You and your rapid response team are called to the room of a 3-month-old male infant who was admitted yesterday with bronchiolitis.
The child has a 3-day history of nasal congestion and low-grade temperatures.
The patient's mother brought him to the hospital for difficulty breathing and not feeding well for the last 24 hours.

Over the past 12 hours since admission, the child has been coughing more, his work of breathing has increased, and he has copious amounts of airway secretions.
Also, he has not been responding to the every four-hour albuterol treatments.

As you enter the room, you first perform the "initial impression" to begin the systematic approach algorithm.
What 3 observations are made with the "initial impression?"

Initial impression of patient:
Appearance: Irritable with mild lethargy
Breathing: Tachypnea and significant work of breathing.
Color: Pink

After the initial at the door impression, you perform the primary assessment.
Primary Assessment:
Airway: airway patent, copious secretions, but the child has significant wheezing and crackles with severe retractions.
Breathing: Respiratory rate is 73, and the breathing is shallow and labored. O2 sat is 86% on 4 L/min by NC. Decreased air movement on auscultation.
Circulation: Heart rate is 190; capillary refill less than 2 sec., 1 wet diaper today; IV placed on admission and maintenance IV infusing.
Disability: Patient moves all extremities, irritable, mild lethargy
Exposure: Skin warm and pink

Vital Signs: 99.9 F (37.7 C); HR 190; RR 73; O2 Sat 86%; BP 95/52

Also, a chest x-ray shows no lung infiltrates, but pt. has hyperinflation.

Based upon the assessment choose the best classification for this type of respiratory distress from the choices below.

What will be the first two most important interventions? (Note: If you need to look at Question #2 for Assessment info use the overview numbers above to review.)

You remove the oral and nasal secretions from the patient's airway using an appropriate sized suction catheter and apply 100% oxygen by non-rebreathing mask. At this time, you also apply a cardiac monitor and continuous pulse oximetry.
After 5 minutes, you reevaluate per the systematic approach algorithm.

Vital Signs: HR 190; RR 70; O2 Sat 94%; BP 95/48

Repeat Focused Primary Assessment:
Airway: The airway remains patent, wheezing and crackles slightly improved with moderate retractions.
Breathing: Respiratory rate is 70, and breathing remains shallow and labored. O2 sat is 94%. Continued decreased air movement on auscultation.
Circulation: Heart rate is 190; capillary refill remains less than 2 sec.; IV is intact with maintenance fluids infusing
Disability: Patient moves all extremities, remains irritable, mild lethargy
Exposure: Skin warm and pink

You see that oxygenation has improved, but the patient continues to have respiratory distress as indicated by the moderate retractions, tachypnea and decreased air movement. Also, remember that previous albuterol treatments did not help with the patient's condition.

Based on the assessment above, what two interventions should be carried out at this time? (Choose two of the options)

After 4 minutes of providing bag-mask ventilations and giving a racemic epinephrine nebulizer, you reevaluate using the systematic approach algorithm.

Vital Signs: HR 200; RR 50; O2 Sat 90%; BP 80/48

Repeat Focused Primary Assessment:

Airway: The airway remains patent, no change in wheezing and crackles with moderate retractions.
Breathing: Respiratory rate is 50, and breathing remains shallow and labored. O2 sat is 90%. Continued decreased air movement on auscultation.
Circulation: Heart rate is 200; capillary refill remains less than 2 sec.; IV is intact with maintenance fluids infusing
Disability: Patient moves all extremities but weaker, lethargy increasing
Exposure: Skin warm and pink

The based upon the assessment above what would be your next intervention?

The patient was sedated, and a successful intubation was performed. Confirmation of ET placement was made using end-tidal CO2 measurement (waveform capnography).

After intubation, auscultation of all lung sounds reveal good air movement in all lung fields bilaterally. Mechanical ventilation was implemented. Now that the patient's airway is secure and maintained, what are some laboratory studies/tests that should be completed given this scenario of lower airway obstruction (bronchiolitis)? (Choose all that apply)

5 minutes after intubation and initiation of mechanical ventilation, you reevaluate per the systematic approach algorithm.

Vital Signs: HR 160; controlled mechanical ventilations 50; O2 Sat 100%; BP 95/52

Repeat Focused Primary Assessment:
Airway: intubated.
Breathing: Respiratory rate is 50 on vent, and good chest rise and fall with mechanical ventilations. O2 sat is 100%. air movement on auscultation improved.
Circulation: Heart rate is 160; capillary refill remains less than 2 sec.; IV is intact with maintenance fluids infusing
Disability: Patient moves all extremities, remains irritable, mild lethargy
Exposure: Skin warm and pink

You see that oxygenation has improved, and now with ventilatory control by mechanical ventilation, the patient's condition is stabilizing. You prepare for the transport of the patient to the pediatric intensive care unit.

After intubation, if there is ever a sudden deterioration in the patient's condition which of the following should be suspected? (choose all that apply)