Welcome to PICU Doc On Call, A Podcast Dedicated to Current and Aspiring Intensivists. I'm Pradip Kamat and I'm Rahul Damania. We are coming to you from Children's Healthcare of Atlanta - Emory University School of Medicine. Welcome to our episode of a three-year-old girl presenting with a cough and difficulty breathing Here's the case presented by Rahul: A previously healthy 3-year-old girl presented to the OSH for difficulty breathing. She had a two-day h/o of cough (worse at night) and congestion but no fever. She has no h/o of emesis, h/o recent travel, or exposure to some/toxins. Initially, she received steroids, albuterol, and O2 but due to continued worsening of breathing and hypoxia-She was transferred to our PICU for initiation of High Flow Nasal Cannula. She has no allergies and her immunizations are up to date. There is a strong family history of asthma and atopic dermatitis. The mother also noted that the patient has h/o of coughing episodes while playing outside with her siblings. Initial Vitals: Temp 37.9, HR 100, BP 97/73, respiratory rate 49, SPO2 98% on 15LPM HFNC at 60% FIO2 , weight 17.5kg On PE: The child is awake, playful. she is tachycardic with no murmur. She has subcostal, intercostal, supra-sternal retractions. There is bilateral symmetric chest expansion. The air entry is decreased with diffuse (B) wheeze. There is atopic dermatitis in the flexor areas of the elbows/knees. The rest of the physical examination was normal. No hepatosplenomegaly. Viral panel: positive for HMP, SARS COV-2 negative CXR: Atelectasis superimposed upon viral pneumonitis versus multifocal bronchopneumonia. No evidence of parapneumonic effusion or air leak. CBC and BMP are normal. To summarize key elements from this case, this 3-year-old girl has: Cough and congestion Increased WOB and difficulty breathing Hypoxia No fever or rash No recent ingestions or exposure to tobacco smoke All of which brings up a concern for a lower airway obstructive process most likely acute asthma Let's transition into some history and physical exam components of this case? Rahul, what are key history features in this child who presents with increased work of breathing? Cough and congestion Difficulty breathing No h/o suggestive of atopic dermatitis Increased WOB: retractions (subcostal, intercostal, suprasternal). Important to note there is no nasal flaring, head bobbing or grunting. Decreased AE Diffuse (B) wheezing. No subcutaneous emphysema on palpation of the chest or cervical region. Hypoxia needing oxygen Atopic dermatitis No crackles No hepatomegaly No altered mental status Not all respiratory distress arises within the respiratory tract. Important physical examination to note in any infant or toddler with increased work of breathing is to palpate for hepatomegaly as well as carefully listen for bilateral inspiratory crackles. The presence of hepatomegaly or (B) crackles should raise concern for myocarditis or congestive heart failure. In Newborns with respiratory distress-always make a habit to feel femoral pulses. Acidosis, intracranial hemorrhage, foreign body, panic attacks can also present as respiratory distress. To continue with our case, Pradip, the patient’s labs/diagnostic were consistent with: CBC, BMP were normal Respiratory viral panel positive for HMP virus, Negative for SARS-COV-2 Chest radiograph: Atelectasis superimposed upon viral pneumonitis versus multifocal bronchopneumonia OK, to summarize, we have: A 3-year-old with acute respiratory distress, wheezing, hypoxia after 2 days h/o of cough/congestion. Rahul, let's start with a short multiple-choice question: A 15-year-old teenager with know h/o asthma presents to the ED in severe respiratory distress, increased work of breathing, hypoxia, and diffuse wheezing. Of the following the presentation that would most likely require intubation in this teenager include- A) Inability to talk in complete sentences B) A blood gas that...