PEARS Managing Respiratory Emergencies — Questions and Answers

Question 1: A 3-year-old presents with sudden onset of stridor, drooling, and refusal to swallow. Which intervention is most appropriate initially?

Perform direct laryngoscopy to inspect the airway
Allow the child to maintain a position of comfort and prepare for airway management (Correct answer)
Insert a nasopharyngeal airway immediately
Begin bag-mask ventilation with 100% oxygen

Correct answer: Allow the child to maintain a position of comfort and prepare for airway management

In suspected epiglottitis, allowing the child to assume a position of comfort (usually tripod position) minimizes agitation and reduces risk of complete airway obstruction.

Question 2: During management of a pediatric patient in respiratory distress, which finding best indicates that bag-mask ventilation is effective?

Heart rate increases to above 160 bpm
Visible chest rise with each breath (Correct answer)
Oxygen saturation immediately reaches 100%
The child begins crying vigorously

Correct answer: Visible chest rise with each breath

Visible and bilateral chest rise confirms adequate tidal volume delivery during bag-mask ventilation.

Question 3: A 6-year-old with known asthma presents with severe wheezing, accessory muscle use, and SpO2 of 88%. After albuterol, SpO2 rises to 91%. What is the next best step?

Discharge home with oral albuterol prescription
Administer systemic corticosteroids and reassess (Correct answer)
Perform immediate endotracheal intubation
Apply a nonrebreather mask only and observe

Correct answer: Administer systemic corticosteroids and reassess

Systemic corticosteroids reduce airway inflammation and are indicated when initial bronchodilator therapy does not fully resolve a moderate-to-severe asthma exacerbation.

Question 4: When selecting a bag-mask for a pediatric patient, which sizing criterion is most important?

The mask covers the mouth, nose, and eyes for a complete seal
The mask covers the nose and mouth without overlapping the eyes or chin (Correct answer)
The bag volume must be at least 1500 mL regardless of patient size
The mask color matches the patient's age group per AHA protocol

Correct answer: The mask covers the nose and mouth without overlapping the eyes or chin

A properly sized mask creates a seal from the bridge of the nose to the chin cleft without covering the eyes, preventing injury and ensuring an airtight seal.

Question 5: A 10-month-old is found unresponsive with labored, gasping respirations. After opening the airway, you note poor air entry. What is the most likely cause?

Tension pneumothorax
Airway obstruction from the tongue (Correct answer)
Severe pulmonary edema
Diaphragmatic hernia

Correct answer: Airway obstruction from the tongue

In an unresponsive infant, the most common cause of airway obstruction is the tongue falling back against the posterior pharynx, which can be relieved by head-tilt chin-lift or jaw thrust.

Question 6: Which clinical sign best differentiates upper airway obstruction from lower airway obstruction in a pediatric patient?

Presence of nasal flaring
Inspiratory stridor versus expiratory wheezing (Correct answer)
Oxygen saturation below 94%
Use of sternocleidomastoid muscles

Correct answer: Inspiratory stridor versus expiratory wheezing

Inspiratory stridor indicates upper airway (extrathoracic) obstruction, while expiratory wheezing indicates lower airway (intrathoracic) obstruction.

Question 7: A 2-year-old with bronchiolitis has increased work of breathing and SpO2 of 90% on room air. Which intervention is the priority?

Administer nebulized albuterol every 20 minutes
Apply supplemental oxygen to achieve SpO2 ≥94% (Correct answer)
Initiate IV corticosteroids immediately
Perform nasotracheal suctioning every 15 minutes

Correct answer: Apply supplemental oxygen to achieve SpO2 ≥94%

Supplemental oxygen to maintain SpO2 ≥94% is the primary supportive intervention for bronchiolitis, as bronchodilators and steroids have not shown consistent benefit.

Question 8: A 5-year-old post-drowning patient is breathing spontaneously but has SpO2 of 85% on 10L nonrebreather mask. What is the next step?

Switch to nasal cannula and reassess in 30 minutes
Provide positive pressure ventilation with bag-mask (Correct answer)
Administer inhaled albuterol for suspected bronchospasm
Begin chest compressions to improve cardiac output

Correct answer: Provide positive pressure ventilation with bag-mask

Failure to maintain adequate SpO2 on high-flow oxygen with spontaneous breathing indicates the need for assisted ventilation with positive pressure.

Question 9: When performing the jaw thrust maneuver in a pediatric trauma patient, why is it preferred over head-tilt chin-lift?

It provides a better mask seal for bag-mask ventilation
It opens the airway without extending the cervical spine (Correct answer)
It is faster and requires only one provider
It is more effective in infants under 12 months

Correct answer: It opens the airway without extending the cervical spine

The jaw thrust opens the airway by displacing the mandible anteriorly without requiring cervical spine extension, making it the preferred maneuver when spinal injury is suspected.

Question 10: A 14-month-old in respiratory distress has nasal flaring, subcostal retractions, and grunting. What does grunting indicate?

The child is in pain and should receive analgesics immediately
The child is generating PEEP to maintain alveolar patency (Correct answer)
The child has a foreign body in the upper airway
The child's diaphragm is paralyzed

Correct answer: The child is generating PEEP to maintain alveolar patency

Grunting is produced by partial closure of the glottis during exhalation, creating autoPEEP to prevent alveolar collapse and maintain functional residual capacity.

Question 11: Which assessment finding in a child with respiratory distress requires the MOST immediate intervention?

Respiratory rate of 40 breaths/min with clear lungs
Central cyanosis unresponsive to supplemental oxygen (Correct answer)
Mild subcostal retractions with SpO2 of 93%
Mild tachycardia with anxious appearance

Correct answer: Central cyanosis unresponsive to supplemental oxygen

Central cyanosis unresponsive to supplemental oxygen indicates severe hypoxemia from cardiac or pulmonary shunting, requiring immediate advanced intervention.

Question 12: A 9-year-old with severe asthma who is not improving with bronchodilators develops a paradoxical pulse (pulsus paradoxus >20 mmHg). What does this indicate?

Normal physiological response to bronchodilator therapy
Severe air trapping causing significant intrathoracic pressure swings (Correct answer)
Cardiac tamponade requiring pericardiocentesis
Successful response to treatment with improving airflow

Correct answer: Severe air trapping causing significant intrathoracic pressure swings

Significant pulsus paradoxus in asthma reflects severe air trapping and increased intrathoracic pressure swings that impede venous return during inspiration.

Question 13: When providing supplemental oxygen to a newborn in respiratory distress, which target SpO2 range is appropriate in the first minutes of life?

≥95% immediately at birth
85-95% in the first 10 minutes, titrating upward (Correct answer)
100% to prevent hypoxic injury
70-80% to avoid oxygen toxicity

Correct answer: 85-95% in the first 10 minutes, titrating upward

SpO2 rises gradually after birth; targeting 85-95% in the first 10 minutes with titration prevents both hypoxia and oxygen toxicity in neonates.

Question 14: A child requiring ventilatory support has gastric distension from bag-mask ventilation. What is the most appropriate intervention?

Increase ventilation rate to push air through the distension
Insert an orogastric or nasogastric tube to decompress the stomach (Correct answer)
Decrease oxygen flow rate to reduce insufflation
Perform Sellick maneuver after the fact to push air out

Correct answer: Insert an orogastric or nasogastric tube to decompress the stomach

An orogastric or nasogastric tube decompresses the stomach, reducing aspiration risk and improving diaphragm excursion during bag-mask ventilation.

Question 15: A 3-year-old is found with a button battery lodged in the esophagus causing stridor and drooling. What is the priority management?

Administer racemic epinephrine and observe
Urgent endoscopic removal due to risk of tissue necrosis (Correct answer)
Encourage the child to swallow water to move the battery
Perform abdominal thrusts to dislodge the object

Correct answer: Urgent endoscopic removal due to risk of tissue necrosis

Esophageal button batteries cause rapid tissue necrosis via electrical current and alkali generation, requiring emergency endoscopic removal within hours.

Question 16: During resuscitation of a 2-year-old, which ventilation rate is recommended when an advanced airway is in place?

8-10 breaths per minute asynchronous with compressions
20-30 breaths per minute coordinated with compressions
1 breath every 6 seconds (10 breaths/min) asynchronously (Correct answer)
1 breath every 3 seconds (20 breaths/min) asynchronously

Correct answer: 1 breath every 6 seconds (10 breaths/min) asynchronously

With an advanced airway secured, deliver 1 breath every 6 seconds (approximately 10 breaths/min) asynchronously with continuous chest compressions to avoid hyperventilation.

Question 17: A 6-year-old has fever, muffled voice, and drools despite sitting upright. Neck radiograph shows a 'thumb sign.' Which diagnosis is most likely?

Viral croup
Epiglottitis (Correct answer)
Peritonsillar abscess
Foreign body aspiration

Correct answer: Epiglottitis

The thumb sign on lateral neck X-ray represents a swollen epiglottis and, combined with fever, drooling, and muffled voice, is pathognomonic of epiglottitis.

Question 18: A 4-year-old with respiratory failure has been intubated. After intubation, SpO2 drops and breath sounds are heard only on the right. What is the most likely cause?

Right-sided tension pneumothorax
Right mainstem intubation (Correct answer)
Esophageal intubation
Equipment failure of the pulse oximeter

Correct answer: Right mainstem intubation

Unilateral breath sounds after intubation most commonly result from advancing the endotracheal tube too far into the right mainstem bronchus; the tube must be pulled back.

Question 19: A 10-year-old with sickle cell disease presents with acute chest syndrome: fever, chest pain, and SpO2 of 89%. Which is the MOST important initial management?

Withhold oxygen to avoid suppressing hypoxic drive
Administer supplemental oxygen and ensure adequate hydration (Correct answer)
Perform immediate phlebotomy to reduce blood viscosity
Administer high-dose corticosteroids as first-line treatment

Correct answer: Administer supplemental oxygen and ensure adequate hydration

Supplemental oxygen to correct hypoxia and IV hydration to prevent further sickling are the cornerstone initial treatments for acute chest syndrome.

Question 20: Which physical finding best indicates successful relief of a foreign body airway obstruction in a conscious child?

Child stops crying and becomes calm
Effective cough returns with improved air entry (Correct answer)
Heart rate decreases to normal range
Skin color returns from mottled to pink

Correct answer: Effective cough returns with improved air entry

Return of an effective cough and improved air entry confirm that the foreign body has been dislodged and the airway is now patent.

Question 21: A 2-month-old presents with rapid, shallow breathing, poor feeding, and intercostal retractions. SpO2 is 91%. Which condition is the most common cause of respiratory failure in infants this age?

Croup
Bronchiolitis caused by RSV (Correct answer)
Bacterial pneumonia requiring antibiotics
Congenital diaphragmatic hernia

Correct answer: Bronchiolitis caused by RSV

Respiratory syncytial virus (RSV) bronchiolitis is the most common cause of lower respiratory tract infection and respiratory failure in infants under 2 years of age.

PEARS Managing Respiratory Emergencies

A 3-year-old presents with sudden onset of stridor, drooling, and refusal to swallow.
Which intervention is most appropriate initially?

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