Asthma
This medication is the first-line controller therapy for persistent asthma.
inhaled corticosteroids (ICS)
Clinical pearl: If symptoms >2 days/week or nighttime awakenings → they need ICS
A child with chronic cough worse at night and exercise. Next diagnostic step?
spirometry with bronchodilator response
💡 Pearl: Confirm before labeling
Term infant, C-section, tachypnea shortly after birth, mild distress. Diagnosis?
Transient Tachypnea of the Newborn (TTN)
💡 Pearl: Fluid clearance issue
A child with croup received racemic epinephrine and improved. What is the required next step?
Observe for at least 2–3 hours
💡 Pearl: Rebound symptoms = board favorite
An infant with bronchiolitis has persistent hypoxia (SpO₂ 88%). Next step?
Supplemental oxygen (consider HFNC if worsening)
💡 Pearl: Oxygen threshold drives admission
A 7-year-old with asthma uses albuterol daily and wakes at night twice weekly. He is on low-dose ICS. What is the next step?
Step up to medium-dose ICS or add LABA
💡 Pearl: Don’t just “increase PRN”—step up controller
Nighttime cough in a child is most suggestive of this condition.
asthma
Night cough = asthma until proven otherwise
👉 Especially if no fever or URI symptoms
Preterm infant with ground-glass lungs and oxygen requirement. Next step?
surfactant administration + respiratory support
💡 Pearl: Classic RDS management
A toxic-appearing child with drooling and stridor is suspected of epiglottitis. First action?
Controlled airway management in OR/ICU setting
💡 Pearl: NOT ED intubation unless crashing
A child with pneumonia has persistent fever after 72 hours of antibiotics. Next step?
Evaluate for complications (effusion/empyema with imaging)
💡 Pearl: Not “change antibiotics blindly”
This is the most appropriate next step in a moderate asthma exacerbation not improving with SABA.
systemic corticosteroids
Steroids early in exacerbation
👉 Don’t wait—give systemic steroids within the first hour in moderate–severe cases
Snoring and daytime behavioral issues in a child suggest this diagnosis.
Obstructive sleep apnea
OSA in kids = behavior changes + snoring
👉 Think ADHD-like symptoms → underlying sleep issue
Term infant with severe distress and patchy infiltrates after meconium-stained delivery. Risk complication?
persistent pulmonary hypertension of the newborn (PPHN)
💡 Pearl: MAS → PPHN risk
A child has recurrent croup episodes. What underlying condition must be considered?
subglottic stenosis or airway anomaly
💡 Pearl: Recurrent = structural until proven otherwise
A child with suspected foreign body aspiration has a normal chest X-ray. Next step?
Rigid bronchoscopy
💡 Pearl: Imaging does NOT rule it out
ER Setting: A child with severe asthma exacerbation is not improving after 3 back-to-back albuterol/ipratropium treatments and steroids. Next step?
IV magnesium sulfate
💡 Pearl: This is the next escalation before intubation
A teen with sudden dyspnea, chest pain, and decreased breath sounds on one side. Diagnosis?
Spontaneous pneumothorax
💡 Pearl: Boards love this in adolescents
A newborn has differential cyanosis (upper vs lower extremities). Diagnosis?
PPHN or ductal-dependent cardiac lesion
💡 Pearl: Think right-to-left shunting
A child with stridor that worsens when supine and improves prone. Diagnosis?
Laryngomalacia
💡 Pearl: Positional stridor = classic
A child with wheezing improves after albuterol during bronchiolitis. Should treatment continue?
Trial continuation ONLY if clear, sustained clinical response
💡 Pearl: Exception—not routine use
ER Setting: A patient improves clinically after severe asthma exacerbation but still has mild wheeze. Disposition?
discharge if no hypoxia, good air entry, reliable follow-up
Residual wheeze ≠ admission
The definitive management for suspected foreign body aspiration.
Rigid bronchoscopy
Rigid bronchoscopy = both diagnostic AND therapeutic
👉 Don’t delay for imaging if suspicion is high
A neonate with respiratory distress does not improve with oxygen. Next step?
evaluate for congenital heart disease or PPHN (pre/post ductal sats, echo)
💡 Pearl: Not all distress is pulmonary
A child with sudden high fever, muffled voice, but is vaccinated and stable. Most likely organism now?
Staphylococcus aureus or Streptococcus species
💡 Pearl: Not just Hib anymore
A child with severe pneumonia develops dullness to percussion and decreased breath sounds. Next step?
Ultrasound or chest imaging to evaluate for empyema → drainage if present
💡 Pearl: Recognize complications early