A 68-year-old man presented with acute breathlessness and wheezing. He had received nebulization at a local facility and was referred as a probable COPD exacerbation.
He was tachypnoeic and anxious. Wheeze was audible on both sides. It was tempting to continue escalating bronchodilators.
Something did not fit
He had no strong smoking history and no previous diagnosis of COPD. His blood pressure was markedly elevated. He preferred sitting upright and said the breathlessness had started suddenly during the night.
The hidden diagnosis
The clinical picture was more consistent with acute pulmonary edema with “cardiac asthma.” Bedside assessment and subsequent investigations supported acute left ventricular failure.
Why the first diagnosis was convincing
Wheeze is commonly associated with asthma and COPD, but airway narrowing can also occur during pulmonary congestion. If the entire picture is not considered, the sound can become an anchor.
Clinical pearls
- Wheeze is a physical sign, not a diagnosis.
- Look for orthopnea, hypertension, crackles, edema and cardiac history.
- In older adults with first-time wheeze, think beyond obstructive airway disease.
- Treatment should target the underlying physiology.
Take-home message
Sometimes the wheeze is coming from the heart.