Wheeze or stridor? A careful listening to prevent impending respiratory doom

We present a rare case of tracheal stenosis masquerading as asthma exacerbation. A 45-year old gentleman presented to the A&E with breathlessness. He is known asthmatic, discharged 10- days ago requiring critical-care admission for intubation following a near fatal asthma. A&E doctor started bronchodilator, steroid assuming an asthma exacerbation as thought to have wheeze.He was being treated in the corridor without supervision.Later, on-call medical registrar noted the patient to actually have inspiratory stridor. Bedside PEFR and spirometry showed an empey index of 12. Chest X-ray demonstrated an abnormal looking trachea, subsequent urgent chest CT revealed tracheal stenosis. A) Immediately transferred to ITU. B) Bronchoscopy revealed significant tracheal stenosis with 80% narrowing of the lumen in the mid portion of the trachea. He underwent dilatation using various sizes of rigid bronchoscope(10,12,14) and stent placement. The case demonstrates the importance of early recognition of upper airway obstruction. Several factors play a role in missed diagnosis as stridor may often be mistaken for wheezing, especially given it is so much more common in asthmatics.11% of critically ill patients had developed tracheal stenosis at the cuff site despite high-volume low- pressure cuff. Tracheal damage and subsequent stenosis can occur in any patient after the intubation of any duration even as short as 24 h. These patients may remain asymptomatic for a variable period. Patients usually remain asymptomatic until the trachea has stenosed to 30% of its original diameter. From exertional breathlessness these patients can progress to airway obstruction with the development of a stridor (80% or more stenosed). Post intubation tracheal stenosis is often misdiagnosed as asthma in as many as 44% of patients. Chest X-ray, bedside PEF, spirometry (Empey index), full pulmonary function test, CT CHEST, bronchoscopy remain standrad investigations for such patients with bronchoscopy remaing as the gold standard. Therapeutic options to treat such patients are- endoscopic dilatation, surgery, stent, argon-plasma-coagulation.