Case 12: 10month old - Foreign body aspiration

Question 1

wheezing in infants

• diffdx
• etiology
• complications
• tx

Answer 1

• asthma
• croup (stridor)
• foreign body aspiration
• Bronchiolitis: Viral respiratory (RSV) ==> airway inflammation and wheezing

complications = later development of asthma

tx = NO bronchodilators, steroids
EXCEPT in those with strong FHx asthma; clear response to bronchodilators.

Question 2

Asthma

• pathophys
• sxs
• triggers
• dx

Answer 2

• pathophys (acute)
  1) airway inflammaiton
  2) mucus hypersecretion
  3) reversible airflow obstruction d/t bronchoconstriction
• sxs = recurrent coughing and/or wheezing responsive to bronchodilators (beta-agonists) & anti-inflammatory meds (steroids)
• triggers = URI, allergies, cold air, exercise, smoke exposure
• dx = responsive to bronchodilators (beta-agonists) & anti-inflammatory meds (steroids); no other identifiable cause for wheezing (regardless of age)

Question 3

what is the difference between asthma and reactive airway disease (RAD)

Answer 3

BOTH = airway hyperresponsiveness

reactive airway disease (RAD) = children with early wheezes that stop at 2-3yo.

Question 4

what is a characteristic of chronic asthma? (less likely in acute asthma)

Answer 4

smooth muscle hyperplasia and hypertrophy

Question 5

signs of respiratory distress

Answer 5

• paradoxical breathing [respiratory muscle fatigue] == subcostal retractions + rising abdomen,
  where force of diaphragmatic contraction&raquo_space;
  ability of chest wall to expand rib cage (infants, young children – greater compliance of chest wall)
• tachypnea, with increased depth & degree of effort (hyperpnea / hypopnea)
• nasal flaring = accessory muscles of respiration
• head bobbing (esp. during sleeping) = accessory muscles of respiration [neck strap]: neck flexion –> head bob forward
• grunting = forced expiration against partially closed glottis –> to help generate positive pressure to stent airways open
• sudden decrease in “signs of respiratory distress” with increase of PCO2 (or decreased HCO3) ==> hypoventilation d/t respiratory muscle fatigue

Question 6

define & interpret hyperpnea

Answer 6

hyperpnea= increased depth of respiration

hyperpnea (-) respiratory distress == non-pulmonary condition

• fever
• acidosis
• extreme anxiety (hyperventilation syndrome)

Question 7

define & interpret hypopnea

Answer 7

hypopnea = reduced tidal volume
==> increased proportion of each breath used to ventilate space –> can lead to hypoventilation even in the setting of a normal / eleavated RR.

Question 8

diffdx infectious respiratory diseases

Answer 8

• Bordetella pertussis
• epiglottitis
• diphtheria
• retropharyngeal / parapharyngeal abscess == pharyngitis + dysphagia + stridor

Question 9

describe Bordetella pertussis

• course:
• complications:
• prevention:

Answer 9

• course:
  1) catarrhal stage (1-2w) = URI sxs
  2) paroxysmal stage (4-6w) = “whoop” (repetitive, forceful coughing THEN massive inspiratory effort); less so in infants
  3) convalescent stage (months) = episodic cough
• complications: (esp in infants) difficulty feeding, CNS complications (apnea)
• prevention: acellular pertussis vaccine (efficacy = 70-90%); wanes over 10y

Question 10

Epiglottitis

• epidemiology
• course:
• complications:
• prevention:

Answer 10

• epidemiology: uncommon d/t immunization [Staph, Strep, Hib]. Ages 2-5yo
• course:
  1) fever, stridor, drooling, dysphonia, dysphagia
  2) respiratory distress == toxic; position “sniffing;” prefer sitting, leaning forward with neck hyperextended & chin protruding
• complications: acute airway obstruction
• prevention: Hib vaccine
• dx: lateral neck xray = thickening of the epiglottis (“thumb sign”), thickened aryepiglottic folds
• tx

Question 11

diphtheria

• signs
• dx

Answer 11

signs = pharyngitis, low-grade fever (esp. with stridor, hoarseness)
dx = pharygeal gray pseudomembrane

esp. if not immunized

Question 12

extrinsic causes of wheezing

Answer 12

• vascular ring / sling
• adenopathy
• mass / other lesion

Question 13

sounds heard on lung exam and what they mean

Answer 13

AIR ENTRY
- if decreased (or differential b/w inspiration and expiraiton) ==> consolidation, atelectasis, pneumothorax, pleural
effusion or airway obstruction.

STRIDOR

• airway narrowing above thoracic inlet [external = lymphadenopathy, neoplasm; croup, inhaled foreign bodywith partial obstruction; laryngomalacia]
• esp. with inspiration; biphasic if severe

WHEEZE (continuous)
- airway narrowing below thoracic inlet [internal = edema, mucus, foreign object]
- esp. with expiration; biphasic or NONE if severe –> esp of multiple small / moderate-sized airways ==> continuous sounds
==> focal: mucus plugging
==> generalized (mostly)
- polyphonic / monophonic

RHONCHI (continuous)
- coarse, low-pitched rattling sounds
- esp. with expiration
==> secretions, narrowing of airways d/t mucus / secretions

CRACKLES (DIScontinuous)
- finer == pulmonary edema & bronchiolitis, interstitial lung dz
- coarse == purulent secretions in alveoli [pneumonia]
- ESP WITH INSPIRATION
==> fluid in alveoli or with opening / closing of stiff alveoli (interstitial dz)

Question 14

compare wheezing and stridor

Answer 14

stridor
- airway narrowing above thoracic inlet [external]

wheezing
- airway narrowing below thoracic inlet [internal]

Question 15

define polyphonic / monophonic wheeze

Answer 15

polyphonic= multiple pitches [asthma]

monophonic = single pitch [focal airway obstruction below thoracic inlet]

Question 16

what does this indicate?

decreased air flow / differential between inspiration and expiration

Answer 16

consolidation, atelectasis, pneumothorax, pleural
effusion or airway obstruction.
dz)

Question 17

what does stridor indicate?

Answer 17

• airway narrowing above thoracic inlet [external]

- esp. with inspiration; biphasic if severe

Question 18

what does wheezing indicate?

Answer 18

• airway narrowing below thoracic inlet [internal]
• esp. with expiration; biphasic or NONE if severe
  ==> focal: mucus plugging
  ==> generalized (mostly)
• polyphonic / monophonic

Question 19

what does rhonchi indicate?

Answer 19

• coarse, low-pitched rattling sounds
• esp. with expiration
  ==> secretions, narrowing of airways

Question 20

what do crackles indicate?

Answer 20

• finer == pulmonary edema, interstitial lung dz
• coarse == purulent secretions in alveoli [pneumonia]
  ==> fluid in alveoli or with opening / closing of stiff alveoli (interstitial

Question 21

define: asthma

Answer 21

inflammation of the airways that leads to airway obstruction

1) infiltration of inflammatory cells into large airway mucosa –> mucosal edema
2) mucus hypersecretion
3) bronchoconstriction

Question 22

asthma presentation

Answer 22

CHRONIC==> recurrent episodes of dyspnea and/or cough

ACUTE exacerbation

• cough, wheezing, tachypnea, dyspnea
• EXAM: wheezing, diminished air exchange

IF SEVERE
- minimal air exchange; NO WHEEZE d/t poor airflow, cyanosis, and pulsus paradoxus

Question 23

what is the cause of wheezing in asthma

Answer 23

1) diffuse

2) focal wheeze ==> d/t mucus plugging

Question 24

you think the child you are seeing in the ED has an asthma exacerbation, but you hear nothing on exam. what should you consider?

Answer 24

IF SEVERE ASTHMA

- minimal air exchange; NO WHEEZE d/t poor airflow, cyanosis, and pulsus paradoxus

Question 25

radiographic findings in asthma

Answer 25

• hyperinflation d/t air trapping
• increased interstiital markings
• patchy atelectasis

Question 26

goals of asthma therapy

Answer 26

ACUTE

1) reduce airway inflammation (STEROIDS)
2) dilate airways - bronchodilation (ALBUTEROL)
3) supportive care for hypoxemia / dehydration

MAINTENANCE

• based on severity
• controller: daily ICS,
• rescue: inhaled b-agonist

Question 27

prognosis of asthma

Answer 27

generally good –> depends on adherence and appropriate step up management

Question 28

define: bronchiolitis

Answer 28

acute bronchiolitis = viral disease lower respiratory tract of infants [starts out as upper respiratory]
==> bronchiolar obstruction (of small airways) ==> d/t edema, mucus, cellular debris

= RSV, influenza, parainfluenza

Question 29

most common cause of wheezing in infants

Answer 29

bronchiolitis

Question 30

sxs of bronchiolitis

Answer 30

VARIABLE
- mild URI sxs, fever of 38.5-39C
==> cough, wheezing, dyspnea, irritability

Question 31

cxr findings of bronchiolitis

Answer 31

• hyperinflation
• increased interstitial markings
• peribronchial cuffing
• scattered atelectasis (d/t bronchial obstruction)

Question 32

treatment of bronchiolitis

Answer 32

SUPPORTIVE
- adequate oxygenation
- adequate hydration
+/- Abx if secondary bacterial pneumonia

OTHERS [tenuous]
- if strong FHx of asthma and it works == bronchodilators
+/- corticosteroids
+/- hypertonic saline to clear mucus

Question 33

define: pneumonia

Answer 33

== inflammation of lung parenchyma (NOT AIRWAYS)

• bugs
• aspiration of gastric contents, hydrocarbons

Question 34

diffdx of coughing in an infant

Answer 34

• asthma
• bronchiolitis
• pneumonia
• foreign body aspiration

Question 35

most common cause of pneumonia in children

Answer 35

viral pneumonia

• adenovirus
• RSV
• parainfluenza
• influenza

Question 36

most severe cause of pneumonia in children

Answer 36

bacterial pneumonia [based on age]

• NEONATAL = GBS, E. coli, Klebsiella (transferred from maternal genital tract)
• 4-12 WEEKS = Chlamydia pneumonia ==> staccato cough
• <5-6yo = Strep pneumoniae
• > 6y = () mycoplasma pneumoniae; (2) Strep pneumoniae

Question 37

sxs of viral pneumonia

Answer 37

1) prodrome = URI - cough, rhinorrhea

2) progressive cough, fever, tachypnea, crackles

Question 38

sxs of bacterial pneumonia

Answer 38

abruptly
or secondary to viral pneumonia

==> fever, cough, signs of respiratory distress (dyspnea, tachypnea, retractions)
- crackles, decreased breath sounds

Question 39

CXR of viral pneumonia

Answer 39

• diffuse/patchy interstitial infiltrates
• hyperinflation
• small pleural effusions

Question 40

Lab findings of viral pneumonia

Answer 40

• nml, slightly elevated WBC

- respiratory secretions = viral antigen testing

Question 41

CXR of bacterial pneumonia

Answer 41

• lobar / segmental consolidation

- air bronchograms

Question 42

Lab findings of bacterial pneumonia

Answer 42

• high WBC

- high neutrophils

Question 43

treatment of viral pneumonia

Answer 43

• supportive (hydration)

Question 44

treatment of bacterial pneumonia

Answer 44

• antibiotics

- supportive

Question 45

foreign body aspiration

• causes
• local tissue reaction
• sequelae

Answer 45

most common = foods, candy, nuts, grapes

local tissue reaction

• aspirated food = fatty oils ==> more severe pneumonitis (surrounding airway mucosa = erythematous, friable) compared to nonfoods.
• disc battery ==> erosion through bronchial wall
• lodged in upper airway (trachea, bronchi) ==> LETHAL

==> can lead to blockage, infection, pneumonia

Question 46

key questions to ask when presented with a child with coughing

Answer 46

“is she still drinking”

• hydration status; severity of breathing difficulty, problems coordinating feeding and breathing
• dysphagia==> concerns of pharyngeal / esophageal foreign body aspiration/laryngeal cleft / TE fistula (esp. choking, coughing, gagging), OR infection
• more important: drinking > eating

“has she had a fever”

• fever / vasculitis
• RECURRENCE of fever several days into respiratory illness ==> superimposed bacterial pneumonia

“did the cough begin suddenly? did you see her choke on anything?”
- esp. in infants and toddlers

“has her voice or her cry been hoarse”

• UPPER AIRWAY (different voice/cry): infection in larynx/pharynx ==> phargyngitis, tonsillitis, epiglottitis
• LOWER AIRWAY (voice / cry is the SAME)

“has her cough been barky? does she make any noises when she breathes?”
- CROUP (laryngotracheobronchitis) - esp. in 2-5yo d/t parainfluenza virus ==> (1) non-specific URi sxs, (2) variable airway obstruction = barky cough, inspiratory stridor

“does she have any other medical problems?”
- birth hx –> PREMATURE = underlying respiratory conditions (e.g. bronchopulmonary dysplasia –> cough and wheezing)
“ear infections? pneumonia? chronic diarrhea? trouble gaining weight?”
- ? immunodeficiency / malabsorptive conditions (e.g. CF)
“spitting up? reflux?”
- likely chronic cough

“has she received all her immunizations?”
- esp. pertussis

history

• heritable conditions = asthma, environmental allergies, CF
• social/environmental = exposure to sick contacts [+/- sick contacts]; childcare, tobacco smoke

Question 47

what does this indicate: coughing with liquids

Answer 47

aspiration

Question 48

what does this indicate: coughing with solids

Answer 48

narrowing of posteiror oropharynx/esophagus

Question 49

what does this indicate: hoarse / different voice or cry

Answer 49

UPPER AIRWAY problem (different voice/cry): infection in larynx/pharynx ==> phargyngitis, tonsillitis, epiglottitis

Question 50

how does the inspiratory stridor change with the severity of the croup

Answer 50

MILD = during agitation
MODERATE = at rest, agitation
SEVERE = expiratory stridor

Question 51

CXR findings in a foreign body aspiration (in the R side)

Answer 51

• PA film = R hemidiaphragm is flattened == UL hyperexpansion
• R decubitus ==> mediastinal structures remain in midline, rather than shifting to the R b/c of fixed hyperinflation of the R lung
• L decubitus ==> mediastinal structures shift to the LEFT (dependent position)

Question 52

Evaluation for foreign body aspiration (e.g. on R)

Answer 52

1) Exam = asymmetric breath sounds (decreased on R); cough sounds obstructed (with end-expiratory wheezes) on R. Cough, tachypnea, focal wheeze, retractions, afebrile.
??? fever
??? cyanosis
??? stridor
2) PA and lateral chest films
- BL decubitus = when dependent lung does NOT deflate as expected ==> obstruction in the large airway
OR
-inspiratory / expiratory chest films ==> where obstruction does not allow the distal lung to deflate fully ==> UL asymmetric deflation with expiration d/t air trapping (more subtle v. decubitus films)

3) Chest fluroscopy = dyanamic evaluation that allows visualization of the airways over several breaths v. single breath
4) Albuterol = wheezing would not improve

Question 53

diffdx of UL large airway obstruction

Answer 53

INFANTS

• foreign body aspiration
• TB (where it is endemic)

ADULTS

• airway tumors
• extrinsic compression
• lymphadenopathy

Question 54

distinguish partial v. complete airway obstruction due to foreign body

Answer 54

PARTIAL
- hyperinflation ==> "ball valve" effect
1) inspiration = partial obstruction
2) expiration = full obstruction
==> air trapping with each breath

COMPLETE = total lack of airflow to the bronchus
==> atelectasis
==> signs of volume loss on xray = mediastinal shift TOWARD affected side / elevation of hemidiaphragm on affected side

Question 55

In what conditions can you have “normal” O2 sat, but actually have low percentage saturation of oxyhemoglobin

Answer 55

• methemoglobinemia (certain toxins, too much anaesthesia)
• carboxyhemoglobinemia (CO poisoning)
• compensated asthma: where hyperventilation –> decreased PCO2 –> as child tires, and can no longer maintain adequate ventilation == PCO2 normalized, elevated + normal oxygenation ==> impending respiratory failure [GET BLOOD GASES]

Question 56

Which of the following signs indicates the most severe respiratory distress? Select the ONE best answer.

A		Tachypnea	
B		Retractions	
C		Nasal flaring	
D		Grunting	
E		Paradoxical breathing

Answer 56

E

d/t respiratory muscle fatigue

Question 57

baby had been having trouble breathing before, but not looks more comfortable on a respiratory level. what do you have to watch out for? What do you do?

Answer 57

respiratory muscle fatigue ==> can reduce signs of respiratory distress BUT pt is actually deteriorating

–> get blood gases == for elevation of PCO2 ==> HYPOVENTILATION

Question 58

interventions for respiratory distress

Answer 58

1) observation == to see if EMERGENT

2) O2 for hypoxemic = blow-by, NC, facemask, endotracheal tube

Question 59

This patient is known to have respiratory disease, such that she is a chronic “CO2 retainer”, and her O2 sats at baseline are always a little low. Should you give her O2?

Answer 59

== chronic hypercarbia

NEVER withhold O2 in cases of severe hypoxemia (<88%)

1) monitor closely
2) give only as much O2 as needed to maintain minimum saturation
3) endotracheal intubation ==> for pts where respiratory failure is imminent or loss of airway is anticipated.

Question 60

diffdx:
Healthy 10-month-old
One-week history of respiratory illness
Acutely worsening cough
Rhinorrhea
Wheeze
No history of fever 
Family history of allergies and asthma

how can you start to rule it out?

A 	Allergic rhinitis
B 	Anatomic abnormality
C 	Asthma exacerbation
D 	Bronchiolitis
E 	Congestive heart failure
F 	Cystic fibrosis
G 	Croup
H 	Foreign body aspiration
I 	Gastroesophageal reflux
J 	56.8%			Community-acquired pneumonia
K 	4.5%			Chlamydia trachomatis
L 	Pertussis
M 	Epiglottitis
N 	Sinusitis
O 	Viral upper respiratory infection (URI)

Answer 60

• allergic rhinitis
• asthma exacerbation
• bronchiolitis
• croup
• foreign body aspiration
• CAP
• pertussis
• sinusitis
• viral URI
• NO FEVER –> less CAP
• NO STRIDOR –> less Croup (unless it’s actually stridor and not a wheeze)
• ACUTE sxs –> less sinusitis = usually longer duration, even though she does have rhinorrhea
• NO CHRONIC ==> less anatomic abnormality, CF, GERD
• VITALS OTHERWISE NORMAL - no CHF
• OLDER - no chlamydia
• NO RESPIRATORY DISTRESS, STRIDOR ==> less epiglottitis

Question 61

what extrisic compression of the airway can cause wheezing?

Answer 61

• a vascular ring or sling
• adenopathy
• a mass or other lesion

Question 62

differentiate rigid v. flexible bronchoscopy

• visualize:
• function:

Answer 62

RIGID = only into the mouth;
==> visualize: upper & large airways
==> function: transbronchial biopsies; remove foreign bodies

FLEXIBLE = nose or mouth
==> visualize: more distal airways
==> function: suction; collect lavage specimens.

Question 63

Question
A 12-year-old male presents to the ED with complaints of anorexia, weight loss, and persistent cough, with nocturnal coughing fits that have been waking him from sleep for the past three weeks. He denies fever, chills, myalgia, sore throat, or rhinorrhea. The patient presented to his primary care physician one week prior with the same complaint, and was treated with amoxicillin and bronchodilator therapy. His chest x-ray was negative for infiltrates at that visit. The patient’s symptoms did not improve with this regimen. The cough became more frequent, sometimes causing emesis. Which of the following is the most likely diagnosis?

A Reactive airway disease
B Infection with Bordetella pertussis in the catarrhal stage
C Infection with Bordetella pertussis in the paroxysmal stage
D Atypical pneumonia due to Mycoplasma pneumoniae
E Laryngotracheobronchitis

Answer 63

C

paroxysmal stage of pertussis lasts four to six weeks and is characterized by repetitive, forceful coughing episodes, followed by massive inspiratory effort. This massive inspiratory effort is what results in the characteristic “whoop”-sounding cough. This is consistent with the patient’s presentation and duration of illness. The forceful coughing fits in pertussis can even lead to conjunctival hemorrhages and pneumothoraces from the increased intrathoracic and intracranial pressures from Valsalva. The antimicrobial agents of choice for treatment of pertussis are azithromycin, clarithromycin, and erythromycin. Antibiotics given in the paroxysmal phase will reduce communicability but will not alter the clinical course.

NOT catarrhal – 1-2w, “URI” sxs.

Question 64

A 12-month-old previously healthy girl presents with cough and mild subcostal retractions. She is afebrile, and physical exam reveals asymmetric wheezing. Chest x-ray demonstrates unilateral air trapping. What is the most likely diagnosis?

A		Croup	
B		Pneumonia	
C		Acute bronchiolitis	
D		Foreign body aspiration	
E		Asthma

Answer 64

D

unexplained wheezing and asymmetric breath sounds, as well as air trapping in one lung indicating unilateral airway obstruction. The right main bronchus is the more commonly obstructed due to anatomy (it is wider and more vertical than the left). The most commonly aspirated foods are hot dogs, nuts, hard candy, grapes, and popcorn.

Question 65

A 10-month-old infant is brought to the Peds ED by her parents, who say she has been coughing persistently for the last three hours. The parents were watching a movie at home when they first noticed their daughter coughing. Patient is a vaccinated, well-nourished infant in moderate distress with retractions, nasal flaring, and grunting. On auscultation, you immediately notice diminished breath sounds in the right lung with normal breath sounds on the left. What other associated physical exam finding do you expect to hear?

A		Stridor	
B		Asymmetric breath sounds and wheezing	
C		Rhonchi	
D		Crackles	
E		Bronchial breath sounds

Answer 65

B

watching movie== popcorn

This infant is in respiratory distress from foreign body aspiration, cBnsistent with the history of acute onset of distress and asymmetric breath sounds. Common foreign bodies include peanuts, popcorn, grapes, hard candy and hot dogs. Respiratory distress from foreign body aspiration is usually accompanied by asymmetric breath sounds and wheezes on auscultation.

Question 66

Susie is a 3-year-old girl brought into the clinic by her mother because she has a gradually worsening cough and she has been having trouble breathing. Her mother says Susie sounds like she is barking when she coughs. Susie is up to date with her vaccinations. Susie’s mom always watches her when she’s playing. On physical exam, you note that Susie has inspiratory stridor. She does not have wheezing, there are no retractions, and she has symmetrical breath sounds. No pseudomembranes are appreciated on physical exam. What is Susie’s most likely diagnosis?

A		Epiglottis	
B		Croup (laryngotracheobronchitis)	
C		Pertussis	
D		Pneumonia	
E		Foreign body aspiration

Answer 66

B

due to a viral infection (Parainfluenza type 1). It is most common in the winter, and often occurs in children age 2 to 5 years. Croup can lead to non-specific URI symptoms with some degree of airway obstruction. A barky or seal-like cough and inspiratory stridor (which should be differentiated from expiratory wheezes) is common in croup.

Her barking cough is more suggestive of croup than the “whooping” cough of pertussis.

Epiglottitis is a life-threatening emergency caused by an infection with H. influenzae type B. It is less common now with the advent of Hib vaccine, but in rare cases can occur due to staphylococcal or streptococcal infections. It most often occurs in children ages 2 to 5 years. Children with epiglottitis present with fever, stridor, drooling, dysphonia, dysphagia, and respiratory distress. They frequently appear toxic and sit in the “sniffing position” (sitting, leaning forward, neck hyperextended, chin protruding). A “thumb sign” (thickened epiglottis and aryepiglottic folds) appears on films. Susie is not exhibiting any of these characteristic symptoms and she is up to date with vaccines, making epiglottitis a less likely diagnosis for her cough.

Question 67

Joe, a previously healthy 11-month-old male with 5-day history of a “cold,” is brought to the ED by mom for one day of acute worsening cough and intermittent wheezing. Per mom, the cough was initially dry but has become more “phlegmy,” making it difficult for Joe to breathe, particularly when he is feeding or more active. His immunizations are up to date, and he has no known allergies. His family history is significant for a 6-year old sister who was diagnosed with asthma four years ago. On exam, Joe is afebrile, mildly tachypneic with normal O2 saturation. He has prominent nasal flaring and mild subcostal retractions. He has clear rhinorrhea but no evidence of oropharyngeal erythema. Lung exam reveals decreased breath sounds and wheezes on the right. What is the most likely diagnosis?

A		RSV bronchiolitis	
B		Epiglottitis	
C		Viral URI	
D		Asthma	
E		Foreign body aspiration

Answer 67

E. foreign body aspiration should always be included in the differential diagnosis for acute onset wheezing. The lung findings of asymmetric breath sounds and wheezing support this diagnosis. Foreign body in the airway can be confirmed by bilateral decubitus or inspiratory/expiratory chest films, characterized by decreased deflation on the affected side. If complete obstruction, x-ray will generally reveal atelectasis (whiting out) and signs of volume loss (mediastinal shift towards affected side to compensate for loss of volume).

NOT bronchiolitis –> everything looks right, EXCEPT for asymmetrical wheezing and decreased breath sounds