An Uncommon Cause of Shortness of Breath

I sometimes explain to patients that shortness of breath is usually one of three things: Bad lungs, bad heart or bad blood. We need the lungs to oxygenate our blood, the heart to pump the blood around and enough hemoglobin in our blood to carry the oxygen. I have sometimes been a little slow in thinking that anemia can be a cause of shortness of breath.

The other day I saw a patient who seemed not fit into either category and he reminded me of Wayne Brown, who died from another condition that can make you short of breath.

I thought of Wayne as I heard the story of Carl, a heavy smoker with severe COPD. He had been to the emergency room half a dozen times since Thanksgiving and had received prednisone with or without antibiotics every time. He had his last chest X-ray in December and it didn’t show anything different from the ones before.

Carl, the man in front of me, made a slight noise with each breath, but it wasn’t quite a wheeze. It was an ever so slight stridor, a sound from higher up in his windpipe.

“I keep telling them it’s not my lungs”, he said, “it’s here”, and pointed to his neck.

Years ago, I remember hearing that same noise as I was leaving the hospital after a meeting one night. My patient, Wayne, was sitting on a bench outside the emergency room. He was waiting for his ride back home after a visit to the ER for breathing problems, diagnosed as another COPD exacerbation. It was a damp, cold evening when you could almost see your breath. He was making this little stridorous noise. He wasn’t hoarse when he talked, but once we got him to see an ear nose and throat doctor, he turned out to have cancer of his larynx. He lived for a while with his tracheostomy, which I helped him manage, and he whispered when we talked for the remaining few months of his life.

Carl had a normal oxygen saturation, a miserable peak flow of 150, poor but clean breath sounds, no cough and no hoarseness. He will of course need a CT of his lungs, because I have seen even large cancers not show on chest X-rays, but he also will need his larynx evaluated.

I hope my hunch is wrong.

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Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.

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