Chest
Volume 135, Issue 6, June 2009, Pages 1680-1683
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Postgraduate Education Corner
Pulmonary and Critical Care Pearls
A 92-Year-Old Woman With Expiratory Wheezing Refractory to Inhaled Bronchodilators

https://doi.org/10.1378/chest.08-2559Get rights and content

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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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The authors have reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/site/misc/reprints.xhtml).

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