An 11-year-old boy with a history of cystic fibrosis and frequent lower respiratory tract infections complains of 3 days of rhinorrhea and cough.  He has been using his bronchodilator with some improvement, until he was traveling with his family across state when his symptoms precipitously worsened -- they drove to the closest ED, yours.  The boy has mild shortness of breath, with no history of fever, productive sputum, abdominal pain, or decreased urine output.  The family is anxious that this is not “their hospital”.

On examination, his vital signs show T 37.7 HR 120 RR 22 100/60 98% RA.  You see a thin chronically ill boy in mild respiratory distress, sitting up in the gurney, playing a game with his older brother.  He has slightly diminished tidal volume bilaterally, and end-expiratory mid-pitched wheezing. The rest of his exam is non-contributory. 

He is placed on a nebulized bronchodilator, and appears to relax initially, then to have slow onset increased work of breathing and more air hunger.  He has no chest pain.  Repeat vital signs show HR 122 RR 24 110/60 96% RA.  His breath sounds are equal and now reveal low-pitched wheezing in both inspiratory and expiratory phases. You order a chest x-ray.

While you await the chest x-ray, which is the next BEST step in his management:

    A.    Prepare to insert bilateral chest tubes
    B.    Stop bronchodilators and start inhaled hypertonic saline
    C.    Prepare to intubate
    D.    Start inhaled N-acetylcysteine


In the meantime, a quote –

“If you cannot make a diagnosis at least make a decision.”

-- Sir Henry Platt (1897-1986)