Attending physician, division of critical care Nemours Childrens Hospital, United States
Introduction: We present a case of cardiac tamponade presenting as acute asthma exacerbation in a patient with congenital absence of the left lung. Wheezing and prolonged exhalation in the setting of acute viral illness are usual indicators of lower airway obstruction. When not responding to conventional treatments other causes of wheezing should be considered. We present this case to demonstrate abnormal pulmonary development as an uncommon cause of wheezing and chronic respiratory failure.
Description: Patient was an 11 year old female with VACTERL syndrome, asthma, and hypoplastic left lung, who was admitted to PICU for acute respiratory failure due to asthma exacerbation secondary to parainfluenza. Shortly after admission she required intubation and invasive mechanical support in addition to steroid, albuterol, magnesium, and terbutaline treatments. On exam she demonstrated tachycardia, wheezing throughout, prolonged and forced expiratory phase, and on intubation a peak-to-plateau pressure >20. Despite asthma treatments, she remained difficult to oxygenate and ventilate. An echocardiogram to evaluate for pulmonary hypertension showed a large pericardial effusion and tamponade physiology. After pericardiocentesis, ventilator was quickly weaned though she remained with wheezing, prolonged expiratory phase, and peak-to-plateau pressure >20. CT chest showed absence of left lung with herniation of right lung across midline occupying left upper chest and heart displaced against left chest wall. Bronchoscopy of the left main bronchus showed blind pouch. Ultimately, respiratory support was weaned and patient extubated. She remained with prolonged forced exhalation and wheezing on discharge.
Discussion: In this case, we present a child with congenital absence of left lung with compensatory growth of the right lung, leading to a missed diagnosis of cardiac tamponade. At her baseline respiratory state, the overgrowth of single lung led to prolonged, forced exhalation and a diagnosis of asthma. Due to her abnormal pulmonary mechanics and intrathoracic anatomy, the typical monitoring of lower airway obstruction led to an anchoring of asthma diagnosis. We present this case as a reminder to consider airway anatomy in the differential diagnosis when wheezing is not responding to typical treatments.
