C. Bronchiolitis

    Bronchiolitis, usually from RSV, causes wheezing and distress in children under 2 after a viral upper respiratory illness. A first-time wheeze in a young infant is rarely asthma.

11. Under the AAP bronchiolitis guideline, giving albuterol to an infant with typical RSV bronchiolitis is:

    1. A. Needed whenever an infant wheezes
    2. B. The single most effective therapy
    3. C. Not recommended as routine care
    4. D. Reserved for afebrile infants
    Show answer

    Answer: C. Not recommended as routine care

    The AAP recommends against routine albuterol in bronchiolitis because trials show no improvement in oxygenation, admission or length of illness; care is supportive, with nasal suctioning, oxygen if hypoxemic, hydration and monitoring for apnea. Wheezing in bronchiolitis does not mean a bronchodilator is required. Albuterol is not the most effective therapy. Fever has no bearing on whether it works. (Ralston et al., Pediatrics 2014.)

12. Infants with RSV bronchiolitis at highest risk for apnea are those who are:

    1. A. Older than 12 months of age
    2. B. Premature or under 2 months old
    3. C. Breastfed and born at term
    4. D. Afebrile with a mild, dry daytime cough
    Show answer

    Answer: B. Premature or under 2 months old

    Apnea can be the first sign of RSV in premature infants and those younger than about 2 months, so monitor these infants closely. Infants older than 12 months and term breastfed infants are at far lower risk. A mild cough without fever does not mark higher apnea risk. (AAP bronchiolitis guideline 2014.)

13. In an infant with fever and cough, which single finding most suggests pneumonia?

    1. A. A runny nose
    2. B. A high fever
    3. C. A barking, seal-like cough
    4. D. Fast breathing for age
    Show answer

    Answer: D. Fast breathing for age

    Tachypnea is the most useful single sign of pneumonia in young children; WHO uses 50 or more breaths/min at 2 to 11 months and 40 or more at 1 to 5 years, along with retractions. A runny nose is common in any viral cold, high fever occurs with many infections that do not involve the lungs, and a barking cough points to croup in the upper airway. (WHO pneumonia classification 2014.)

14. A 7-year-old with asthma still has wheezing and retractions after two albuterol treatments. Adding which medication is reasonable?

    1. A. Nebulized ipratropium
    2. B. Oral diphenhydramine
    3. C. Oral montelukast
    4. D. Inhaled salmeterol by MDI
    Show answer

    Answer: A. Nebulized ipratropium

    Ipratropium added to albuterol improves bronchodilation in moderate to severe asthma. Antihistamines such as diphenhydramine do not reverse bronchospasm and can dry secretions. Montelukast and long-acting salmeterol are controller medicines that act too slowly to help an acute attack.

15. A 10-month-old with tetralogy of Fallot becomes deeply cyanotic, breathes fast, and is irritable after a long crying spell. A first step is to:

    1. A. Lay him flat and raise both legs above his head
    2. B. Give a 20 mL/kg fluid bolus before anything else
    3. C. Encourage him to keep crying to expand his lungs
    4. D. Calm him and hold his knees up to his chest
    Show answer

    Answer: D. Calm him and hold his knees up to his chest

    In a 'tet spell,' crying and agitation increase right-to-left shunting across the heart defect. Holding the child in a knee-chest position raises systemic resistance and pushes more blood to the lungs; keep him calm, give oxygen, and transport. More crying worsens the spell.

16. For a 20-kg child with status asthmaticus unresponsive to bronchodilators, the IV magnesium sulfate dose is:

    1. A. 2 to 5 mg/kg by rapid IV push
    2. B. 25 to 50 mg/kg over 15 to 20 min
    3. C. 100 mg/kg by rapid IV push
    4. D. 250 to 500 mg/kg over 1 hour
    Show answer

    Answer: B. 25 to 50 mg/kg over 15 to 20 min

    Magnesium sulfate 25 to 50 mg/kg (maximum 2 g) is infused over 15 to 20 minutes to relax bronchial smooth muscle. Rapid push risks hypotension and bradycardia.

17. The pediatric (0.15-mg) epinephrine auto-injector is generally intended for children weighing about:

    1. A. 5 to 10 kg
    2. B. 30 to 45 kg
    3. C. 15 to 30 kg
    4. D. Over 45 kg
    Show answer

    Answer: C. 15 to 30 kg

    FDA labeling gives the 0.15-mg auto-injector for about 15 to 30 kg and the 0.3-mg device for 30 kg or more, with a 0.1-mg device for 7.5 to 15 kg in some brands; the AAP (2017) suggests moving to the 0.3-mg device at about 25 kg because 0.15 mg underdoses heavier children. 5 to 10 kg is the 0.1-mg range or below. 30 to 45 kg and over 45 kg call for the 0.3-mg device. (Sicherer SH, Simons FER, AAP. Epinephrine for First-aid Management of Anaphylaxis. Pediatrics 2017;139:e20164006.)

18. A 7-year-old who had COVID-19 a month ago has had fever for 5 days, red eyes, a rash, belly pain, and now a BP of 76/40 mmHg with cool extremities. You should suspect:

    1. A. Multisystem inflammatory syndrome in children
    2. B. A simple viral rash that can be treated with oral fluids
    3. C. Appendicitis with a rash from an unrelated virus
    4. D. An allergic reaction to an earlier COVID-19 vaccine
    Show answer

    Answer: A. Multisystem inflammatory syndrome in children

    MIS-C appears weeks after a COVID-19 infection with persistent fever, inflammation of several organs (often the gut, skin, eyes, and heart), and sometimes shock from heart dysfunction. Treat the shock with careful fluid boluses, watching for heart failure, and transport to a pediatric center.

19. A choking 4-year-old becomes unresponsive. After you lower her to the floor, you should:

    1. A. Begin CPR, looking in the mouth before breaths
    2. B. Do blind finger sweeps, then give rescue breaths
    3. C. Give supine abdominal thrusts first
    4. D. Check a pulse for a full 20 seconds
    Show answer

    Answer: A. Begin CPR, looking in the mouth before breaths

    An unresponsive choking child gets CPR, because compressions can expel the object; look in the mouth before each set of breaths and remove a visible object. Blind sweeps can push the object deeper, and pulse checks should not exceed 10 seconds.

20. A 3-year-old swallowed a coin an hour ago. She is drooling and refuses to swallow but is breathing easily. The coin is most likely in the:

    1. A. Trachea
    2. B. Stomach
    3. C. Small bowel
    4. D. Esophagus
    Show answer

    Answer: D. Esophagus

    Drooling and refusal to swallow with normal breathing suggest an object stuck in the esophagus, often at the level of the upper esophageal sphincter; keep her upright, let her spit, and transport for removal (a button battery must be excluded). A tracheal object would cause coughing, stridor or respiratory distress. A coin in the stomach or small bowel usually causes no symptoms. (Caroline 9th ed.)

21. Which finding in a 2-year-old with respiratory distress indicates progression to respiratory failure?

    1. A. Tachypnea and nasal flaring
    2. B. Bradycardia and lethargy
    3. C. Agitation and retractions
    4. D. Loud expiratory wheezing
    Show answer

    Answer: B. Bradycardia and lethargy

    A falling heart rate and decreasing responsiveness signal hypoxia and fatigue, the hallmarks of respiratory failure; prepare to ventilate. Tachypnea, flaring, and agitation reflect compensated distress.

22. Head bobbing in an infant with respiratory distress is caused by:

    1. A. Meningeal irritation from fever
    2. B. Nasal obstruction from mucus
    3. C. Use of neck accessory muscles
    4. D. Weak neck muscles from lethargy
    Show answer

    Answer: C. Use of neck accessory muscles

    Head bobbing occurs as the infant contracts the neck accessory muscles to lift the chest; the head rises and falls with each breath. It is a sign of increased work of breathing, not of meningeal irritation, nasal blockage, or neck weakness from lethargy, although a tiring infant may later lose the effort.

23. A 2-month-old has paroxysms of rapid coughing with gagging, vomiting after coughing, and brief spells of apnea. Both parents have had a lingering cough for 3 weeks. The most likely disease is:

    1. A. Croup
    2. B. Asthma
    3. C. Pertussis
    4. D. Epiglottitis
    Show answer

    Answer: C. Pertussis

    Paroxysmal cough, post-tussive vomiting, and apnea in a young infant whose household contacts have a chronic cough suggest pertussis; young infants may not whoop. Use droplet precautions and monitor for apnea.

24. A 3-year-old has a fever, tachypnea, grunting, and crackles with decreased breath sounds over the right lower chest. The most likely diagnosis is:

    1. A. Asthma
    2. B. Croup
    3. C. Bronchiolitis
    4. D. Pneumonia
    Show answer

    Answer: D. Pneumonia

    Fever, grunting, and focal crackles with diminished breath sounds suggest pneumonia. Asthma causes diffuse wheezing rather than focal crackles.

25. A 9-month-old with bronchiolitis becomes limp, with a respiratory rate of 10 breaths/min and SpO2 of 82% on a nonrebreather mask. Your next step is to:

    1. A. Ventilate with a bag-valve mask
    2. B. Give nebulized albuterol
    3. C. Continue the nonrebreather mask
    4. D. Switch to blow-by oxygen
    Show answer

    Answer: A. Ventilate with a bag-valve mask

    A slow rate, hypoxia, and limpness mean respiratory failure, which requires assisted ventilation with a BVM and 100% oxygen. A nonrebreather supplies oxygen but cannot move air into a child who is not breathing adequately.