From the Guidelines
The patient's shortness of breath is most likely due to airway disease with wall thickening and mild mucous plugging in the lower lobes, and treatment should focus on managing this condition to improve symptoms and quality of life. The complete blood count (CBC) is normal, and while the total bilirubin is slightly elevated at 1.4, this is likely not clinically significant in this context 1. The D-dimer is normal at 0.27, and the CT angiogram of the chest shows no pulmonary embolism, aortic aneurysm, or dissection, which rules out these life-threatening conditions.
The primary finding of airway disease with wall thickening and mild mucous plugging in the lower lobes is consistent with bronchitis or possibly asthma/COPD exacerbation. According to the American College of Chest Physicians clinical practice guideline 1, for patients with symptomatic nonmalignant central airway obstruction, therapeutic bronchoscopy may be considered as an adjunct to systemic medical therapy. However, given the patient's presentation and the absence of severe central airway obstruction, initial treatment should focus on medical management.
- Bronchodilator therapy such as albuterol 2.5mg via nebulizer or 2 puffs via inhaler every 4-6 hours as needed, possibly with ipratropium bromide 0.5mg via nebulizer or 2 puffs via inhaler, may help alleviate symptoms.
- A short course of oral corticosteroids like prednisone 40mg daily for 5 days may help reduce airway inflammation 1.
- Adequate hydration is important to help thin secretions.
- If there are signs of infection (fever, purulent sputum), consider adding an antibiotic such as azithromycin 500mg on day 1, then 250mg daily for 4 more days.
It is essential to monitor the patient's response to treatment and adjust the management plan as needed to improve symptoms and quality of life 1.
From the Research
Patient Presentation
The patient presents with shortness of breath (SOB) and has undergone several tests, including a complete blood count (CBC), comprehensive metabolic panel (CMP), D-dimer, and computed tomography angiography (CTA) of the chest.
- The CBC is unremarkable.
- The CMP shows a total bilirubin level of 1.4, which is within normal limits.
- The D-dimer level is 0.27, which is below the threshold for pulmonary embolism.
- The CTA chest reads no acute pulmonary embolus, no saccular thoracic aortic aneurysm or dissection, and the lungs appear generally clear of acute findings.
- There is airway disease with wall thickening and mild mucous plugging in the lower lobes, but no definite pleural effusion or large pericardial effusion.
Differential Diagnosis
Based on the patient's presentation and test results, the differential diagnosis may include:
- Chronic obstructive pulmonary disease (COPD) 2, 3
- Asthma-COPD overlap syndrome (ACOS) 2
- Other causes of chronic dyspnea, such as heart failure, myocardial ischemia, interstitial lung disease, or psychogenic disorders 4
Management
The management of the patient's condition will depend on the underlying cause of their symptoms.
- For patients with COPD, treatment may include long-acting bronchodilators, inhaled corticosteroids, and phosphodiesterase inhibitors 3.
- For patients with ACOS, treatment may include a combination of inhalers used to treat COPD and asthma, as well as advanced therapies such as leukotriene receptor antagonists and immunotherapy 2.
- For patients with chronic dyspnea, further evaluation may be necessary to determine the underlying cause, and treatment will depend on the specific diagnosis 4, 5.
Further Evaluation
Further evaluation may be necessary to determine the underlying cause of the patient's symptoms, and may include: