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An 83-year-old woman with no known systemic disease presented to the emergency department with shortness of breath and audible abnormal breath sounds which she had had for 1 week. She reported that the abnormal breath sounds had been heard intermittently for more than a decade, occurring mostly during forceful expiration, coughing or when she had a common cold. One hour later, respiratory distress with accessory muscle use and paradoxical abdominal movement developed, and she was admitted to the intensive care unit for management of impending respiratory failure. The presumed diagnosis was severe asthma due to bilateral expiratory wheezes detected by the emergency physician.
At admission, a follow-up auscultation disclosed an expiratory stridor loudest at the suprasternal notch, with synchronous expiratory wheezes in the bilateral chest. An anteroposterior chest radiograph showed right tracheal compression at the level of the thoracic inlet (figure 1A), and a coronal view of a chest CT scan disclosed a dilated and tortuous innominate artery causing tracheal deviation (figure 1B). Bronchoscopy at the subglottic level showed pulsatile external compression of the right upper trachea, causing nearly total obstruction during forceful cough (figure 2A, B, see online supplementary video). A diagnosis of tracheomalacia secondary to innominate artery compression was established. After admission, non-invasive ventilation was initiated for respiratory support, together with an inhaled bronchodilator and other supportive care. Her respiratory status was stabilised. Non-invasive ventilation was discontinued on day 3 and she was discharged on day 10 without sequelae.
Tracheomalacia is a disease with weakness of the trachea, making it more vulnerable to expiratory collapse. It is a rare but underdiagnosed disease in intensive care units.1 The most common causes in adults include tracheostomy or endotracheal intubation, chronic inflammation or irritants and chronic external compression from a variety of aetiologies.2 The primary diagnostic modality for tracheomalacia is bronchoscopy, but dynamic expiratory CT findings have been found to be highly concordant with bronchoscopic findings.3 Besides radiological and bronchoscopic evaluation, lung function tests may show the typical pattern of a repeatable plateau of forced expiratory flow on the flow-volume loop.4 The patient's tracheomalacia was probably caused by prolonged undue vascular pressure from the innominate artery, aggravated by a superimposed respiratory event.
This case emphasises the famous adage, “all that wheezes is not asthma”, made by Chevalier Jackson,5 and the key to correct diagnosis is the detection of suprasternal expiratory stridor as the cause of expiratory wheezes in bilateral lungs, prompting further radiological and bronchoscopic evaluation.
Contributors L-TK: drafted the manuscript. C-JC: prepared the images and revised the manuscript.
Competing interests None declared.
Patient consent Obtained.
Provenance and peer review Not commissioned; externally peer reviewed.
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