A Wheezing Toddler
Matthew is a 22-month-old previously healthy male who woke up from his afternoon nap with sudden onset of rapid, labored breathing and restlessness. He is taken to a nearby emergency center for evaluation. On examination in the emergency center, he is grunting and is in moderate respiratory distress. A chest radiograph shows bilateral hyperinflation. The patient's persistent wheezing and need for continuous bronchodilator therapy prompts transfer via specialty transport service to a nearby tertiary pediatric hospital, where he can be closely monitored in a pediatric intensive care unit (PICU).

The patient's review of systems is negative except for a coughing episode approximately two weeks ago, which resolved spontaneously and quickly by parental report. There is no report of fever, nausea, vomiting, or history of foreign body ingestion. He has no known drug allergies. He has no food allergies. He has never been hospitalized or undergone any surgery. His past medical history is negative for episodes of bronchiolitis, pneumonia, asthma, gastroesophageal reflux, and swallowing dysfunction. His immunizations are up to date by parental report. He is developmentally appropriate. The family history is negative for asthma or other respiratory problems. He lives at home with mom and dad. The parents deny smoking and the use of drugs or alcohol in the home. They also deny the presence of environmental factors at home such as new carpet, remodeling, or the presence of potent fumes.

Physical examination on admission to the tertiary hospital is as follows. Vital signs: temperature is 98° Fahrenheit axillary, heart rate is 160, respiratory rate is 55, blood pressure is 126/59. Pulse oximeter is 99% on 5 liters oxygen via facemask. He is in moderate-to-severe respiratory distress, as evidenced by tachypnea and use of accessory respiratory muscles. Other remarkable features of the physical examination indicative of his distress include fair-to-poor air exchange with audible inspiratory stridor, diffuse wheezes and rales bilaterally, tachycardia without an audible murmur, and restlessness but comforted by mother.

Continuous bronchodilator therapy is started at the outside hospital and is continued. Intravenous terbutaline sulfate and dexamethasone is started for persistent wheezing. Inhaled racemic epinephrine is initiated as needed for stridor. He is given nothing by mouth in light of his respiratory status and intravenous fluids are started. The chest radiograph from the emergency center where the child was taken before he was brought to the tertiary care PICU is of good quality, so it is not repeated on admission to the tertiary center.

On the morning after admission, Matthew has a sudden increase in his work of breathing with unequal breath sounds, which are diminished on the right side.