Hands on SpirometryHands on Spirometry

Dennis R. Ownby, M.D.Dennis R. Ownby, M.D.Chief, Section Allergy, Immunology, Chief, Section Allergy, Immunology,

RheumatologyRheumatology

Georgia Health Sciences UniversityGeorgia Health Sciences University

Augusta, Georgia, USAAugusta, Georgia, USA

Case of New Onset Case of New Onset WheezingWheezing

11 year old male with no prior history of asthma11 year old male with no prior history of asthma Developed intermittent cough and persistent Developed intermittent cough and persistent

nasal congestion 1 month prior to admissionnasal congestion 1 month prior to admission PCP started albuterol and fluticasone MDI 2 PCP started albuterol and fluticasone MDI 2

weeks prior to admission due to wheezing on weeks prior to admission due to wheezing on exam exam

No improvement in symptoms with medicationsNo improvement in symptoms with medications Day of admission developed increased cough and Day of admission developed increased cough and

dyspnea while in showerdyspnea while in shower In ED found to have inspiratory and expiratory In ED found to have inspiratory and expiratory

wheezing and severe dyspneawheezing and severe dyspnea

Presentation to PICU Presentation to PICU Wheezing continued to worsen despite Wheezing continued to worsen despite

continuous nebulized albuterol, plus IV continuous nebulized albuterol, plus IV magnesium and corticosteroids in ED magnesium and corticosteroids in ED

Transferred to PICUTransferred to PICU Intubation strongly considered for Intubation strongly considered for

respiratory difficultyrespiratory difficulty Symptom improvement with ketamine Symptom improvement with ketamine Allergy-Immunology consulted for Allergy-Immunology consulted for

status asthmaticusstatus asthmaticus

Past Medical HistoryPast Medical History

Full term, normal growth and Full term, normal growth and developmentdevelopment

Recurrent ear infections as infant-PE Recurrent ear infections as infant-PE tubes placed tubes placed

No history of atopic dermatitis, No history of atopic dermatitis, allergic rhinitis, pneumonia, or allergic rhinitis, pneumonia, or recurrent coughrecurrent cough

Past Medical History - Past Medical History - AccidentAccident

Motor vehicle accident 2 months prior to Motor vehicle accident 2 months prior to admissionadmission

Sustained skull fracture, subdural Sustained skull fracture, subdural hematoma, pulmonary contusion, scalp hematoma, pulmonary contusion, scalp avulsion, clavicle and spine fractureavulsion, clavicle and spine fracture

Hospital course complicated by Hospital course complicated by polymicrobial scalp infectionpolymicrobial scalp infection

Treated with multiple antibiotics and Treated with multiple antibiotics and antifungalsantifungals

Past Medical History Past Medical History AccidentAccident

Surgeries: left craniotomy, T1-T3 Surgeries: left craniotomy, T1-T3 spinal fusion, debridement of scalp spinal fusion, debridement of scalp laceration and skin graftlaceration and skin graft

Intubated for four days, no Intubated for four days, no respiratory difficulties after respiratory difficulties after extubationextubation

Normal mental status by discharge Normal mental status by discharge one month laterone month later

Family HistoryFamily History

2 brothers have asthma and allergic 2 brothers have asthma and allergic rhinitisrhinitis

No history of unusual infections or No history of unusual infections or autoimmune disease in familyautoimmune disease in family

Post-PICU Clinic EvaluationPost-PICU Clinic Evaluation

Has felt well since leaving PICUHas felt well since leaving PICU Resumed normal activityResumed normal activity No more wheezing or shortness of No more wheezing or shortness of

breathbreath Taking fluticasone from MDITaking fluticasone from MDI Has not needed albuterol MDIHas not needed albuterol MDI

Spirometry ResultsSpirometry Results

Flow-Volume LoopFlow-Volume Loop

Differential DiagnosisDifferential Diagnosis

Given the history and spirometry Given the history and spirometry results what is the most likely cause results what is the most likely cause of his recent wheezing episode?of his recent wheezing episode?