This is a 53‐year‐old woman with a history of asthma since childhood. Over the course of a year her dyspnea and wheezing worsened, severely limiting her functional status. She was treated with multiple courses of antibiotics, pulse steroids, inhaled corticosteroids and combination inhalers without clinical benefit. She self‐referred to a pulmonologist within our institution for second opinion. Chest x‐ray showed hilar/parenchymal calcific and fibronodular changes, and a normal cardiac silhouette. She was subsequently admitted for further workup. Patient described herself as a “wheezy kid” with noisy breathing sometimes described as a whistle while inspiring. Her dyspnea was worse in the dorsal recumbent position, associated with intermittent chest tightness, and wheezing described as worst in the morning and with activity but improved with rest. Other complaints included daily dry cough, postprandial cough and reflux. She denied any recent travel, sick contacts, new pets, or change in her home or work environment. She denied fevers, chills, or dysphagia. Initial vitals were within normal limits and physical exam was unremarkable. EKG and echocardiogram were normal. Pulmonary function tests showed mild obstruction and no significant bronchodilator response. CT Scan, to evaluate pulmonary nodules, revealed a double aortic arch with a dominant right arch, mildly hypoplastic left arch, and a complete vascular ring noted to compress the trachea and esophagus. The patient was referred to cardiothoracic surgery for definitive treatment.
A double aortic arch (DAA), although relatively uncommon, is not rare. Almost always cause some level of symptoms due to the constriction of the trachea and/or esophagus by the surrounding vascular structures. Most present in infancy or early childhood; however, sporadic adult cases have been reported. Patients with less severe tracheal compression may give a history of persistent respiratory symptoms, classically diagnosed as asthma or recurrent lower respiratory infections. Dysphagia often occurs later. Extrinsic compression of the trachea or esophagus suspected from chest x‐ray, can be confirmed further by bronchoscopy and barium swallow, but is best diagnosed by CT scan due to advantage of demonstrating both the lumen and the anatomy of the extrinsic compression.
Hospitalists should be aware of DAA and vascular rings in adults, as it could be a major pitfall in patients diagnosed with asthma unresponsive to conventional treatment. Greater awareness of the possibility of this condition as a cause of tracheal compression and dysphagia in adults is paramount as timely surgical intervention can minimize airway complications, and surgery has almost 100% success in symptomatic relief for these patients.
Contrast‐enhanced CT showing a DAA involving a complete vascular ring around the trachea and esophagus.
To cite this abstract:Barbastefano J, Barbastefano N. Dyspnea, Wheezes, and Cough: Not Always the Usual Suspect. Abstract published at Hospital Medicine 2013, May 16-19, National Harbor, Md. Abstract 417. Journal of Hospital Medicine. 2013; 8 (suppl 2). https://www.shmabstracts.com/abstract/dyspnea-wheezes-and-cough-not-always-the-usual-suspect/. Accessed July 16, 2019.