18 intubations and 1 missed diagnosis
Learning objectives: 1) Understand the importance of maintaining a broad differential diagnosis in patients with shortness of breath. 2) Explain the impact of not properly documenting medical histories in the electronic health record. Case information: A 50 year old woman with asthma, anxiety, bipolar disorder, and 18 previous intubations presented with shortness of breath, non-productive cough, and conversational dyspnea. On exam, she was using accessory muscles and tachypneic. Expiratory phase was prolonged and wheezing was noted. Cardiac exam, chest x-ray and EKG were unremarkable. B-natriuretic peptide and troponins were not elevated. Patient was placed on BiPAP, but eventually required intubation. She was transferred to the ICU with a diagnosis of acute exacerbation of asthma and treated accordingly. Peak inspiratory pressures on the ventilator were normal. A detailed chart review showed a laryngoscopy, performed 7 months earlier, was significant for Paradoxical Vocal Fold Motion. The diagnosis was not added to the patient's history in the electronic health record and was not noted on any of the admissions that occurred post-procedure. Discussion: Paradoxical Vocal Fold Motion (PVFM) is a condition in which there is inappropriate adduction of the true vocal folds during inspiration. Patients present with shortness of breath, cough, and dysphonia. They are often misdiagnosed and therefore receive suboptimal or inappropriate treatment. This case illustrates the importance of having a broad differential diagnosis and importance of documenting medical histories appropriately. PVFM is a cause of obstructive airway disease and can be mistaken for asthma. The level of obstruction, however, is extra-thoracic and it is treated acutely with breathing maneuvers. An association with psychiatric disorders is observed, but PVFM is also misdiagnosed as anxiety. It is important to have a high index of suspicion to ensure appropriate care, prevent unnecessary intubation, and potentially, unnecessary admissions.