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HERMES Paediatric Respiratory study materials
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HERMES Paediatric Respiratory practice questions

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Question 1Paediatric respiratory medicine (single combined syllabus; subdomains not enumerated in source)

A 4-year-old presents with a 3-day history of coryza followed by a barking cough and hoarse voice. He has inspiratory stridor at rest and a mild suprasternal recession. What is the most appropriate first-line pharmacological treatment?

  1. Nebulised salbutamol
  2. Nebulised adrenaline
  3. Oral amoxicillin
  4. Oral prednisolone Correct answer.

Explanation

This is croup (laryngotracheobronchitis), and a single dose of oral dexamethasone (or an equivalent corticosteroid such as prednisolone) is first-line for all severities because it reduces airway oedema and need for further intervention. Nebulised adrenaline is reserved for moderate-to-severe disease with marked recession or hypoxia, and antibiotics have no role in a viral illness.

Question 2Paediatric respiratory medicine (single combined syllabus; subdomains not enumerated in source)

Which clinical feature most strongly suggests that a child's stridor is due to laryngomalacia rather than another cause?

  1. Stridor that is present from birth and worsens in the supine position Correct answer.
  2. Stridor accompanied by a barking cough
  3. Stridor that appears only during expiration
  4. Stridor that begins suddenly after choking on a nut

Explanation

Laryngomalacia is the commonest cause of congenital stridor and characteristically produces inspiratory stridor that is worse when supine, feeding, or crying, and improves in the prone position. It typically presents in the first weeks of life and resolves spontaneously as the laryngeal cartilages stiffen.

Question 3Paediatric respiratory medicine (single combined syllabus; subdomains not enumerated in source)

A 6-year-old with asthma uses a salbutamol inhaler with a spacer. Which instruction best reflects correct spacer technique?

  1. Actuate the puff and inhale forcefully and immediately in a single breath
  2. Actuate the puff and hold the breath for at least 30 seconds
  3. Actuate one puff at a time and take five to ten tidal breaths before the next puff Correct answer.
  4. Actuate several puffs into the spacer at once and breathe normally

Explanation

With a spacer, one puff is actuated at a time and the child takes around five to ten tidal breaths (or a single slow deep breath if able) before the next actuation. This allows the aerosol to be inhaled without requiring perfect coordination and reduces oropharyngeal deposition.

Question 4Paediatric respiratory medicine (single combined syllabus; subdomains not enumerated in source)

Which finding on spirometry is most consistent with a diagnosis of asthma in a symptomatic school-age child?

  1. A reduced FEV1/FVC ratio that improves significantly after a bronchodilator Correct answer.
  2. A fixed reduction in FEV1/FVC that does not change after bronchodilator
  3. A raised residual volume with a normal FEV1/FVC ratio
  4. A restrictive pattern with a normal FEV1/FVC ratio

Explanation

Asthma produces variable, reversible airflow obstruction, so spirometry typically shows a reduced FEV1/FVC ratio with meaningful improvement in FEV1 after a short-acting bronchodilator. Demonstrating reversibility supports the diagnosis and distinguishes asthma from fixed obstructive disease.

Question 5Paediatric respiratory medicine (single combined syllabus; subdomains not enumerated in source)

A 3-year-old has a 4-week history of persistent wet cough that is worse at night and on waking, and has failed two courses of antibiotics. Which underlying diagnosis should be specifically considered?

  1. Gastro-oesophageal reflux
  2. Viral wheeze
  3. Primary ciliary dyskinesia
  4. Protracted bacterial bronchitis Correct answer.

Explanation

A chronic wet cough lasting more than four weeks with no other explanation, especially one that responds poorly to standard courses, is the classic picture of protracted bacterial bronchitis. It is managed with a prolonged course of an appropriate antibiotic such as amoxicillin-clavulanate, and failure to respond should prompt reconsideration of the diagnosis.

Question 6Paediatric respiratory medicine (single combined syllabus; subdomains not enumerated in source)

A 2-year-old with cystic fibrosis has a productive cough. Which airway clearance approach is most appropriate as routine daily therapy?

  1. Chest physiotherapy with postural drainage and percussion, adapted to age Correct answer.
  2. Regular nebulised hypertonic saline alone without physiotherapy
  3. Scheduled oral corticosteroids to reduce airway inflammation
  4. Continuous low-dose oxygen therapy during sleep

Explanation

Airway clearance is a cornerstone of cystic fibrosis care, and age-adapted techniques such as modified postural drainage, percussion, and assisted cough are used daily. Hypertonic saline and other mucolytics are adjuncts that enhance clearance but do not replace the mechanical clearance routine.

Question 7Paediatric respiratory medicine (single combined syllabus; subdomains not enumerated in source)

A 10-year-old with cystic fibrosis has a positive respiratory culture. Which organism is most strongly associated with accelerated decline in lung function in this population?

  1. Streptococcus pneumoniae
  2. Moraxella catarrhalis
  3. Pseudomonas aeruginosa Correct answer.
  4. Haemophilus influenzae

Explanation

Chronic infection with Pseudomonas aeruginosa is linked to more rapid loss of lung function, increased exacerbations, and worse survival in cystic fibrosis. Eradication protocols are used at first isolation, and chronic suppressive therapy is started once infection becomes established.

Question 8Paediatric respiratory medicine (single combined syllabus; subdomains not enumerated in source)

A term newborn develops respiratory distress within the first hours of life. Chest radiograph shows a ground-glass appearance with low lung volumes and air bronchograms. What is the most likely diagnosis?

  1. Respiratory distress syndrome Correct answer.
  2. Congenital diaphragmatic hernia
  3. Meconium aspiration syndrome
  4. Transient tachypnoea of the newborn

Explanation

Respiratory distress syndrome results from surfactant deficiency and produces low lung volumes with a diffuse ground-glass pattern and air bronchograms, typically in a preterm infant though occasionally in a term infant. Surfactant replacement is the definitive treatment.

Question 9Paediatric respiratory medicine (single combined syllabus; subdomains not enumerated in source)

Which statement about the inheritance of cystic fibrosis is correct?

  1. It is caused by a mitochondrial mutation inherited from the mother
  2. It is an autosomal recessive condition requiring two carrier parents Correct answer.
  3. It is an X-linked recessive condition affecting mainly boys
  4. It is an autosomal dominant condition with variable penetrance

Explanation

Cystic fibrosis is autosomal recessive, caused by biallelic pathogenic variants in CFTR on chromosome 7. Carrier parents are usually unaffected, and each pregnancy carries a one-in-four risk of an affected child.

Question 10Paediatric respiratory medicine (single combined syllabus; subdomains not enumerated in source)

A 7-year-old is brought in with sudden onset of coughing and wheeze that began while eating peanuts. He has unilateral reduced air entry and a wheeze on the affected side. What is the most appropriate next step?

  1. Arrange urgent rigid bronchoscopy for removal Correct answer.
  2. Start a course of oral antibiotics for pneumonia
  3. Reassure and discharge with a salbutamol inhaler
  4. Perform a chest radiograph and observe for 24 hours

Explanation

A history of sudden choking while eating followed by unilateral reduced air entry indicates an inhaled foreign body, which requires urgent bronchoscopic removal. Delay risks complete obstruction, distal infection, and airway damage.

Question 11Paediatric respiratory medicine (single combined syllabus; subdomains not enumerated in source)

Which feature best distinguishes bronchiolitis from asthma in an infant under 12 months?

  1. Eosinophilia on a full blood count
  2. Recurrent episodes of wheeze triggered by exercise
  3. A strong personal history of atopy
  4. Diffuse fine crackles and wheeze following a coryzal illness in the first year of life Correct answer.

Explanation

Bronchiolitis is a viral lower respiratory infection, most often respiratory syncytial virus, occurring in the first year of life after a few days of coryza, with fine crackles and wheeze. Asthma is characterised by recurrent, variable, often atopy-associated wheeze rather than a single viral episode in infancy.

Question 12Paediatric respiratory medicine (single combined syllabus; subdomains not enumerated in source)

An infant with bronchiolitis is hypoxic with saturations of 88% in air and is struggling to feed. Which intervention is most appropriate?

  1. Nebulised salbutamol
  2. Supplemented humidified oxygen and nasogastric or intravenous fluids Correct answer.
  3. Nebulised adrenaline as routine therapy
  4. Oral corticosteroids

Explanation

Management of bronchiolitis is supportive, with humidified oxygen for hypoxia and fluid support when feeding is inadequate. Bronchodilators, corticosteroids, and routine adrenaline have not been shown to alter the disease course.

Question 13Paediatric respiratory medicine (single combined syllabus; subdomains not enumerated in source)

A 12-year-old with poorly controlled asthma is reviewed. Which factor is most likely to contribute to ongoing symptoms despite prescribed inhaled corticosteroid?

  1. Regular use of a peak flow meter
  2. Poor adherence and incorrect inhaler technique Correct answer.
  3. Use of a written asthma action plan
  4. Excessive use of a spacer device

Explanation

Poor adherence and faulty inhaler technique are the commonest reasons for uncontrolled asthma in children and should be checked before escalating therapy. A spacer, peak flow monitoring, and an action plan all improve control rather than worsen it.

Question 14Paediatric respiratory medicine (single combined syllabus; subdomains not enumerated in source)

A 9-year-old has an acute asthma attack with oxygen saturations of 91% in air, inability to complete sentences, and a silent chest. Which treatment should be given first alongside high-flow oxygen?

  1. Oral theophylline
  2. Inhaled beclometasone
  3. Nebulised salbutamol and ipratropium bromide Correct answer.
  4. Oral montelukast

Explanation

A silent chest with hypoxia and inability to speak indicates a life-threatening attack requiring high-flow oxygen plus repeated nebulised short-acting beta-2 agonist and ipratropium. Systemic corticosteroids and, if needed, intravenous magnesium are added for severe or refractory disease.

Question 15Paediatric respiratory medicine (single combined syllabus; subdomains not enumerated in source)

A 5-year-old has a persistent dry cough and poor growth. Sweat chloride testing is arranged. Which result supports a diagnosis of cystic fibrosis?

  1. A sweat chloride of 45 mmol/L on one occasion
  2. A sweat chloride of 65 mmol/L on two occasions Correct answer.
  3. A sweat chloride of 30 mmol/L on one occasion
  4. A sweat chloride of 20 mmol/L on two occasions

Explanation

A sweat chloride of 60 mmol/L or more on two separate occasions is diagnostic of cystic fibrosis. Values between 30 and 59 mmol/L are intermediate and require further evaluation such as genetic testing.

Question 16Paediatric respiratory medicine (single combined syllabus; subdomains not enumerated in source)

Which finding on a chest radiograph is most characteristic of a large pleural effusion in a child?

  1. Bilateral perihilar infiltrates with air bronchograms
  2. A dense uniform opacity with a meniscal upper border and mediastinal shift away from the effusion Correct answer.
  3. Hyperinflation with flattened hemidiaphragms
  4. A thin rim of air outlining the mediastinum

Explanation

A large pleural effusion produces a dense, homogeneous opacity with a curved upper border and may push the mediastinum to the opposite side. This distinguishes it from consolidation and from pneumothorax.

Question 17Paediatric respiratory medicine (single combined syllabus; subdomains not enumerated in source)

A 14-year-old presents with a spontaneous pneumothorax. Which underlying condition should be considered in a tall, thin adolescent with a history of recurrent pneumothoraces?

  1. Primary ciliary dyskinesia
  2. Cystic fibrosis
  3. Bronchopulmonary dysplasia
  4. Marfan syndrome Correct answer.

Explanation

Marfan syndrome causes connective tissue weakness, and affected individuals are typically tall and thin with an increased risk of spontaneous pneumothorax from apical blebs. Recurrent pneumothoraces in this body habitus should prompt consideration of the diagnosis.

Question 18Paediatric respiratory medicine (single combined syllabus; subdomains not enumerated in source)

Which feature most reliably indicates that a child's recurrent wheeze is likely to persist into school age?

  1. Wheeze that resolves with a single dose of salbutamol
  2. Wheeze only during viral colds in the first two years of life
  3. A history of preterm birth without chronic lung disease
  4. A personal history of atopic dermatitis and a parental history of asthma Correct answer.

Explanation

The combination of atopic dermatitis and parental asthma substantially increases the likelihood that early wheeze will persist, as reflected in the asthma predictive index. Viral wheeze alone in the first years of life often remits.

Question 19Paediatric respiratory medicine (single combined syllabus; subdomains not enumerated in source)

A child with cystic fibrosis is being reviewed for pancreatic involvement. Which manifestation is most typical?

  1. Exocrine pancreatic insufficiency with steatorrhoea and failure to thrive Correct answer.
  2. Normal fat absorption with isolated diabetes
  3. Primary biliary cirrhosis as the first manifestation
  4. Recurrent acute pancreatitis from an early age

Explanation

Most children with cystic fibrosis have exocrine pancreatic insufficiency causing fat malabsorption, steatorrhoea, and poor weight gain, which requires pancreatic enzyme replacement with meals. This is a direct consequence of duct obstruction and fibrosis.

Question 20Paediatric respiratory medicine (single combined syllabus; subdomains not enumerated in source)

A 3-year-old is drowsy with a respiratory rate of 60, marked recession, and saturations of 86% in air after two days of coryza. Which action is most appropriate?

  1. Arrange outpatient follow-up in one week
  2. Escalate to a high-dependency or intensive care setting for respiratory support Correct answer.
  3. Give a single dose of oral paracetamol and reassess in four hours
  4. Discharge with safety-netting advice

Explanation

Drowsiness with marked recession and hypoxia indicates impending respiratory failure and requires escalation for close monitoring and respiratory support. Delay in this setting risks cardiac arrest from exhaustion.

Question 21Paediatric respiratory medicine (single combined syllabus; subdomains not enumerated in source)

Which statement about the use of chest radiography in uncomplicated asthma is correct?

  1. It is routinely indicated to confirm the diagnosis
  2. It is not routinely indicated and is used to exclude alternative diagnoses Correct answer.
  3. It reliably distinguishes asthma from viral wheeze
  4. It should be performed before every course of corticosteroids

Explanation

A chest radiograph is not part of the routine diagnostic workup for typical asthma; it is reserved for atypical features, suspected complications, or to exclude alternative diagnoses such as pneumonia or foreign body. The diagnosis is clinical, supported by spirometry.

Question 22Paediatric respiratory medicine (single combined syllabus; subdomains not enumerated in source)

A 6-week-old ex-preterm infant has recurrent apnoeas and bradycardias during a respiratory syncytial virus infection. Which factor best explains this presentation?

  1. Immature respiratory control and reduced respiratory reserve in infancy Correct answer.
  2. Underlying congenital heart disease in all cases
  3. A primary immunodeficiency
  4. Hyperreactive airways disease

Explanation

Young infants, particularly those born preterm, have immature respiratory control and limited reserve, so RSV infection can present with apnoea rather than classic wheeze. This explains why apnoea is a recognised presentation in this age group.

Question 23Paediatric respiratory medicine (single combined syllabus; subdomains not enumerated in source)

Which advice should be given to parents of a child with cystic fibrosis regarding infection control at home?

  1. Share nebuliser equipment with siblings to save costs
  2. Stop airway clearance during periods of good health
  3. Avoid close contact with other people with cystic fibrosis and maintain separate equipment Correct answer.
  4. Encourage close contact with other children with cystic fibrosis to build immunity

Explanation

People with cystic fibrosis are advised to avoid close contact with each other because of the risk of cross-infection with organisms such as Pseudomonas and Burkholderia. Equipment should be personal and cleaned according to advice.

Question 24Paediatric respiratory medicine (single combined syllabus; subdomains not enumerated in source)

A child is diagnosed with primary ciliary dyskinesia. Which combination of features is most typical?

  1. Chronic wet cough, recurrent sinusitis, and situs inversus in some cases Correct answer.
  2. Recurrent pneumothoraces with tall thin habitus
  3. Wheeze only during exercise with normal growth
  4. Isolated dry cough with normal chest examination

Explanation

Primary ciliary dyskinesia causes impaired mucociliary clearance, producing chronic wet cough, recurrent upper and lower respiratory infections, and sinusitis. Around half of affected individuals have situs inversus, forming Kartagener syndrome.

Question 25Paediatric respiratory medicine (single combined syllabus; subdomains not enumerated in source)

A 10-year-old with severe asthma is started on a biologic after optimisation of inhaler therapy. Which monitoring consideration applies to omalizumab?

  1. Observation after administration because of the risk of anaphylaxis Correct answer.
  2. Mandatory liver biopsy before each dose
  3. Routine measurement of serum theophylline levels
  4. Monthly chest radiographs

Explanation

Omalizumab is an anti-IgE monoclonal antibody that carries a risk of anaphylaxis, so patients are observed after administration according to local protocols. It is reserved for severe allergic asthma that remains uncontrolled despite optimised standard therapy.

Question 26Paediatric respiratory medicine (single combined syllabus; subdomains not enumerated in source)

A 4-year-old child is brought to the emergency department with drooling, a muffled voice, and a high fever. He is sitting forward and refuses to lie flat. Which is the most appropriate immediate action?

  1. Place the child supine to palpate the neck and assess meningism
  2. Inspect the throat with a tongue depressor to look for membrane
  3. Keep the child calm and upright while arranging urgent senior airway review in theatre Correct answer.
  4. Obtain an anteroposterior neck radiograph before any other step

Explanation

The picture is epiglottitis, a supraglottic emergency in which the airway can obstruct abruptly. The child should be kept calm and upright, with urgent anaesthetic and ENT involvement for controlled airway securing, and no examination of the throat or forced positioning.

Question 27Paediatric respiratory medicine (single combined syllabus; subdomains not enumerated in source)

Which finding is most characteristic of croup on physical examination?

  1. Inspiratory stridor that is constant and unchanged by crying
  2. Expiratory wheeze with prolonged expiration and chest hyperinflation
  3. Inspiratory stridor with a barking cough and hoarse voice Correct answer.
  4. Stridor with a muffled voice and absent cough

Explanation

Croup is subglottic laryngotracheitis, producing a barking cough, hoarseness and inspiratory stridor that typically worsens with agitation. Expiratory wheeze suggests lower airway obstruction, while a muffled voice with absent cough suggests supraglottic disease.

Question 28Paediatric respiratory medicine (single combined syllabus; subdomains not enumerated in source)

A 6-year-old with acute asthma is treated with inhaled salbutamol via a spacer. Which mechanism explains the rapid bronchodilation?

  1. Leukotriene receptor antagonism reducing airway inflammation
  2. Beta-2 receptor stimulation relaxing bronchial smooth muscle Correct answer.
  3. Muscarinic receptor blockade reducing vagal tone
  4. Inhibition of mast cell degranulation preventing mediator release

Explanation

Salbutamol is a short-acting beta-2 agonist that relaxes bronchial smooth muscle within minutes, giving rapid relief of bronchospasm. Anti-inflammatory and mediator-blocking actions belong to other drug classes and act more slowly.

Question 29Paediatric respiratory medicine (single combined syllabus; subdomains not enumerated in source)

A 3-year-old has a harsh systolic murmur and a history of recurrent chest infections. Which congenital cardiac lesion most typically causes increased pulmonary blood flow and pulmonary hypertension?

  1. Coarctation of the aorta
  2. Tricuspid atresia
  3. Large ventricular septal defect Correct answer.
  4. Severe pulmonary stenosis

Explanation

A large ventricular septal defect allows left-to-right shunting, increasing pulmonary blood flow and risking pulmonary hypertension and recurrent infections. Obstructive and duct-dependent lesions reduce rather than increase pulmonary flow.

Question 30Paediatric respiratory medicine (single combined syllabus; subdomains not enumerated in source)

A 2-year-old is suspected of having inhaled a foreign body. Which investigation is the most appropriate first-line imaging study?

  1. Inspiratory chest radiograph only
  2. Bilateral decubitus chest radiographs Correct answer.
  3. Magnetic resonance imaging of the chest
  4. Computed tomography of the chest

Explanation

Most inhaled foreign bodies are radiolucent, so plain films may be normal; bilateral decubitus views can reveal air trapping on the obstructed side. CT and MRI are not first-line and involve unnecessary delay or sedation.

Question 31Paediatric respiratory medicine (single combined syllabus; subdomains not enumerated in source)

Which statement about the neonatal respiratory transition at birth is correct?

  1. Pulmonary blood flow falls as the ductus arteriosus constricts
  2. Fetal haemoglobin rises sharply in the first hours after delivery
  3. Surfactant secretion begins only after the first week of life
  4. Lung liquid is absorbed and replaced by air as pulmonary vascular resistance falls Correct answer.

Explanation

At birth, lung liquid is cleared and replaced by air, and with the first breaths and rising oxygen, pulmonary vascular resistance falls and pulmonary blood flow increases. Surfactant is present before birth and fetal haemoglobin declines after delivery.

Question 32Paediatric respiratory medicine (single combined syllabus; subdomains not enumerated in source)

A 7-year-old with a respiratory tract infection develops a cough and fever. Which feature most suggests pneumonia rather than simple viral bronchitis?

  1. Focal crackles and reduced air entry with tachypnoea Correct answer.
  2. Bilateral fine crackles that clear after coughing
  3. Clear chest with a harsh barking cough
  4. Scattered wheeze responsive to salbutamol

Explanation

Focal crackles with reduced air entry and tachypnoea suggest alveolar consolidation from pneumonia. Diffuse wheeze or a clear chest with barking cough is more typical of viral illness, and crackles that clear with coughing are not focal.

Question 33Paediatric respiratory medicine (single combined syllabus; subdomains not enumerated in source)

A 10-year-old with a peanut allergy develops acute stridor, urticaria and hypotension after eating. Which drug should be given first?

  1. Nebulised salbutamol
  2. Intravenous chlorphenamine
  3. Intramuscular adrenaline into the anterolateral thigh Correct answer.
  4. Oral prednisolone

Explanation

This is anaphylaxis, and intramuscular adrenaline into the anterolateral thigh is the first-line treatment because it reverses airway oedema and hypotension rapidly. Antihistamines and steroids are adjuncts and do not treat the acute airway and circulatory compromise.

Question 34Paediatric respiratory medicine (single combined syllabus; subdomains not enumerated in source)

A 5-year-old with cystic fibrosis is reviewed. Which feature is most typical of meconium ileus?

  1. Projectile non-bilious vomiting at three weeks of age
  2. Passage of bloody stools with a palpable abdominal mass in a well infant
  3. Failure to pass meconium with bilious vomiting and abdominal distension in the first days Correct answer.
  4. Chronic constipation presenting after weaning

Explanation

Meconium ileus presents in the first days with failure to pass meconium, bilious vomiting and distension, and is strongly associated with cystic fibrosis. The other patterns describe intussusception, pyloric stenosis and simple constipation respectively.

Question 35Paediatric respiratory medicine (single combined syllabus; subdomains not enumerated in source)

A 6-year-old has been treated for pneumonia and remains unwell with a persistent cough after four weeks. Which complication is most likely?

  1. An empyema
  2. A lung abscess
  3. A pneumothorax
  4. A small pleural effusion Correct answer.

Explanation

A small pleural effusion is a common complication of bacterial pneumonia and may persist with a residual cough. Pneumothorax, empyema and abscess are less common and usually produce more dramatic systemic or respiratory features.

Question 36Paediatric respiratory medicine (single combined syllabus; subdomains not enumerated in source)

A 12-year-old is diagnosed with obstructive sleep apnoea. Which feature on history is most strongly supportive?

  1. Snoring only during upper respiratory infections
  2. Loud snoring with witnessed apnoeas and daytime sleepiness Correct answer.
  3. Frequent night terrors without snoring
  4. Night-time cough that wakes him once weekly

Explanation

Loud habitual snoring with witnessed pauses in breathing and daytime sleepiness is the classic triad suggesting obstructive sleep apnoea in children. Intermittent snoring only during infections or isolated night terrors is less specific.

Question 37Paediatric respiratory medicine (single combined syllabus; subdomains not enumerated in source)

A 1-year-old with a large ventricular septal defect is failing to thrive. Which feature on examination best indicates a large left-to-right shunt?

  1. A loud pansystolic murmur with a hyperdynamic praecordium and hepatomegaly Correct answer.
  2. A continuous machinery murmur below the clavicle
  3. A quiet chest with a single second heart sound and cyanosis
  4. An ejection systolic murmur radiating to the back with weak femoral pulses

Explanation

A large left-to-right shunt causes a pansystolic murmur, a hyperdynamic circulation and signs of heart failure such as hepatomegaly and poor growth. Cyanosis with a quiet chest suggests Eisenmenger physiology, while the other murmurs suggest a patent ductus arteriosus or coarctation.

Question 38Paediatric respiratory medicine (single combined syllabus; subdomains not enumerated in source)

A 9-year-old with asthma is prescribed a preventer inhaler. Which statement about inhaled corticosteroid therapy is correct?

  1. Rinsing the mouth after use reduces the risk of oral candidiasis Correct answer.
  2. They are first-line for a child with infrequent mild symptoms
  3. They provide rapid relief of acute bronchospasm
  4. They should be used only when symptoms are present

Explanation

Inhaled corticosteroids are preventive anti-inflammatory agents that require regular use and mouth rinsing to reduce local candidiasis and dysphonia. They do not relieve acute bronchospasm and are not indicated for very infrequent symptoms.

Question 39Paediatric respiratory medicine (single combined syllabus; subdomains not enumerated in source)

A 2-year-old is admitted with bronchiolitis. Which finding most strongly predicts the need for escalation of respiratory support?

  1. A single episode of vomiting after feeding
  2. A transient temperature of 38.2 degrees Celsius
  3. Rising respiratory rate with increasing apnoea and exhaustion Correct answer.
  4. Scattered fine crackles on auscultation

Explanation

Increasing respiratory rate with apnoea and exhaustion signals impending respiratory failure and warrants escalation. Fever, crackles and a single vomit are common and do not by themselves indicate deterioration.

Question 40Paediatric respiratory medicine (single combined syllabus; subdomains not enumerated in source)

A 13-year-old presents with sudden pleuritic chest pain and breathlessness. Which finding on examination most supports a pneumothorax?

  1. A pleural rub with normal percussion note
  2. Bronchial breathing and dullness on the affected side
  3. Reduced breath sounds and hyper-resonance on the affected side Correct answer.
  4. Bilateral coarse crackles and fever

Explanation

A pneumothorax produces reduced air entry and hyper-resonance due to air in the pleural space. Dullness with bronchial breathing suggests consolidation or effusion, and a rub without percussion change is non-specific.

Question 41Paediatric respiratory medicine (single combined syllabus; subdomains not enumerated in source)

A 3-year-old has recurrent episodes of pneumonia in the same lobe. Which underlying diagnosis should be most strongly considered?

  1. Cystic fibrosis
  2. An inhaled foreign body or structural airway abnormality Correct answer.
  3. Primary ciliary dyskinesia
  4. Simple viral wheeze

Explanation

Recurrent pneumonia confined to one lobe suggests a local cause such as an inhaled foreign body, bronchial stenosis or sequestration. Cystic fibrosis and primary ciliary dyskinesia usually cause diffuse or multi-lobar disease.

Question 42Paediatric respiratory medicine (single combined syllabus; subdomains not enumerated in source)

A 5-year-old with a suspected empyema has a large pleural effusion. Which management step is most appropriate after initial drainage?

  1. Immediate surgical decortication in all cases
  2. Observation without drainage
  3. Insertion of a chest drain with intrapleural fibrinolysis Correct answer.
  4. Oral antibiotics alone without drainage

Explanation

Empyema requires drainage of pus, usually with a chest drain, and intrapleural fibrinolytics improve drainage of loculated collections. Surgery is reserved for failure of medical management, and antibiotics alone are insufficient.

Question 43Paediatric respiratory medicine (single combined syllabus; subdomains not enumerated in source)

A 4-year-old with cystic fibrosis has a chronic productive cough. Which feature on spirometry best indicates obstructive airway disease?

  1. A reduced FEV1 with a reduced FEV1/FVC ratio Correct answer.
  2. An increased FEV1 with a normal FEV1/FVC ratio
  3. A reduced FVC with a normal FEV1/FVC ratio
  4. A reduced peak expiratory flow with a normal FVC

Explanation

Obstruction reduces FEV1 proportionally more than FVC, lowering the FEV1/FVC ratio. Restrictive disease reduces FVC with a preserved or raised ratio, and isolated peak flow reduction is not diagnostic.

Question 44Paediatric respiratory medicine (single combined syllabus; subdomains not enumerated in source)

A 6-week-old infant has poor feeding, tachypnoea and a capillary refill of four seconds. Which of the following is the most important initial management step?

  1. Start oral antibiotics and review in 48 hours
  2. Perform a chest radiograph before any treatment
  3. Assess airway, breathing and circulation and give high-flow oxygen with fluid resuscitation Correct answer.
  4. Arrange an outpatient echocardiogram

Explanation

The infant is shocked with respiratory distress, so airway, breathing and circulation take priority, with oxygen and circulatory support before investigations. Delaying treatment for imaging or outpatient review risks deterioration.

Question 45Paediatric respiratory medicine (single combined syllabus; subdomains not enumerated in source)

A 2-year-old has a persistent cough and a foreign body is suspected. Which statement about management is correct?

  1. Antibiotics alone will resolve the obstruction
  2. Flexible bronchoscopy is preferred for removal of a peanut
  3. Rigid bronchoscopy is the definitive diagnostic and therapeutic procedure Correct answer.
  4. Bronchodilators will clear the obstruction

Explanation

Rigid bronchoscopy allows controlled visualisation and retrieval of an inhaled foreign body and is the definitive procedure. Flexible bronchoscopy is less suitable for extraction, and drugs do not remove the obstruction.

Question 46Paediatric respiratory medicine (single combined syllabus; subdomains not enumerated in source)

A 10-year-old with cystic fibrosis is reviewed. Which statement about airway clearance is correct?

  1. Postural drainage with head-down tilt is recommended for all infants
  2. Exercise is contraindicated in cystic fibrosis
  3. Techniques should be individualised and performed regularly, often twice daily Correct answer.
  4. Airway clearance is only needed during exacerbations

Explanation

Airway clearance in cystic fibrosis is individualised and performed regularly, usually twice daily, with techniques such as the active cycle of breathing and positive expiratory pressure devices. Head-down drainage is avoided in infants because of reflux risk, and exercise is encouraged.

Question 47Paediatric respiratory medicine (single combined syllabus; subdomains not enumerated in source)

A 14-year-old has a spontaneous pneumothorax and a tall, thin habitus. Which underlying condition is most strongly associated?

  1. Neurofibromatosis type 1
  2. Achondroplasia
  3. Marfan syndrome Correct answer.
  4. Turner syndrome

Explanation

Marfan syndrome causes apical blebs and an increased risk of spontaneous pneumothorax, particularly in tall, thin individuals. The other conditions are not classically associated with this presentation.

Question 48Paediatric respiratory medicine (single combined syllabus; subdomains not enumerated in source)

A 7-year-old with asthma has poor control despite correct inhaler technique. Which factor is most likely to explain ongoing symptoms?

  1. Regular use of a preventer inhaler
  2. A personal action plan
  3. Use of a spacer device
  4. Ongoing exposure to tobacco smoke at home Correct answer.

Explanation

Passive tobacco smoke exposure is a major driver of poor asthma control and increases exacerbations. Spacers, regular preventer use and a written action plan all improve rather than worsen control.

Question 49Paediatric respiratory medicine (single combined syllabus; subdomains not enumerated in source)

A 3-year-old has a chronic cough and clubbing. Which investigation is most useful to detect bronchiectasis?

  1. Chest radiograph alone
  2. High-resolution computed tomography of the chest Correct answer.
  3. Sweat chloride testing
  4. Spirometry

Explanation

High-resolution CT is the investigation of choice for detecting and characterising bronchiectasis, which plain radiography may miss. Spirometry and sweat testing assess function and cystic fibrosis but do not image the airways.

Question 50Paediatric respiratory medicine (single combined syllabus; subdomains not enumerated in source)

A 12-year-old with severe asthma is started on a biologic. Which monitoring consideration is most appropriate?

  1. Repeat spirometry only once after five years
  2. Review of exacerbation frequency and symptom control at regular intervals Correct answer.
  3. Stopping the inhaled corticosteroid immediately
  4. Routine measurement of serum salbutamol levels

Explanation

Biologic therapy is monitored by tracking exacerbation frequency, symptom control and lung function over time. There is no role for measuring salbutamol levels, and inhaled corticosteroids must be continued.