Clinical Mimics: An Emergency Medicine-Focused Review of Asthma Mimics

The Saudi initiative for asthma - 2024 update: Guidelines for the diagnosis and management of asthma in adults and children

The Saudi Initiative for Asthma 2024 (SINA-2024) is the sixth version of asthma guidelines for the diagnosis and management of asthma for adults and children that was developed by the SINA group, a subsidiary of the Saudi Thoracic Society. The main objective of the SINA is to have guidelines that are up-to-date, simple to understand, and easy to use by healthcare workers dealing with asthma patients. To facilitate achieving the goals of asthma management, the SINA Panel approach is mainly based on the assessment of symptom control and risk for both adults and children. The approach to asthma management is aligned for age groups: adults, adolescents, children aged 5-12 years, and children aged <5 years. SINA guidelines have focused more on personalized approaches reflecting a better understanding of disease heterogeneity with the integration of recommendations related to biologic agents, evidence-based updates on treatment, and the role of immunotherapy in management. The medication appendix has also been updated with the addition of recent evidence, new indications for existing medication, and new medications. The guidelines are constructed based on the available evidence, local literature, and the current situation at national and regional levels. There is also an emphasis on patient-doctor partnership in the management that also includes a self-management plan.

The Prevalence of Bronchodilator Responsiveness "Asthma" Among Adult Indigenous Australians Referred for Lung Function Testing in the Top End Northern Territory of Australia

Background

Among Indigenous Australians, studies examining the clinical significance of airway bronchodilator responsiveness (BDR) are limited. In this retrospective study, we examined the nature of underlying lung disease in adult Indigenous patients with BDR referred for lung function testing (LFT) in the Top End Health Service region of the Northern Territory of Australia.

Methods

Presence or absence of BDR as per usual (FVC or FEV₁ change pre to post ≥12% and ≥0.2L) and updated (2021 ">10% predicted) ATS/ERS criteria among Indigenous and non-Indigenous Australians was determined. The radiological findings in the Indigenous study participants with and without BDR were next assessed for the presence of underlying chronic airway/lung disease.

Results

We found that 123/742 (17%) Indigenous and 578/4579 (13%) non-Indigenous patients had a significant BDR. Indigenous patients with BDR were younger (mean difference 7 years), with a greater proportion of females (52 vs 32%), underweight (15 vs 4%) and current smokers (52 vs 25%). Indigenous patients with BDR displayed lower LFT values, and a higher proportion exhibited FVC BDR compared to non-Indigenous (34 vs 20%). Almost half (46%) of Indigenous patients with BDR had evidence of COPD and/or bronchiectasis on radiology. Adjusting for the presence of radiologic or spirometric evidence of COPD, the presence of BDR was similar between Indigenous and non-Indigenous patients (5-8 vs 7-11%), irrespective of which BDR criteria was used.

Conclusion

BDR was higher overall among Indigenous in comparison to non-Indigenous patients; however, a significant proportion of Indigenous patients demonstrating BDR had evidence of underlying COPD/bronchiectasis. This study highlights that although presence of BDR among Indigenous people may indicate asthma, it may also be observed among patients with COPD/bronchiectasis or could represent asthma/COPD/bronchiectasis overlap. Hence, a combination of clinical history, LFT and radiology should be considered for precise diagnosis of lung disease in this population.

Dramatic improvement in innominate artery compression syndrome with only postural changes in a bedridden elderly patient

We present the case of a bedridden elderly patient who demonstrated dramatic improvement in innominate artery compression syndrome with postural changes alone. A 94-year-old woman presented with dyspnea. Physical findings revealed stridor in the right-sided decubitus position. Her symptoms did not improve with conventional asthma treatment. Plain computed tomography revealed tracheal compression by the bent innominate artery. Contrast-enhanced computed tomography with postural changes altered the compression sites of the organs, resolving the tracheal stenosis. The number of similar bedridden elderly patients will increase in an aging society. We report this case to aid physicians in managing such patients.

Wheezing of unexpected etiology: A case report of pea aspiration mimicking bronchus obstruction caused by a tumor

Introduction

Geriatric patients with foreign body aspiration (FBA) lack a detailed medical history. Meanwhile, FBA can mimic other diseases and present with wheezing. Here, we report on the difficulty of making a diagnosis of FBA in an elderly man with wheezing.

Case presentation

An 84-year-old man presented with wet cough. He had progressive lung cancer, for which only supportive care was provided. His physical examination revealed wheezing. We presumptively diagnosed acute exacerbation of chronic obstructive pulmonary disease (AE-COPD) and administered inhaled procaterol and parenteral methylprednisolone, which did not mitigate his symptoms. Computed tomography revealed a round nodule, 1 cm in diameter, in his right intermediate bronchus. Central airway obstruction (CAO) caused by the tumor was initially suspected. However, bronchoscopy revealed a pea (Pisum sativum) lodged in his right bronchus, which was removed using forceps.

Discussion

The typical clinical presentations of FBA are sudden-onset cough and dyspnea. However, some geriatric patients do not have cough or lack the cognitive capacity to inform of an episode of FBA. FBA can mimic other entities including AE-COPD and CAO, as seen in our case. Clinicians should not terminate the diagnostic process until all available information explaining the patient's signs and symptoms is collected.

Conclusion

Despite the lack of apparent aspiration, FBA is an important differential diagnosis of new wheezing in the elderly. Physicians need to carefully evaluate “trivial” information or collect additional information when encountering airway symptoms in elderly patients to avoid missing an FBA diagnosis.

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Geriatric patients with foreign body aspiration (FBA) lack a detailed medical history.

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FBA can mimic other diseases and present with wheezing.

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Clinicians should not terminate the diagnostic process early to avoid missing FBA.

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Availability and anchoring biases could be involved during the process to diagnose FBA.

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We should seek more information from accompanying persons to diagnose FBA early.

Diagnostic Performance of Pulmonary Embolism Imaging in Patients with History of Asthma

Asthma and pulmonary embolism (PE) can present with overlapping symptoms, and distinguishing between these 2 conditions can be challenging. Asthma may limit imaging for PE because of either worsened ventilation defects on ventilation-perfusion scanning (VQ) or increased motion artifacts on CT pulmonary angiography (CTPA). Methods: We identified adults evaluated for PE with VQ or CTPA from 2012 to 2016. Patients with chronic lung disease (other than asthma) were excluded. Studies were classified as negative, positive, or nondiagnostic. Follow-up of negative cases was reviewed to determine the rate of repeat exams (within 1 wk) and the false-negative rate (defined as diagnosis of venous thromboembolism within 90 d). Results: We reviewed 19,412 adults (aged 52 ± 18 y, 70% women) evaluated for PE (60% with VQ, 40% with CTPA); 23% had a history of asthma. Nondiagnostic results were comparable for those with and without asthma for both VQ (asthma, 3.3%; nonasthma, 3.8%; P = 0.223) and CTPA (asthma, 1.6%; nonasthma, 1.5%; P = 0.891). A history of asthma was not associated with a higher rate of repeat exams after negative imaging for VQ (asthma, 1.9%; nonasthma, 2.1%; P = 0.547) or CTPA (asthma, 0.6%; nonasthma, 0.6%; P = 0.796), nor was a history of asthma associated with a higher false-negative rate for VQ (asthma, 0.4%; nonasthma, 0.9%; P = 0.015) or CTPA (asthma, 1.9%; nonasthma 1.5%; P = 0.347). Conclusion: A history of asthma in the preceding 10 y was not associated with impaired diagnostic performance of PE imaging for either VQ or CTPA.

A 9-month-old with wheezing and acute hypoxic respiratory failure

Foreign body aspiration remains a diagnostic challenge, especially in an infant. While acute onset wheezing is highly suggestive of an aspiration, wheezing carries a broad differential diagnosis resulting in frequent misdiagnoses. Many cases present with a range of nonspecific findings and normal imaging, stressing the importance of a high index of suspicion.