A 46-year-old female with dyspnoea, stridor and chronic cough

Abstract

A 46-yr-old female presented to the chest clinic with chronic dry cough and increasing dyspnoea on exertion. The patient's symptoms had deteriorated over the past 15 months and, at presentation, the patient developed dyspnoea after only 50 yards of walking. She had experienced multiple emergency department visits and frequent admissions to the hospital because of breathing difficulties. Also, during the last year, she experienced recurrent respiratory infections with a frequency of one to two infections per month. The patient received a diagnosis of bronchial asthma and was treated with short courses of systemic steroids, multiple inhalers and courses of antibiotics; resulting in only mild and temporary improvement in her symptoms. Pulmonary function tests (PFTs) 15 months earlier had shown a forced expiratory volume in one second (FEV1) of 1.5 L (84% predicted). The patient's past medical history was unremarkable. Specifically, there was no history of childhood asthma or frequent infections. She was an ex-smoker with 15 pack-yrs. Family history, environmental allergies and occupational exposures were all unremarkable. At presentation her medications included salmeterol-fluticasone inhaler, tiotropium, montelukast, prednisone 30 mg daily and pantoprazole. The patient appeared well with a blood pressure of 130/80 mmHg, heart rate of 80·min-1 and regular, respiratory rate of 18·min-1. Her saturation on room air was at 95%. Head and neck examination did not demonstrate lymphadenopathy or signs of chondral inflammation. Her cardiovascular examination revealed a normal jugular vein pulse with normal heart sounds and no pedal oedema. Respiratory examination demonstrated absence of clubbing and no evidence of wheezing or crackle. However, forced expiration produced an audible stridor sound. Spirometry demonstrated a forced vital capacity (FVC) of 1.7 L (75% pred), FEV1 0.65 L (25% pred), and FEV1/FVC 35%. A flow/volume curve is shown in figure 1⇓. Diffusing …