As it happens, a little trough runs between the epiglottis and the tongue, and several pits lie behind the laryngeal opening, where secretions or food particles can accumulate. When we clear our throats, that’s generally the stuff we’re bringing up. Despite vocal cords that slam shut at the least irritation and a cough reflex that can blast air out at 50 miles an hour, fully half of healthy people inhale some stomach contents during sleep. As we age, weakened muscles and sluggish reflexes aggravate the problem. Every year many thousands of pneumonia cases among older people result from misswallowed food and drink.
I wondered if some of the oral contrast had pooled around my patient’s larynx, setting off irritation and swelling. Maybe she had then coughed some up and inhaled it.
Nurses and medical residents stood at her bedside. The level of oxygen in her blood had sagged into the 80s—definitely not good. I leaned over her bed rail to listen closely. The hrahaahr, hrahaahr rattled my ribs. Beads of sweat broke out on her face as she fought harder to breathe.
Upper airway obstruction but not stridor? The question raced inside my mind.
As a treatment of last resort we could inject epinephrine, also known as adrenaline, which is the most potent of antiallergy drugs. But this woman was 75 years old: The adrenaline boost could easily jolt her heart into a lethal rhythm. Besides, she showed no signs of a bodywide allergic reaction. The more I listened, the more obvious it seemed that her problem lay in the throat.
Two surgery residents were passing by. “I may need you here in a minute,” I told them. “If we can’t turn her around, she could be too swollen to intubate. Might need a trach.”
If we couldn’t slip a breathing tube down her narrowed throat, we would need to cut a hole in the windpipe, or trachea, to create an airway. A tracheostomy is a bloody and usually panic-lit procedure. We needed to be ready.
“Hrahaahr, hrahaahr,” she brayed. Her oxygen level now read 85 percent. We were losing ground.
“Somebody call a doctor,” I muttered.
The residents chuckled. They thought I was kidding.
Then I remembered another way to administer epinephrine. When children have croup, a viral infection that causes swelling in the trachea below the vocal cords, we give a different type of epinephrine—called racemic epinephrine—that can be inhaled. The inhaled mist constricts blood vessels in the airway and reduces inflammation. But I’d never used it on an adult.
“Nina, how about some racemic epinephrine?” I said. “You know, the kind we use on croupy kids.”
She looked doubtful. “I’ll take a look.”
“It can’t really hurt,” I wheedled.
The vials came down. Nina read and reread the instructions. She poured the clear liquid into a pod-shaped container, attached it to a mask, hooked up oxygen delivery, and strapped the contraption around the patient’s face. With a sharp hiss, a cloud filled the face mask. She breathed in and out a dozen times.
Precisely 45 seconds later the noise ceased. We all looked at each other. I listened again to her chest. Air, sibilant and clean, whistled through it.
“I’ll be darned,” I said.
Nina wasn’t sure. “Could it act so fast?”
“Oh, epinephrine works fast,” I told her. “I’m just surprised it worked at all. Maybe some of the contrast stayed in her throat and made everything swell up, or maybe it gurgled into her airway.”
“Hours later?” Nina asked.
“The anatomy ain’t perfect, you know.”
Ten minutes later, the patient got a little noisy again.
“Let’s give her another,” I told Nina.
Forty-five seconds later, there was the same result—this time for good.
“You convinced?” I asked Nina.
“Sure. But what’s the diagnosis?”
“Beats me,” I confessed. “But I’ll take a good cure over a clear diagnosis any day.”
The woman’s belly pain went away on its own over the next two days. In retrospect, she probably hadn’t needed the CT scan. But at least there was no more trouble with her airway. My best guess was that the oral material must have been the culprit—and I tried not to wonder how many patients undergo unnecessary CT scans. One thing I was sure of, though: It would be good to always be so lucky.
Tony Dajer is assisant director of the emergency medicine department at
New York University Downtown Hospital in lower Manhattan. The cases described in Vital Signs are true stories, but the authors have changed some details about the patients to protect their privacy.