Monday, October 03, 2005

Wheezing

40 year old woman with with a diagnosis of asthma with 9 previous intubations and multiple ER visits came in with typical attack; very short of breath, wheezing and getting somnelent. An ABG showed 7.08 pCO2 of 88 with pO2 of 54 (I think room air but not sure). She was intubated. The CXR was probably negative, but here it is:

2 Hours after intubation on AC 12/500 PEEP 5, she was doing well. No wheezing. Good airmovement. Peak and plateau insp pressures were not high and repeat ABG showed 7.37 pCO2 43 pO2 98 on 40% FiO2. She was extubated and did fine.
Next step: a. discharge to floor. b. further workup and why?

9 comments - CLICK HERE to read & add your own!:

Arenberg said...

All that wheezes is not asthma, but lets just asume this was for the sake of arguement. If she had asthma bad enough to get intubated, I would not expect her to improve over 2 hours. My guess is this is an asthma mimic, and she has a severe form of vocal chord dyskinesia. I'd get her to see a good speech pathologist and evaluate her for this.

Baleeiro said...

That is really too much improvement in 2 hours to be "real" asthma. Vocal cord dysfunction would also fit the Hx of multiple visits and even intubations.

Jennings said...

I had the same thoughts (pulmonary fellow lurkers: this is a classic boards question). I ordered a bed side spiro. I will post the results later today. From what I hear, the inspiratory loop did not appear to be flat but I will hve to look myself and will post it when I get back to the hospital. Speech path has also been consulted. We will also likely get ENT to have a look.
What if it is confirmed that the loop is *not* flat?

Arenberg said...

The bedside spiro/loop has poor sensitivity for detecting this problem Jeff, if I recall correctly. The spiro can look just like true asthma. The best bet is to get a speech pathologist with experience in htis area to do a provocative test. I cannot recall just how they do it.

Mendez said...

Nothing else to add except that she may have both asthma and vocal cord dyskinesia. CXR shows pretty flattened diaphragms (and almost right main stem intubation by the way).

Jeff H said...

I agree with all of the above. I believe that up to 1/3 of patients with VCD do also have asthma.

As for flattening of the inspiratory loop, I would only expect to see this while the patient is actually having symptoms. If the cords are open and the patient is asymptomatic, than the loop can be absolutely normal. In many cases, there is a significant amount of variation between loops, such that it can be difficult to get a consistent study.

Baleeiro said...

The FVL will not help you much in this case. The obstruction is not fixed and doesn't happen all the time. Speech Pathologists and ENTs will usually try and replicate the symptomns while watching the vocal cords with a laryngoscope docummenting paradoxical motion of the cords.

Jennings said...

Thanks. I never thought about the fact that a normal loop while the patient is asymptomatic might be normal - good point. The patient has since been sent to the floor; I'll follow up and re-post with regrds to wht speech path found (and make sure they did some type of provocation test).

Jennings said...

also good point about the tube placement; she was extubated by the time I saw her for the first time the next morning.