The wheezing "red herring"

February 1, 2007

A 9-year-old male is transferred to your general pediatric service from the Pediatric Intensive Care Unit (PICU) with a diagnosis of resolving inhalation pneumonitis. Your review of the admission history reveals that he had been admitted 2 days previously when he presented to the Emergency Department (ED) with the following history.

DR. DOUGLAS is pursuing a fellowship in pediatric hematology/oncology at the Children's Hospital of Los Angeles.

MS. SCIUTO is a board-certified pediatric nurse practitioner in pediatric critical care medicine at the University of Miami School of Medicine/Holtz Children's Hospital/Jackson Memorial Medical Center, Miami.

DR. SWAMINATHAN is a clinical assistant professor of pediatrics and co-director of the pediatric noninvasive cardiovascular laboratory at the University of Miami School of Medicine/Holtz Children's Hospital/Jackson Memorial Medical Center, Miami.

DR. SIBERRY is an assistant professor of pediatrics in the divisions of general pediatric and adolescent medicine and pediatric infectious diseases at Johns Hopkins Hospital, Baltimore.

The authors and section editor have nothing to disclose in regard to affiliations with, or financial interests in, any organization that may have an interest in any part of this article.

He had been helping his aunt clean the bathroom with a mixture of disinfectant and bleach with the bathroom door closed. After cleaning for 3 to 4 minutes, he developed a dry cough associated with "hard" breathing and chest tightness. He was reported to appear sleepy, and had watery eyes. He was taken outside to get fresh air, and was offered water. Paramedics were summoned, and advised that nothing be given by mouth. They administered nebulized albuterol while in transit to the ED.

A past history, but unremarkable physical exam

The presenting complaints logged in the ED were shortness of breath, wheezing, and chest tightness. The past medical history was noted for varicella, asthma (last episode 2 years previous), and prematurity 31-32 weeks. He had been intubated and reported to have a heart murmur during the neonatal period. In the ED, vitals were noted: temperature 97.6° F, heart rate 106/min, respiratory rate 50/min, blood pressure 120/61 mm Hg. General exam was significant for injected sclerae, moderate respiratory distress, and normal attentiveness. Oxygen saturation was 86% on room air. The respiratory exam was significant for use of accessory muscles, retractions, generalized wheezing, and decreased air movement. Cardiovascular exam revealed normal heart sounds and grade 2/6 systolic murmur. The remainder of the physical exam was unremarkable.

Laboratory findings revealed: arterial blood gas (room air), pH 7.32; pCO2, 48; pO2, 51; HCO3, 24; BE, –2; oxygen saturation, 83%; WBC, 9,000; Hgb, 15; Hct, 45; platelets, 260,000. A chest radiograph revealed clear lung fields without pneumothorax or significant hyperinflation.

He was treated with levalbuterol (Xopenex) nebulizations and methylprednisolone sodium succinate (Solu-Medrol), with clinical improvement noted. His diagnosis was felt to be straightforward inhalation pneumonitis, and he was admitted to the PICU.

The patient was treated in the PICU for 24 hours with continued bronchodilator therapy and steroids, and is now your patient on the general pediatric team. His respiratory exam is remarkable for some intermittent bilateral wheezing and mild use of accessory muscles of respiration. At present, the respiratory rate is between 24/min and 31/min with oxygen saturation at 92% to 93% on 0.5 L of oxygen by nasal cannula. He is also being followed by the pulmonary team who was consulted in the PICU. His medications include albuterol, fluticasone (Flovent), montelukast (Singulair), and Solu-Medrol. You anticipate he will be discharged soon.