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A 55-Year-Old Man Admitted to the Medical ICU With the Diagnosis of Status Asthmaticus Responds Poorly to Intensive Asthma Therapy* FREE TO VIEW

Richard S. Irwin, MD, FCCP
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*From the ACCP-SEEK program, reprinted with permission. Items are selected by Department Editors Richard S. Irwin, MD, FCCP, and John G. Weg, MD, FCCP. For additional information about the ACCP-SEEK program, phone 1-847-498-1400.

Correspondence to: Richard S. Irwin, MD, FCCP, Department of Medicine, University of Massachusetts Medical Center, 55 Lake Ave, Worcester, MA 01655-0330; e-mail: irwinr@ummhc.org

Chest. 2000;117(3):892-893. doi:10.1378/chest.117.3.892
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A 55-year-old man was admitted to the medical ICU with the diagnosis of status asthmaticus. He had a history of poorly controlled asthma and frequent episodes of heartburn and regurgitation of 5 years’ duration. Despite receiving 360 μg of albuterol and 72 μg of ipratropium by metered-dose inhaler every 4 h, 125 mg of methylprednisolone every 6 h, and oxygen by nasal cannula (2 L/min) for 6 days, the patient’s condition was not improved. He continued

to complain of dyspnea at rest and diffuse inspiratory and expiratory wheezing; use of accessory muscles were still noted on physical examination, and peak expiratory flow rates remained reduced, at 40% of predicted. Chest radiograph revealed clear lung fields; oxygen saturation was 98% by pulse oximeter. Because of inspiratory wheezing, a flow-volume loop was obtained (Fig 1) and direct laryngoscopy performed. The vocal cords are shown during inspiration (Fig 2). Which of the following will most likely lead to the eventual resolution of the patient’s respiratory distress?

  1. A. Speech and psychiatric consultations

  2. 24-hour esophageal pH monitoring

  3. Bronchoscopy

  4. Skin testing for allergy to methylprednisolone

  5. Repeating the flow-volume loop comparing the effects of heliox vs air

Since the patient under discussion was not responding as expected to conventional treatment for acute asthma, the treating physician began to consider other conditions that can mimic asthma and obtained a flow-volume loop. It revealed near-constant flows during the midportions of the maximum inspiratory and maximum expiratory flow-volume curves. This pattern is typical of a fixed upper airway obstructing lesion that, in our patient, was due to subglottic stenosis (Fig 3) caused by aspiration from gastroesophageal reflux disease (GERD). Of the choices listed, only bronchoscopy will lead to the eventual resolution of the patient’s respiratory distress. In our patient, bronchoscopy led to the diagnosis and subsequent resolution of the upper airway obstruction by dilatation. Recurrence was prevented by medical therapy for GERD.

Speech and psychiatric consultations were not indicated because the typical paradoxical adduction of the vocal cords during inspiration was not seen during direct laryngoscopy to support the diagnosis of the vocal cord dysfunction syndrome.

Because GERD with aspiration is known to cause subglottic stenosis, 24-hour esophageal pH monitoring potentially can be useful in managing patients with subglottic stenosis, but only after the lesion is identified. It can reveal reflux to the hypopharynx that places the patient at risk of aspiration, and it can reveal that the risk has disappeared with medical therapy.

Allergic and pseudoallergic reactions (eg, anaphylaxis, urticaria-angioedema, bronchospasm) may uncommonly result from systemic corticosteroids. They most commonly occur with methylprednisolone sodium succinate and hydrocortisone sodium succinate, and immediately after administration. There was no history to suggest this time course in our patient. Moreover, since there was no angioedema of the vocal cords, there was no possible way that steroid allergy could have produced this flow-volume loop configuration. Therefore, skin testing, which has not always been predictive of steroid reactions, would not have been helpful.

While flow limitation due to upper airway obstruction will improve with heliox compared to air, assessing the comparative responses would not have provided any additional information that would have resolved our patient’s condition.

Koufman JA. The otolaryngologic manifestations of gastroesophageal reflux disease (GERD): a clinical investigation of 225 patients using ambulatory 24-hour pH monitoring and an experiment investigation of the role of acid and pepsin in the development of laryngeal injury. Laryngoscope 1991; 101 (suppl 53):1–78

Moreno-Ancillo A, Martin-Munoz F, Martin-Barroso J-A, et al. Anaphylaxis to 6-alpha-methylprednisolone in an eight-year-old child. J Allergy Clin Immunol 1996; 97:1169–1171

Smyrnios NA, Irwin RS. Wheeze and cough in the elderly. In: Mahler DA, ed. Pulmonary disease in the elderly patient. New York, NY: Marcel Dekker, 1993; 113–157



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