Odd respiratory patient presentation-any ideas?

[Riblett]

I had an unusual respiratory case today...not sure what was going on with this lady. Any ideas as to what it was or how it should have been treated are welcomed.

Dispatched to a local health clinic for SOB. UOA found 73 y/o female pt seated in w/c in no obvious distress. RN at the clinic tells us that she was there to have her toes checked as part of diabetes care plan. She also states severe dyspnea upon exertion. Otherwise normal.

Only known medical hx is 5 prior MIs, HTN, IDDM, ESRF and PVD. Nothing particularly respiratory in nature. The patient's BP is 115/70, and for all her medical hx that is a good darn BP. RR 16. HR 88. 12 lead sinus rhythm with obvious RBBB, q-waves in II, III, and AVF, T wave inversion in V1-V4. Lung sounds are clear and equal bilat with good air movement, 100% on 2lpm NC. So at this point she seems fine to me, and I am bit annoyed that my beef and broccoli was sitting in the truck.

The patient operates the controls on her scooter w/c to move herself out to the hall (using one hand on the controls, and nothing more) and her respiratory rate shoots up to 40+. She started looking like a CHFer does when the are full of fluid, the guppy fish breathing look about her. Lung sounds still clear, 10-15 beat HR increase, and still 100% O2 sats. This continued for the duration of the call. She would be fine one minute and the next she looked like she was fighting to breathe, with the dyspneic episodes lasting no more than 2 minutes and maintaining good sats and clear lungs.

So with her good sats, normal vitals, and clear lung sounds I thought maybe it could be psychosomatic. Or maybe related to an ESRF induced acid/base imbalance somehow manifesting itself as a respiratory presentation. I also entertained the idea of a pulmonary embolism, but the fact that it was drastically intermittent was really throwing me off. So I did what any good medic does when they are clueless....IV, O2 w/NRB, and 12 lead and high tailed it for the ED.

Any ideas?

[vs-eh?]

Ummm....

Sorry, did you speak to this patient or did the RN simply tell you about the toes and increased SOB on exertion?

What did the patient say about these episodes of apparent severe dyspnea? Normal? Past hx of same? Any pain/discomfort/"funny feeling"? Why is she doing this? Etc...

Standard hx questions...

[DwayneEMTP]

Off the top of my head I'm going to guess laryngospasm.

I dealt with this a few months ago. Throat felt tight, I was starved for air, heart rate up into the 140s. It was the strangest thing because I could feel my lungs filling, I knew for a fact that when they put a pulse ox on me it would read high 90s at least, but still felt like I was suffocating. I controlled my breathing, so no hyperventilation.

It would last about two minutes or so...scared the bejeezus out of me! Then I'd be fine for a few minutes, and then it would repeat.

0.5mg of glucagon at the ER and it soon resolved.

Dwayne

[firemedic37]

What medications was she on? Could it be a poisoning (overdose) of some type? Respiratory alkalosis due to Aspirin Build up, since she has hx of MIs?

[Kaisu]

I not an expert yet by any means, but the T wave inversion in V1-V4 tells me possible septal-anterior ischemia. With this lady's history (MI x 5) I would call this unstable angina - (mabe prinzemetals) obstruction somewhere in the LADD - Not sure - don't care - My treatment - MONA and beat feet to a cath lab.

[Riblett]

As far as history goes, the medical history I wrote in the original post was taken off her chart from the clinic. There was no medication list and the patient did not know what medical problems she had, much less what medicines she takes.

I asked her if this had ever happened before. She said that sometimes she gets "a little winded" when she was doing housework but never like this. That was all I was able to get out of her. She denied any chest pain, n/v, or any other symptoms. I asked her was there anything else wrong and all she said was " I am tired, I am just tired."

[hammerpcp]

Off the top of my head I'm going to guess laryngospasm.

I dealt with this a few months ago. Throat felt tight, I was starved for air, heart rate up into the 140s. It was the strangest thing because I could feel my lungs filling, I knew for a fact that when they put a pulse ox on me it would read high 90s at least, but still felt like I was suffocating. I controlled my breathing, so no hyperventilation.

It would last about two minutes or so...scared the bejeezus out of me! Then I'd be fine for a few minutes, and then it would repeat.

0.5mg of glucagon at the ER and it soon resolved.

Dwayne

Glucagon eh? Interesting. Did they figure out what caused your laryngospasm? Was it idiopathic or what?

[ccmedoc]

I've heard of glucagon used to treat refractory bronchospasm from anaphylaxis. Complex mechanism of action, supposedly bypasses the beta2 receptors and acts directly to relax smooth muscle in the bronchi. I haven't any literature on it though...

[DwayneEMTP]

Glucagon eh? Interesting. Did they figure out what caused your laryngospasm? Was it idiopathic or what?

That was interesting. He said he thought it was secondary to acid reflux. I told him no heartburn, no sore throat, etc, etc. Anyway, he put me on a trial of (I can't rememeber. That antacid pill that's on the TV every other commercial?) acid reducer and sure enough it hasn't reoccured.

Dwayne

[zzyzx]

My best guess is that she her feeling of being short of breath is not due to any respiratory problem but that that it's cardiovascular.

Imagine running round the block as fast as you can. You'd get to the point where you'd feel like you couldn't catch your breath anymore. But in fact it's not your lungs that can't keep up but your heart.

We can assume that this lady has CHF considering that she's had 5 MI's, so she probably has very little cardiac reserve. Her heart can't keep up with even a little exertion. She'd feel short of breath and panicked, and that would explain her respiratory rate.

This is obviously a very sick lady, and you'd have to wonder if perhaps she had yet another MI. You certainly did the right thing by taking her to the ER quickly.