We report a case of an 85-year-old female, previously demented and dependent on others, who presented to the emergency department with sudden dyspnea following a coughing paroxysm. She was polypneic and with a diminished vesicular murmur at pulmonary auscultation but with audible bowel sounds in the right hemithorax. Arterial blood gases showed hypoxemic respiratory failure but the additional blood work was unremarkable. A thoracic radiograph suggested the presence of small bowel on the thoracic cavity. A thoracic computed tomography confirmed the diagnosis of an anterior right giant paracardiac transdiaphragmatic hernia of small bowel through the foramen of Morgagni with secondary passive pulmonary atelectasis. A posterior left transhiatal gastric hernia was also found. She was treated conservatively with nasogastric intubation and discharged home two days later, asymptomatic and without respiratory failure. Spontaneous diaphragmatic hernias are extremely rare, non-traumatic surgical emergencies, almost invariably requiring surgical correction. This case shows that a conservative approach is an alternative in selected patients.
Spontaneous diaphragmatic hernias (SDHs) are extremely rare, non-traumatic surgical emergencies (<1% of all diaphragmatic hernias). There are only around 30 reports of this entity in the literature [1-3]. An SDH originates from a lesion to the diaphragm induced by a sudden increase in intra-abdominal pressure, which leads to the extension of intra-abdominal contents into the thoracic cavity through the resulting diaphragmatic defect. The more frequently reported causes of the rise in intra-abdominal pressure leading to SDH are physical exercise, labor and delivery, coughing, vomiting, and defecation .
An 85-year-old female, dependent on others because of advanced dementia, and with a past medical history of hypothyroidism and peptic ulcer disease, presented to the emergency department (ED) with complaints of dyspnea, productive cough, and fever with 48 hours of evolution.
After four days, she returned to the ED with a sudden worsening of dyspnea following a coughing paroxysm. On a physical examination, she was hemodynamically stable but polypneic, with a diminished vesicular murmur at pulmonary auscultation and with audible bowel sounds in the right hemithorax. The rest of the physical examination was unremarkable.
Arterial blood gases showed hypoxemic respiratory failure. Complete blood count, renal function, serum ionogram, and C-reactive protein were within the normal range.
A thoracic radiograph (Figure 1) suggested the presence of the small bowel inside the thoracic cavity, which was confirmed by a thoracic computed tomography (Figure 2). The diagnosis of an anterior right giant para-cardiac transdiaphragmatic hernia of the small bowel through the foramen of Morgagni (Figures 2A-2B; arrow) with secondary passive pulmonary atelectasis and of a posterior left transhiatal gastric hernia (Figure 2B; arrowhead) was made.
The general surgery team evaluated the patient, and she was treated conservatively with nasogastric intubation. The evolution was excellent and, after two days, she was discharged home asymptomatic and without respiratory failure.
The diagnosis of SDH requires high clinical suspicion and depends on thoracic imaging. There are some red flags that should not
This patient’s presentation suggests that the coughing paroxysm was the plausible cause of the increase in intra-abdominal pressure leading to the anterior right giant
The most remarkable findings on physical examination are the absence of breath sounds and
Chest radiograph and computed tomography are the most accurate imaging techniques for an SDH diagnosis and are readily available. Yet,
The identification of an SDH should not
Although surgical repair is the mainstay of SDH treatment, nasogastric tube intubation and decompression can relieve symptoms. This case shows that a conservative approach can be an acceptable option for patients with a prohibitive surgical risk as exemplified by this case [2,6].
SDHs are rare causes of respiratory failure but should be considered in the appropriate context. The prompt identification of an SHD is essential to prevent life-threatening complications. Surgical treatment is almost always the indicated therapy, but in selected cases, a conservative approach with nasogastric tube intubation and decompression may suffice.
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Sudden Respiratory Failure after a Coughing Paroxysm
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Cite this article as:
Alexandre A, Pinto S (November 23, 2019) Sudden Respiratory Failure after a Coughing Paroxysm. Cureus 11(11): e6221. doi:10.7759/cureus.6221
Received by Cureus: November 18, 2019
Peer review began: November 20, 2019
Peer review concluded: November 21, 2019
Published: November 23, 2019
© Copyright 2019
Alexandre et al. This is an open access article distributed under the terms of the Creative Commons Attribution License CC-BY 3.0., which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.