1. Hands on Spirometry Dennis R. Ownby, M.D. Chief, Section Allergy, Immunology, Rheumatology Georgia Health Sciences University Augusta, Georgia, USA

2. Case of New Onset Wheezing 11 year old male with no prior history of asthma 11 year old male with no prior history of asthma Developed intermittent cough and persistent nasal congestion 1 month prior to admission Developed intermittent cough and persistent nasal congestion 1 month prior to admission PCP started albuterol and fluticasone MDI 2 weeks prior to admission due to wheezing on exam PCP started albuterol and fluticasone MDI 2 weeks prior to admission due to wheezing on exam No improvement in symptoms with medications No improvement in symptoms with medications Day of admission developed increased cough and dyspnea while in shower Day of admission developed increased cough and dyspnea while in shower In ED found to have inspiratory and expiratory wheezing and severe dyspnea In ED found to have inspiratory and expiratory wheezing and severe dyspnea

3. Presentation to PICU Wheezing continued to worsen despite continuous nebulized albuterol, plus IV magnesium and corticosteroids in ED Wheezing continued to worsen despite continuous nebulized albuterol, plus IV magnesium and corticosteroids in ED Transferred to PICU Transferred to PICU Intubation strongly considered for respiratory difficulty Intubation strongly considered for respiratory difficulty Symptom improvement with ketamine Symptom improvement with ketamine Allergy-Immunology consulted for status asthmaticus Allergy-Immunology consulted for status asthmaticus

4. Past Medical History Full term, normal growth and development Full term, normal growth and development Recurrent ear infections as infant-PE tubes placed Recurrent ear infections as infant-PE tubes placed No history of atopic dermatitis, allergic rhinitis, pneumonia, or recurrent cough No history of atopic dermatitis, allergic rhinitis, pneumonia, or recurrent cough

5. Past Medical History - Accident Motor vehicle accident 2 months prior to admission Motor vehicle accident 2 months prior to admission Sustained skull fracture, subdural hematoma, pulmonary contusion, scalp avulsion, clavicle and spine fracture Sustained skull fracture, subdural hematoma, pulmonary contusion, scalp avulsion, clavicle and spine fracture Hospital course complicated by polymicrobial scalp infection Hospital course complicated by polymicrobial scalp infection Treated with multiple antibiotics and antifungals Treated with multiple antibiotics and antifungals

6. Past Medical History Accident Surgeries: left craniotomy, T1-T3 spinal fusion, debridement of scalp laceration and skin graft Surgeries: left craniotomy, T1-T3 spinal fusion, debridement of scalp laceration and skin graft Intubated for four days, no respiratory difficulties after extubation Intubated for four days, no respiratory difficulties after extubation Normal mental status by discharge one month later Normal mental status by discharge one month later

7. Family History 2 brothers have asthma and allergic rhinitis 2 brothers have asthma and allergic rhinitis No history of unusual infections or autoimmune disease in family No history of unusual infections or autoimmune disease in family

8. Post-PICU Clinic Evaluation Has felt well since leaving PICU Has felt well since leaving PICU Resumed normal activity Resumed normal activity No more wheezing or shortness of breath No more wheezing or shortness of breath Taking fluticasone from MDI Taking fluticasone from MDI Has not needed albuterol MDI Has not needed albuterol MDI

9. Spirometry Results

10. Flow-Volume Loop

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