She Struggled With Asthma, but It Had Never Been This Bad

The 58-year-old woman struggled to get out of her car at the West Roxbury Veterans Affairs Medical Center just outside Boston. When she finally made it to her feet, she leaned on the trunk of her car as she gasped for air. She was wheezing so loudly that she could hear it as well as feel it rumble in her chest. This was in 2019 — a time before the novel coronavirus that causes Covid-19 turned this kind of respiratory distress into an everyday event.

In the E.R., the wheezing woman was immediately moved to the treatment area. A mask hissing with a watery mist was placed over her nose and mouth, and only then did her breathing begin to ease.

She had a long history of asthma, the woman told her E.R. doctor, but it had never been this bad. Four weeks earlier, after the start of the new year, she came down with a terrible pneumonia in her right lung. The middle lobe had collapsed completely, she was told. She spent two days in a community hospital, but even after she was sent home, she didn’t feel well. Her chest was tight, and the slightest effort turned her breaths into wheezes. Her friends at work were worried. Go back to the hospital, they urged. But she hated hospitals, so she waited as long as she could. By the time she decided to drive herself to the V.A. hospital where she got much of her care, her entire body was exhausted simply from the effort it took for her to breathe.

In the E.R., a chest X-ray showed that she had another pneumonia. She was started on antibiotics and admitted to the hospital. A CT scan showed one possible reason for the back-to-back pneumonias. Deep in her right lung something — it wasn’t clear what — was blocking one of the main airways. Pneumonias frequently occur when an airway is occluded. The patient had a distant history of smoking, which made lung cancer a possibility. Her medical team reached out to the pulmonology service, the lung specialists, in case the patient needed a bronchoscopy — a bronch, for short. In that procedure, a small camera embedded at the end of a long tube is snaked through the nose or mouth, down the throat and into the lungs to get a closer look at the airways or something inside the airways.

Dr. Justin Rucci was the pulmonologist in training assigned to the patient’s case. If she needed a bronch, he’d be the one to do it. Rucci carefully went over the patient’s records. She didn’t have a fever, but she needed supplemental oxygen to keep her in the normal range. That was new. Her chest X-ray showed a pneumonia, and the CT scan clearly revealed a blockage, cutting off the airways into the lower lobe.

Rucci had access to the records from the hospital where the patient was treated for pneumonia the month before. He immediately clicked on the imaging. In the chest X-ray done during that hospital stay, Rucci easily identified the bright white disk against the textured gray of the lungs that indicated a pneumonia; it was in the same lung but in the middle lobe, not the lower lobe. At that time, her lower lobe looked fine. If the pneumonia she had now was caused by the obstruction they saw in the CT scan, could the same problem also have somehow caused the earlier pneumonia in the middle lobe?

Credit…Illustration by Ina Jang

Rucci had seen plenty of patients with blocked airways. The most common culprits were cancer, a mucus plug or an aspirated foreign body. A blockage caused by cancer shouldn’t move, and it shouldn’t grow fast enough to reach the lower lobe in the time between the two pneumonias. So cancer seemed unlikely. And she didn’t have any problems in her lungs like scarring or diseases like cystic fibrosis that make mucus plugs common. Foreign bodies are not often found in adults, but Rucci was pretty sure that’s what she had.

He went to see the patient late that afternoon. She was in bed and cheerful, despite the plastic tubing that delivered oxygen-enriched air to her nostrils. After hearing her story, Rucci had a question. Did she ever have problems swallowing? In fact, she did. She always had to have a big glass of water at hand to help her get her food down.

What about choking? Did she recall if she recently had a really bad choking episode — when her food had gone down the wrong pipe? She most certainly did. Maybe three months earlier, she was eating a salad and something hard dropped into her airway. She was home alone, and suddenly she couldn’t breathe at all. She couldn’t even cough, though she could feel herself trying to. She jumped up and ran out of the old farmhouse. She lived alone and the only other person she could think of on the property was her elderly landlord, and she couldn’t see him anywhere. Dark spots appeared before her eyes, and she wondered if she’d be found dead with a piece of her salad stuck in her throat. After what seemed like forever but was probably less than a minute, something shifted, and the airway popped open. Her heart raced. She was an Army veteran, but she’d never felt closer to death than she had right then.

Afterward, her chest was sore, but her breathing was back to normal. So she hadn’t thought of it months later when the wheezing started. Even when the doctors at that first hospital told her she might have a mass, her thoughts went to cancer and not to that choking episode.

  • Frequently Asked Questions and Advice

    Updated June 16, 2020

    • What is pandemic paid leave?

      The coronavirus emergency relief package gives many American workers paid leave if they need to take time off because of the virus. It gives qualified workers two weeks of paid sick leave if they are ill, quarantined or seeking diagnosis or preventive care for coronavirus, or if they are caring for sick family members. It gives 12 weeks of paid leave to people caring for children whose schools are closed or whose child care provider is unavailable because of the coronavirus. It is the first time the United States has had widespread federally mandated paid leave, and includes people who don’t typically get such benefits, like part-time and gig economy workers. But the measure excludes at least half of private-sector workers, including those at the country’s largest employers, and gives small employers significant leeway to deny leave.

    • Does asymptomatic transmission of Covid-19 happen?

      So far, the evidence seems to show it does. A widely cited paper published in April suggests that people are most infectious about two days before the onset of coronavirus symptoms and estimated that 44 percent of new infections were a result of transmission from people who were not yet showing symptoms. Recently, a top expert at the World Health Organization stated that transmission of the coronavirus by people who did not have symptoms was “very rare,” but she later walked back that statement.

    • What’s the risk of catching coronavirus from a surface?

      Touching contaminated objects and then infecting ourselves with the germs is not typically how the virus spreads. But it can happen. A number of studies of flu, rhinovirus, coronavirus and other microbes have shown that respiratory illnesses, including the new coronavirus, can spread by touching contaminated surfaces, particularly in places like day care centers, offices and hospitals. But a long chain of events has to happen for the disease to spread that way. The best way to protect yourself from coronavirus — whether it’s surface transmission or close human contact — is still social distancing, washing your hands, not touching your face and wearing masks.

    • How does blood type influence coronavirus?

      A study by European scientists is the first to document a strong statistical link between genetic variations and Covid-19, the illness caused by the coronavirus. Having Type A blood was linked to a 50 percent increase in the likelihood that a patient would need to get oxygen or to go on a ventilator, according to the new study.

    • How many people have lost their jobs due to coronavirus in the U.S.?

      The unemployment rate fell to 13.3 percent in May, the Labor Department said on June 5, an unexpected improvement in the nation’s job market as hiring rebounded faster than economists expected. Economists had forecast the unemployment rate to increase to as much as 20 percent, after it hit 14.7 percent in April, which was the highest since the government began keeping official statistics after World War II. But the unemployment rate dipped instead, with employers adding 2.5 million jobs, after more than 20 million jobs were lost in April.

    • Will protests set off a second viral wave of coronavirus?

      Mass protests against police brutality that have brought thousands of people onto the streets in cities across America are raising the specter of new coronavirus outbreaks, prompting political leaders, physicians and public health experts to warn that the crowds could cause a surge in cases. While many political leaders affirmed the right of protesters to express themselves, they urged the demonstrators to wear face masks and maintain social distancing, both to protect themselves and to prevent further community spread of the virus. Some infectious disease experts were reassured by the fact that the protests were held outdoors, saying the open air settings could mitigate the risk of transmission.

    • My state is reopening. Is it safe to go out?

      States are reopening bit by bit. This means that more public spaces are available for use and more and more businesses are being allowed to open again. The federal government is largely leaving the decision up to states, and some state leaders are leaving the decision up to local authorities. Even if you aren’t being told to stay at home, it’s still a good idea to limit trips outside and your interaction with other people.

    • What are the symptoms of coronavirus?

      Common symptoms include fever, a dry cough, fatigue and difficulty breathing or shortness of breath. Some of these symptoms overlap with those of the flu, making detection difficult, but runny noses and stuffy sinuses are less common. The C.D.C. has also added chills, muscle pain, sore throat, headache and a new loss of the sense of taste or smell as symptoms to look out for. Most people fall ill five to seven days after exposure, but symptoms may appear in as few as two days or as many as 14 days.

    • How can I protect myself while flying?

      If air travel is unavoidable, there are some steps you can take to protect yourself. Most important: Wash your hands often, and stop touching your face. If possible, choose a window seat. A study from Emory University found that during flu season, the safest place to sit on a plane is by a window, as people sitting in window seats had less contact with potentially sick people. Disinfect hard surfaces. When you get to your seat and your hands are clean, use disinfecting wipes to clean the hard surfaces at your seat like the head and arm rest, the seatbelt buckle, the remote, screen, seat back pocket and the tray table. If the seat is hard and nonporous or leather or pleather, you can wipe that down, too. (Using wipes on upholstered seats could lead to a wet seat and spreading of germs rather than killing them.)

    • Should I wear a mask?

      The C.D.C. has recommended that all Americans wear cloth masks if they go out in public. This is a shift in federal guidance reflecting new concerns that the coronavirus is being spread by infected people who have no symptoms. Until now, the C.D.C., like the W.H.O., has advised that ordinary people don’t need to wear masks unless they are sick and coughing. Part of the reason was to preserve medical-grade masks for health care workers who desperately need them at a time when they are in continuously short supply. Masks don’t replace hand washing and social distancing.

    • What should I do if I feel sick?

      If you’ve been exposed to the coronavirus or think you have, and have a fever or symptoms like a cough or difficulty breathing, call a doctor. They should give you advice on whether you should be tested, how to get tested, and how to seek medical treatment without potentially infecting or exposing others.

But after she was discharged that first time, she was still coughing up a storm. After one bad bout of hacking, she brought up something solid. When she fished it out of her mouth, she saw what looked like a piece of walnut and recalled those terrible moments when she thought the thing might kill her. She figured she’d gotten rid of the problem. Perhaps she’d been wrong.

On Day 5 of this second hospital stay, she was scheduled for the bronch. She was positioned in a chair that reminded her of the one in her dentist’s office. Once she was sedated, Rucci gently introduced the endoscope into her mouth, through her vocal cords and into her lungs. He directed the camera through the complex intersections of the large airways until he was all the way down to the lower lobe. And there it was — wedged in tight, blocking off the entire section. He could see a sliver of free space near the top of the object. He slid a tiny tool through the tubing past the camera, and then to the far side of the object. Once there he moved a switch and felt, rather than saw, a small net open behind the obstruction. He coaxed the net forward until he was certain he’d captured the thing. It was too large to be pulled out through the scope, so he slowly withdrew the entire instrument, keeping an eye on the captured object. The retrieved item clattered into the specimen container. Rucci squinted at the object. It was beige and hard. It was the rest of the snorted walnut. Suddenly it made sense. The patient had inhaled the nut, which got stuck in the middle lobe. Her violent cough broke it in two, and one part came up and the other, now smaller, piece dropped farther down the progressively narrower airways.

While food is what’s usually aspirated, a surprisingly wide variety of items manage to make their way into the lungs. Chevalier Jackson, a physician during the late 19th and early 20th centuries, devoted his career to developing instruments and techniques to retrieve these misplaced items. During Jackson’s 75-year career, he extracted 2,374 inhaled or swallowed foreign bodies from patients’ throats, esophagi and lungs, including safety pins, buttons, screws, dentures and lots and lots of toys. More than 80 percent of those objects were found in children. The entire collection, along with details of the patients from whom they were retrieved and the techniques used, is housed in the Mütter Museum in Philadelphia.

Like most patients, this one did well after the object was retrieved. Once the airway was opened, the pneumonia cleared up easily. She went home a couple of days later. The patient tells me that she still has trouble swallowing. She recently heard about a kind of physical therapy that might help, and plans to try that — once her doctors start seeing patients again.

View original article here Source

Related Posts