Chest
Postgraduate Education CornerPulmonary and Critical Care PearlsA 92-Year-Old Woman With Expiratory Wheezing Refractory to Inhaled Bronchodilators
Section snippets
Physical Examination
On hospital admission, the patient was conscious and afebrile with a pulse rate of 101 beats/min, BP of 115/65 mm Hg, and respiratory rate of 24 breaths/min. Examination of the chest showed symmetric expansion and bilateral diffuse expiratory wheezing breathing sounds. The neck was supple, without jugular vein distension or lymphadenopathy. Otherwise, the physical examination findings were unremarkable.
Laboratory Findings
Arterial blood gas levels measured while the patient breathed in room air showed a pH of 7.32, a Paco2 of 66 mm Hg, a Pao2 of 44 mm Hg, and a bicarbonate concentration of 33 mEq/L. The WBC count was 7.22 × 103 cells/μL, with 89.9% neutrophils, 2.6% monocytes, and 7.2% lymphocytes. Serum chemistry, hematocrit, platelet count, and renal and liver function test results were within normal limits. Figure 1 shows the posteroanterior chest radiograph.
Initial Hospital Course
Inhaled bronchodilators and a ventilatory support system were applied, but dyspnea persisted. She was then transferred to our ICU for further management. One day later, persistent CO2 retention and drowsy consciousness were found. She was intubated, but expiratory wheezing was noted occasionally despite the inhalation of high-dose bronchodilators and corticosteroids. She was extubated on the sixth hospital day after passing a spontaneous breathing trial under a pressure support of 5 cm H2O.
Discussion
Tracheobronchomalacia (TBM) and excessive dynamic airway collapse (EDAC) are morphologically, etiologically, and physiologically distinct forms of dynamic central airway obstruction that may or may not coexist. TBM is defined as a condition in which there is weakness of the tracheal and bronchial walls due to softening of the supporting cartilage and hypotonia of myoelastic elements. TBM can have a crescent, saber-sheath, or circumferential appearance on bronchoscopic or radiographic
Clinical Pearls
- 1.
TBM and EDAC should be listed in the differential diagnosis of expiratory wheezing that is refractory to bronchodilator therapy.
- 2.
TBM is characterized by a weakness of the tracheobronchial cartilaginous structures, whereas EDAC is marked by excessive bulging of the posterior membrane into the airway lumen during exhalation.
- 3.
TBM and EDAC present with various symptoms ranging from cough and mild shortness of breath to respiratory failure.
- 4.
Bronchoscopy or dynamic imaging studies are the “gold
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