Long-ago asthma diagnosis didn’t explain boy’s difficulty breathing

It was early May, a hot and humid Friday night for the under-11 boys soccer game. My 10-year-old son collapsed on the field, unable to breathe. The coach grabbed another child’s inhaler and administered it to Ian, who, after six puffs (instead of the usual two) was able to catch his breath and stand.

I wasn’t at the game, so I heard about the incident from my husband, who is unruffled at even the most dramatic moments. “Oh, yeah,” he said that night as we were headed to bed. “Ian had an asthma attack during the game, but he was fine.” It was only later that I heard the full, scary story from the coach.

(JAVIER JAEN BENAVIDES FOR THE WASHINGTON POST) - Mother’s frightening episode trying to find out why her 10 year old couldn’t breathe.

A few years earlier, on the heels of an upper-respiratory infection, Ian had been given a diagnosis of asthma. For a few months, he occasionally used an inhaler, but then the attacks stopped and we eventually stopped carrying it with us. Now, we were afraid, we were back to the asthma diagnosis.

On Saturday morning, we took him to the nurse practitioner at the pediatrician’s office. She diagnosed a sports-induced bronchiospasm and sent Ian on his way with an inhaler (two puffs before every practice and game) along with antihistamines to counter any allergies he might be experiencing. She didn’t think it was anything serious — it seemed like a situation that millions of children and adults live with each day.

So I was unprepared for what happened Wednesday night. Ian had played soccer without incident. He stayed up late watching “The Miracle” on my laptop while I dozed on the couch. Around 10:30 p.m. (way past bedtime, but my husband was out of town and we were living loose), Ian woke me.

“I can’t breathe,” he croaked, clutching his throat. “Can’t breathe.”

I grabbed the inhaler and administered the prescribed two puffs. No relief. Two more puffs. Tears streamed down his cheeks as he whispered, “Can’t breathe.” The fact that he could whisper indicated that he could breathe — but his lips were turning blue. I called 911.

To the hospital

The EMTs were at the house within minutes. They administered oxygen and a nebulizer, packed him up on the gurney and rushed us to the hospital. There, a physician listened closely to his lungs but could hear no telltale wheezing, the signature sound of an asthma attack. Still, his other symptoms seemed to indicate that he had experienced one and that his panic had worsened the symptoms. The ER doctor prescribed a large dose of oral steroids and another nebulizer.

A second doctor later listened to Ian’s lungs and his comments that he was still having trouble breathing, that his throat felt tight and his chest hurt. A chest X-ray revealed clear lungs. The doctor noted that Ian seemed a little anxious and suggested that this was contributing to the breathing trouble, so she administered half a milligram of an anti-anxiety drug to calm him down. Around 4 a.m., they sent us home.

I kept Ian home from school on Thursday, and we saw our pediatrician. Midday, just after he’d had a drink of water, he began to complain again that he could not breathe. Two puffs on the inhaler gave no relief. Another call to 911.

By the time the medics arrived, Ian had hyperventilated; his legs and arms were numb. At the ER, another doctor examined him, concluding that he did not appear to have had an asthma attack. Perhaps, she suggested, it was an anxiety attack, and it was my responsibility to calm him down, not call 911. A soft tissue X-ray of his neck revealed a clear airway and no structural abnormalities.

Over the next few days we were in and out of that ER. Each time, Ian’s lungs were clear, and there was no evidence of asthma. The doctors were perplexed, and we were scared.

Meanwhile, I scheduled an appointment with a local asthma specialist. He ran Ian through a test that involved blowing out virtual candles through a tube; the machine measured his lung capacity as he inhaled and exhaled. In the course of collecting Ian’s medical history, the asthma specialist mentioned something about acid reflux, and I noted that, in fact, Ian had suffered from terrible acid reflux as an infant and had taken Prilosec drops for more than a year.

“You know, he doesn’t have asthma symptoms — no wheezing, no coughing. Clear lungs,” the specialist said. “I think he is having larynx spasms triggered by acid reflux, which would explain all of his symptoms.” He recommended discussing this with Ian’s pediatrician, whom we saw later that day. The pediatrician agreed with the asthma specialist and suggested that we consider treating Ian for acid reflux, a treatment that would take some time to take effect.

And the very next morning, we were back at the ER, where I explained the history to yet another doctor. This one listened to Ian's throat — not his chest or lungs. And there it was, the wheezing.

‘This isn’t asthma!’

“This isn’t asthma!” he said. “This is called paradoxical vocal cord motion,” in which the brain sends confused signals to the vocal cords. Instead of opening when Ian inhaled, the vocal cords were slamming shut — hence his sensation of breathlessness and the tightness in his throat. The doctor immediately called an ear, nose and throat specialist, who agreed to see Ian that morning.

We waited three hours in the office, while Ian continued to experience breathing spasms.

Once the ENT saw us, it took him just a few moments to place the endoscope in Ian’s nose. The numbing drops he administered triggered a larynx spasm, captured on camera by the endoscope. Sure enough, when Ian inhaled, his vocal cords snapped shut and stayed that way. Paradoxical vocal cord motion — PVCM.

The ENT calmed him, reassuring him that he could breathe and that he’d be okay.

It is not clear, the ENT explained, just what causes this condition, although at times stress or worry can exacerbate it, as can exercise and environmental irritants. I asked if the fact that Ian plays the bass clarinet might have done anything to trigger his symptoms, and the doctor said that, indeed, while Ian could soon resume normal activities, bass clarinet playing will have to be put on hold.

The treatment plan, which we began the next day, includes working with a speech therapist, who has taught Ian breathing techniques to help him manage and cope with his symptoms. In our first meeting, she explained to him how important it would be to learn to breathe from his diaphragm, to get long, steady breaths of air flowing smoothly over his vocal cords. She also reminded him to think, whenever a spasm hits, that he will be okay. She told me that the condition is a bit mysterious but not uncommon. Indeed, some research indicates that people who don’t respond to treatment for apparent asthma should be evaluated for PVCM.

The odds are in Ian's favor. With the right kinds of support and attention, he seems to have been restored to his ordinary laughing and lighthearted self. When a spasm hits, he does deep-breathing exercises and imagines the reassuring voices of the ENT and the speech therapist.

Our 21 / 2-week experience reminds me just how compassionate and tenacious health-care professionals can be, how hard they work to alleviate patient suffering and how difficult the art of medicine can be, chasing unexpected solutions to patient problems.

Schuster is a Washington area freelance writer.

 
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