You are treating a short of breath 9-year-old male with a history of asthma. on scene he presents in severe respiratory distress with noted intercostal retraction, lethargy, and expiratory wheezing. his pulse is 136, respirations 32, and spo2 95%. you have assisted him with his albuterol mdi and are transporting emergently to the hospital. as you reassess the patient, what finding is most concerning?