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Bronchiolitis with impending respiratory failure — MRCEM SBA MCQ

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HardPaediatric emergenciesBronchiolitis with impending respiratory failureMRCEM SBA

A 5-week-old infant is brought to the emergency department after three days of coryza, cough and increasingly difficult feeding. He has widespread crackles and has taken about 40% of his usual milk today. His temperature is 36.8°C. Despite supplemental oxygen, his oxygen saturation remains 91% between episodes. Staff witness two brief episodes of apnoea requiring stimulation; afterwards he is less responsive and his respiratory effort is reduced. No upper-airway secretions are visible. Which management plan is most appropriate now?

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Correct answer: C — Suction the upper airway, consider CPAP, start intravenous isotonic fluids and seek urgent critical-care review.

This infant’s coryzal illness, cough and crackles are consistent with bronchiolitis, but the decisive finding is **impending respiratory failure**: recurrent apnoea, reduced respiratory effort and failure to maintain adequate saturation despite oxygen. NICE advises urgent action because such infants may need intensive care, and recommends considering CPAP. It also specifies upper-airway suction for bronchiolitis presenting with apnoea, even when no secretions are visible. Intravenous isotonic fluids, rather than nasogastric fluids, are indicated when respiratory failure is impending. Oxygen and readiness to escalate airway support remain essential. ([nice.org.uk](https://www.nice.org.uk/guidance/ng9/chapter/recommendations)) A provides enteral fluid and ward care appropriate to less severe feeding difficulty, but misses respiratory escalation. B selects the appropriate fluid route yet still treats impending failure as a ward-level problem. D recognises the need for CPAP assessment and critical-care review but selects nasogastric fluid despite impending failure. E addresses respiratory support and fluids but omits suction, which is specifically indicated after apnoea even without visible secretions. ([nice.org.uk](https://www.nice.org.uk/guidance/ng9/chapter/Recommendations))

Reference: NICE NG9, Bronchiolitis in children: diagnosis and management, recommendations 1.1.10 and 1.4.5 (9 August 2021) — https://www.nice.org.uk/guidance/ng9/chapter/recommendations NICE NG9, Bronchiolitis in children: diagnosis and management, recommendation 1.4.8 (9 August 2021) — https://www.nice.org.uk/guidance/ng9/chapter/recommendations NICE NG9, Bronchiolitis in children: diagnosis and management, recommendations 1.4.11–1.4.12 (9 August 2021) — https://www.nice.org.uk/guidance/ng9/chapter/recommendations