What are the potential causes of shortness of breath (SOB), voice loss, stridor, and retractions in an elderly patient?

Acute Upper Airway Obstruction in Elderly Patients

In an elderly patient presenting with shortness of breath, voice loss, stridor, and retractions, the most critical immediate concern is acute upper airway obstruction requiring urgent assessment for epiglottitis, foreign body impaction, or laryngeal pathology, with immediate preparation for emergency airway management. 1, 2

Immediate Life-Threatening Causes

Acute Epiglottitis

• Epiglottitis is a rapidly fatal condition in adults that presents with the classic tetrad: fever, stridor, sore throat with odynophagia (painful swallowing), and drooling—often accompanied by the "tripod sign" (patient leaning forward with neck extended). 2
• Voice changes (muffled or "hot potato" voice) rather than complete voice loss are typical, distinguishing it from complete laryngeal obstruction. 2
• The patient's airway must be continuously monitored during evaluation to avoid complete obstruction, and intubation should only be attempted by the most skilled personnel available. 2
• Lateral neck radiography showing the "thumb sign" (swollen epiglottis) and direct laryngoscopy are diagnostic, but never perform laryngoscopy without personnel skilled in emergency airway management immediately available. 2

Foreign Body Impaction

• In elderly patients with cognitive impairment, accidental ingestion of food bolus or other objects is common and can cause airway obstruction when lodged at the hypopharynx or upper esophagus. 1
• Choking, stridor, and dyspnea indicate airway obstruction or aspiration rather than simple esophageal impaction. 1
• Physical examination may reveal fever, cervical subcutaneous emphysema, or neck tenderness if perforation has occurred. 1
• CT scan has 90-100% sensitivity for detecting foreign bodies and should be performed urgently if plain radiographs are negative and clinical suspicion remains high. 1

Subglottic Stenosis

• Acute respiratory failure from subglottic stenosis can present with stridor, shortness of breath, and voice changes, particularly after a precipitating event like coughing. 3
• This may occur at the level of the cricopharyngeus or in retrosternal locations, making nasopharyngoscopy falsely reassuring. 3
• Chest radiography showing mediastinal abnormality or CT imaging is necessary to identify retrosternal obstruction. 3

Secondary Considerations in Elderly Patients

Iatrogenic Laryngeal Injury

• Recent endotracheal intubation causes laryngeal injury in 94% of patients intubated >4 days, with 44% developing vocal fold granulomas within 4 weeks of extubation. 1
• Prolonged true vocal fold immobility persists in some patients for ≥4 weeks after extubation, and chronic phonatory dysfunction can occur years later. 1
• Recent neck surgery (thyroidectomy, anterior cervical spine surgery) or cardiothoracic procedures can cause recurrent laryngeal nerve injury with rates of 0.85-24.2%. 1

Laryngeal Malignancy

• In elderly tobacco smokers, hoarseness with stridor requires expedient assessment for head and neck cancer, which is associated with increased frequency of polypoid vocal fold lesions. 1
• Laryngoscopy should be performed urgently in any patient with voice changes lasting >2-4 weeks, particularly with risk factors including tobacco use, radiation history, or progressive symptoms. 1

Inducible Laryngeal Obstruction (ILO)

• ILO causes episodic breathing problems with stridor due to inappropriate laryngeal closure during inspiration or expiration. 1
• This diagnosis requires excluding fixed anatomical obstruction and physiological laryngospasm, as these are mimics rather than true ILO. 1

Critical Diagnostic Approach

Immediate Assessment

• Assess respiratory rate, oxygen saturation, work of breathing, and ability to speak in full sentences to determine severity. 4
• Signs of severe respiratory distress include respiratory rate >25/min, oxygen saturation <90%, use of accessory muscles, and inability to complete sentences. 4
• Provide supplemental oxygen targeting saturation 94-98% if hypoxemia is present. 4

Imaging Strategy

• Lateral neck radiography is the initial screening test but has false-negative rates up to 47% for radiolucent objects. 1
• CT scan of the neck and chest should be performed urgently in patients with suspected perforation, complications, or when plain films are negative despite high clinical suspicion. 1
• Contrast swallow studies should be avoided as they delay definitive intervention. 1

Laryngoscopic Examination

• Direct or indirect laryngoscopy must be performed to visualize the larynx, but only with emergency airway equipment and skilled personnel immediately available. 1, 2
• Nasopharyngoscopy alone may miss retrosternal or subglottic pathology. 3

Management Priorities

The emergency airway team should be notified immediately for any adult presenting with stridor, as surgical airway (emergency tracheostomy) may be required. 5

Avoid Common Pitfalls

• Never use racemic epinephrine in suspected epiglottitis due to rebound effect that can worsen obstruction. 2
• Do not assume bronchospasm is the primary problem—inhaled bronchodilators are ineffective for fixed upper airway obstruction. 3
• Repeated intubation attempts increase periepiglottal swelling and obstruction risk; ensure the most skilled operator performs the first attempt. 2
• Do not delay definitive airway management for additional diagnostic testing if respiratory failure is imminent. 2, 3

Multidisciplinary Coordination

• Successful management requires immediate coordination between emergency medicine, anesthesiology, and otolaryngology. 2
• If epiglottitis is suspected, empiric broad-spectrum antibiotics should be initiated immediately after securing the airway. 2