Recurrent wheeze in preschool children — branching viva

Station opening

Examiner: "Define recurrent preschool wheeze and reproduce the phenotype classification." [2]

Strong candidate (must-hit)

• Defines recurrent preschool wheeze as a descriptive umbrella — repeated wheeze in a child under six — deliberately not the diagnosis 'asthma'; reproduces the ERS temporal phenotypes (episodic viral wheeze with discrete colds-associated attacks and well intervals, versus multiple-trigger wheeze with interval symptoms provoked by exercise, allergen, and cold air); adds that the phenotypes overlap, can switch over time, and guide rather than dictate treatment, and that the Tucson trajectories (transient early, late-onset, persistent) explain why most early wheeze remits. [2]

Weak candidate

• "It's just toddler asthma." [2]

Branch A — The 2-year-old with colds-only wheeze, well between

Examiner: "A 2-year-old has had six wheeze episodes this year, each with a cold, and is completely well between. How do you classify and manage him?" [2] [3]

Strong

• Classifies episodic (viral) wheeze; applies the Asthma Predictive Index (≥4 episodes/year plus one major or two minor criteria) to stratify future asthma risk; if API-negative and non-atopic, manages with as-needed salbutamol via spacer and no daily controller, noting episodic LTRA or ICS give only modest benefit; eliminates tobacco smoke, checks spacer technique, provides an action plan, and reassures the family that the wheeze is likely to be outgrown. [2] [3]

Weak

• "Start daily inhaled steroid for life." [4]

Branch B — The 4-year-old atopic multiple-trigger child

Examiner: "A 4-year-old wheezes on exercise and in cold air as well as with colds, has eczema, and his father has asthma. What is your preventive plan and what evidence supports it?" [3] [4]

Strong

• Recognises multiple-trigger, API-positive atopic wheeze with likely eosinophilic steroid-responsive inflammation; offers a monitored trial of daily inhaled corticosteroid for eight to twelve weeks, reviewed and stepped down or stopped if it does not clearly help; cites PEAK (Guilbert) that daily ICS controls symptoms but does not modify the disease once stopped and has a small transient growth effect, and MIST (Zeiger) that intermittent high-dose budesonide is broadly comparable to daily low-dose budesonide for exacerbations; manages the eczema and addresses smoke exposure and inhaler technique. [4] [7]

Weak

• "The echo... I mean, just give antibiotics for the chest." [2]

Branch C — The 3-year-old in a severe acute attack

Examiner: "A 3-year-old presents with SpO2 90 percent, marked recession, and is too breathless to talk. What is your immediate management and what is the role of oral steroid?" [2] [8]

Strong

• Grades a severe attack; gives controlled oxygen to keep SpO2 ≥92%, nebulised salbutamol with ipratropium repeated by response, and a systemic corticosteroid for the severe attack; escalates with IV magnesium sulphate and IV salbutamol or aminophylline for life-threatening features and involves senior and PICU/retrieval teams early; cites Panickar that oral prednisolone does not shorten admission for mild-to-moderate viral wheeze, so systemic steroid is targeted at the severe attack and atopic phenotype rather than given reflexively. [2] [8]

Weak

• "Give a fluid bolus and a routine course of prednisolone for every wheezy child." [8]

Branch D — The 18-month-old with a monophonic wheeze since choking

Examiner: "An 18-month-old has had a persistent monophonic wheeze on one side since choking on a nut a month ago. What is the diagnosis and what do you do?" [2]

Strong

• Diagnoses an inhaled foreign body until proven otherwise, given the choking history and the fixed monophonic unilateral wheeze; states that a normal chest radiograph does not exclude it because organic objects are radiolucent and the film may show only subtle air trapping; arranges urgent rigid bronchoscopy for diagnosis and removal, because a missed foreign body causes persistent wheeze, recurrent pneumonia, and bronchiectasis; does not settle for a bronchodilator trial. [2]

Weak

• "The chest x-ray is normal, so reassure and treat as viral wheeze." [2]

Close

Examiner: "Summarise your approach to the recurrently wheezy preschooler in one sentence." [2] [4]

Strong

• "Recurrent preschool wheeze is a descriptive umbrella, not a diagnosis: I confirm it is truly wheeze, classify the phenotype as episodic viral or multiple-trigger while noting the labels overlap and switch, stratify future asthma risk with atopy and the Asthma Predictive Index, and exclude the red-flag mimics such as inhaled foreign body and cystic fibrosis; I treat the acute attack by severity with salbutamol via spacer, oxygen, and targeted systemic steroid (recalling Panickar's negative result for mild-to-moderate viral wheeze); and I offer preventive therapy only as a monitored trial matched to the phenotype — reliever alone for episodic viral wheeze, a reviewed daily inhaled-steroid trial for the atopic API-positive child (PEAK: control not cure), and pre-emptive high-dose inhaled steroid for selected severe intermittent wheezers — while eliminating tobacco smoke, checking inhaler technique, and reassuring the family that most children outgrow it." [4] [5]

Weak

• "Treat them all as asthmatics and hope for the best." [2]