Objectives. Phil Slocum, D.O. FCCP, FACOI, FCCM, FACP Professor of Medicine. All that wheezes (or has intermittent dyspnea) is not asthma

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1 * Phil Slocum, D.O. FCCP, FACOI, FCCM, FACP Professor of Medicine Objectives All that wheezes (or has intermittent dyspnea) is not asthma Ockham's Razor does not work in evaluating patients with shortness of breath and cough PreTEST A 41 year old woman is seen for a history of asthma which began when she was in her teen years. Some years it seems symptoms might be worse spring and fall. She denies red, itchy eyes or nasal itching or paroxysmal sneeze. She experiences voice quality changes frequently. She has been on a recue inhaler and ICS & LABA because symptoms persisted, yet spirometry is only shows mild OAD and occasions moderate OAD. When she is seen for exacerbations notes often reflect that wheeze is located in the throat. A normal TE is found but FET is 10 seconds with noted wheeze. Of the listed possibilities, the most important next step should be: A. Begin prednisone 40 mg a day and taper based on symptomatic response B. Perform a methacholine challenge C. Have a GI evaluation for occult GERD D. Have an ENT evaluation for VCD 1

2 PreTEST A 41 year old woman is seen for a history of asthma which began when she was in her teen years. Some years it seems symptoms might be worse spring and fall. She denies red, itchy eyes or nasal itching or paroxysmal sneeze. She experiences a sensation she cannot get air in and she experiences numbness and tingling in her fingers, toes, and lips and has a sense like she is going to pass out because she is suffocating. She has been on a recue inhaler but often it worsens her dyspnea and wheeze and ICS & LABA because symptoms persisted, yet spirometry is only shows mild OAD. A normal TE is found and FET with clear breath sounds. Of the listed possibilities, the most appropriate next step is to: A. Begin prednisone 40 mg a day and taper based on symptomatic response B. Perform a hyperventilation challenge C. Perform an echocardiogram D. Perform a cardiopulmonary stress test A 37 year old woman who has a history of asthma since the age of 6. She remains on LABA and inhaled steroids but still uses her her rescue Inhaler several times a week, usually late morning or afternoon. Upon exam her VSS and she demonstrated normal chest wall and 4 cm diaphragm excursion by percussion. Her pulsus paradoxus was 24. She had a normal TE & an FET of 8 seconds. She had expiratory wheeze localized in the larynx. Asthma Background Aspirin-induced GERD Exercise-induced Occupational Obesity Nasal associated symptoms 2

3 Asthma Presentation- Wheeze, cough, shortness of breath, & chest tightness Physical findings- Tachypnea & tachycardia Prolonged TE & FET Increased pulsus paradoxus Desaturation and hypercapnia Asthma Differential Diagnosis- Foreign body Bronchiectasis Allergic bronchopulmonary aspergillosis- ABPA COPD Heart Failure Vocal cord dysfunctions Hyperventilation/panic attacks Cystic fibrosis GERD Chronic sinus conditions Asthma 3

4 Ockham's Razor and the Rule of Parsimony William of Ockham (late 13 th /early 14 th century philosopher/theologian When competing hypothesis that work equally well, the argument with the fewest assumptions is the correct one Rule of Parsimony Hickman s dictum John Hickman, M.D. Originally at Duke in the 1950s Became Chair of Medicine University of Indiana Patients can have as many diseases as they damn well please. Difficult to Control Asthma Clinic 152 new consecutive patients were evaluated 33 had a diagnosis of various pulmonary conditions 119 had the diagnosis of asthma On many asthma medications 39 (32.7%) methacholine challenge & laryngoscopy 38 (99%) has a negative methacholine challenge 36 of the 39 (82%) had laryngoscopy proven VCD The Problem of Vocal Cord Dysfunction Original description and first studies The number different names Munchausen s stridor Irritable larynx syndrome or emotional laryngeal Psuedo-asthma or factious asthma or functional asthma Paradoxical vocal fold motion, laryngeal pharyngeal reflux Lack of a GOLD diagnostic standard Lumpers & Splitters 4

5 Vocal Cord Dysfunction 7.5 years with the diagnosis of asthma before the diagnosis is made Medications Disability * 5

6 Psychological Testing in VCD Patients 45 consecutive patients 81% female VCD patients scored high on hypochondriasis and hysteria scales 18/45 had conversion disorder (another 13 scored high but not high enough to be diagnostic Highest scored on hypochondriasis and hysteria scales were patients with asthma & GERD Co-morbidities with VCD Asthma was found in 65% GERD in 51% History of abuse in 38% MOST IMPORTANT 11/45 had NO psychopathology found Slocum s Anecdotal Criteria for VCD Evaluation Anyone who presents with wheeze, undiagnosed cough, shortness of breath AND has History of abrupt onset voice change or hoarseness, with or without choking sensation, with acute dyspnea that lasts 30 minutes or less. History of witnessed (by self or others) of laryngeal wheeze or stridor Laryngeal wheeze on physical exam Inspiratory loop truncation on F-V Loop in an appropriate patient A 37 year old woman who has a history of asthma since the age of 16. She remains on LABA and inhaled steroids but still uses her rescue inhaler several times a week, usually late morning or afternoon. She denies change in voice quality. Shortness of breath is severe and associated with dizziness and a sense she will pass out. On direct questioning she admits to numbness of lips, fingers, and toes Upon exam, her VSS and she demonstrated normal chest wall and4 cm diaphragm excursion by percussion. She had a normal TE & an FET. She had no wheeze. 6

7 Panic/Hyperventilation Syndrome Most authorities don t link these together but they have very similar symptoms that vary largely be degree (THEY ARE NOT THE SAME) Symptom complex that recurs enough to seek medical attention: Acute onset choking, dyspnea, impending death Chest tightness, crushing chest, or chest pain Paresthesias Near syncope, dizzy, giddy, out of body, light headed, faint, or going crazy Panic/Hyperventilation Syndrome Common Panic occurs in up to 6 % of general population and 10 % of a GIM population 50 % of panic patients have hyperventilation symptoms Female: male ratio is 7:1 Most common ages are Risk Factors 80 % had a major life stress in past 12 months High incidence of child abuse or sexual abuse Teens who smoke are at increased risk Panic/Hyperventilation Syndrome Treatments- Milder cases Patient awareness 7/11 breathing CBT More severe cases Should be managed by psychiatry CBT + medications has a 60% response at 4 months CBT alone had nearly a 50% improvement Medication alone had a 46 % improvement 7

8 Slocum s Anecdotal Approach to Panic/Hyperventilation Syndrome Difficult to treat respiratory patients or undiagnosed dyspnea patients who respond positively to: Do you have a difficult time getting air in? Do you feel like you are going to die? Do you have numbness and/or tingling in your lips, fingers or toes during attacks? Do you feel dizzy, giddy, panicky, light headed? AND Slocum s Anecdotal Approach to Panic/Hyperventilation Syndrome They have a normal lung evaluation (including all the typical diagnostic toys we have on hand) OR Their pathophsyiology remains at or near baseline Slocum s Anecdotal Approach to Panic/Hyperventilation Syndrome Hyperventilation Challenge Tell the patient what you are going to do. Do it Help the patient return to baseline function 8

9 Has Psychiatry Become Modern Medicine s New Religion? Medieval thought and disease Modern thought and mental illness Summary Asthma has many diseases that simulate its features Many conditions can coexist with asthma We must be vigilant in our search for causes of poorly controlled asthma including specifically evaluating for Vocal Cord Dysfunction Panic/Hyperventilation Lastly When it comes to clinical medicine, William of Ockham was an idiot 9

10 Post TEST It is important to consider vocal cord dysfunction in patients because: A. It is a commonly occurring disease B. Patients are often wrongly diagnosed with other diseases C. Suffer needless expense and complication from unneeded medications D. All the above Post TEST A patient is determined to have mild hyperventilation syndrome. The most appropriate initial first line treatment is: A. Sertraline B. Reassurance, patient education, and teaching 7/11 breathing C. Referral to psychiatry D. None of the above 10