DESCRIPTION

An 82-year-old man was admitted as an emergency with acute shortness of breath. He had a background history of dementia, atrial fibrillation, hypertension, cerebrovascular accident and thoracic aortic aneurysm (TAA) for which he had previously declined surgery.

He was distressed, tachypnoeic, tachycardic and hypertensive. Expiratory “wheeze” was audible from the end of the bed. Chest auscultation revealed monophonic, expiratory wheeze. Chest x ray (fig 1) revealed a large TAA and no obvious lung pathology.

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Figure 1

Chest radiograph on admission showing thoracic aortic aneurysm.

Initial treatment with nebulised salbutamol resulted in no immediate improvement and tracheal compression from the TAA was suspected.

Computed tomographic (CT) scan (fig 2) showed marked tracheal narrowing caused by extrinsic compression from the TAA. The aneurysm had increased in size compared to the most recent CT thorax from 18 months previously at which time no tracheal compression was seen.

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Figure 2

CT thorax demonstrating narrow trachea (arrow) due to extrinsic compression from thoracic aortic aneurysm.

Stenting of the trachea was considered but the patient (and his family) declined this. Conservative management with blood pressure control was agreed to be appropriate.

The patient gradually improved without definitive intervention. He was previously on warfarin, which was discontinued, and he was well enough to be discharged home a few days later.

This case highlights a recognised but uncommon cause of stridor.1 The patient had no history of respiratory disease and had never smoked, making an exacerbation of asthma or chronic obstructive pulmonary disease unlikely. Intra-thoracic upper airway obstruction may present with expiratory rather than inspiratory stridor and should be considered in a patient with monophonic wheeze.