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Allergy and Airway |

An Unusual Case of "Adult-Onset" Asthma

Kriti Lonial, MD; Anuja Vyas, MD
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University of Connecticut Health Center, Farmington, CT


Chest. 2012;142(4_MeetingAbstracts):23A. doi:10.1378/chest.1390716
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Abstract

SESSION TYPE: Airway Student/Resident Case Report Posters

PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM

INTRODUCTION: We present a case of asthma exacerbation resistant to conventional medical management

CASE PRESENTATION: A 74-year-old female recently diagnosed with asthma by her primary care provider presented to our hospital with progressively worsening shortness of breath. She had been having flu-like illness for the past week. Patient was on inhaled bronchodilators at home but her asthma was never “well-controlled”. Chest radiograph in the ED showed a complete white-out of the right lung (Fig. 1) . Computerized tomography (CT) of the chest showed atelectatic right lung with loculated effusion (Fig. 2). Despite chest tube and broad spectrum antibiotics her condition did not improve. A repeat CT scan showed obstruction in right lower lobe. Consequent flexible bronchoscopy performed to evaluate for an endobronchial tumor, revealed a foreign body (Fig. 1) in the distal portion of the right bronchus intermedius. The foreign body was retrieved after multiple attempts and laser removal of the granulation tissue. The patient was extubated soon after. On discussing the findings with the family, the daughter mentioned that the patient did choke on a piece of chicken two years ago. Not surprisingly, she was diagnosed with asthma a few months later.

DISCUSSION: Tracheobronchial obstruction by a foreign body was first discovered as a cause of wheezing by Struthers in 1852. In adults, food products like vegetables, peanuts and bones are the usual offending agents. Foreign bodies often lodge at the carina or the right mainstem bronchus due to the anatomy of the airways. Stridor and localized wheezing occur due to turbulent airflow around the narrowed airway, however, irritation of the airway causing bronchospasm can produce generalized wheezing, indistinguishable from asthma. Foreign body aspiration in adults is more common in the setting of alcohol use, poor dentition, underlying neurologic disease and advanced age. Flexible bronchoscopy is successful at removing 60-90% of foreign bodies, but rigid bronchoscopy should be used in retrieval of objects too large to grasp firmly via the flexible fiberoptic scope.

CONCLUSIONS: Not all wheeze is asthma and a comprehensive history is often instrumental in making an early diagnosis of foreign body aspiration.

1) Thomas, PS, Geddes, DM, Barnes, PJ. Pseudo-steroid resistant asthma. Thorax 1999; 54,352-356.

2) Zaas, D, Brock, M, Yang, S. An uncommon mimic of an acute asthma exacerbation. Chest 2002; 121:1707-1709.

3) Ferrer, M, Ferrer, A, Marin, A. Removal of a large endobronchial foreign body with a fiberoptic bronchoscope. Respiration 1991; 58,231-232.

DISCLOSURE: The following authors have nothing to disclose: Kriti Lonial, Anuja Vyas

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