Wheezing Secondary to Obstructing Endobronchial Tumor

With a 1-year history of episodic wheezing, a 62-year-old woman (a smoker for the past 30 years) was being treated for bronchial asthma, but bronchodilator therapy did not control her symptoms. She was hospitalized with worsening dyspnea and a 4.5-kg (10-lb) weight loss over the past 3 months. There was no hemoptysis.

The patient's vital signs were stable, but chest auscultation revealed wheezing that was more prominent on the left side. A roentgenogram showed hyperinflated left lung zones; CT confirmed this finding and suggested the presence of a lesion in the left main-stem bronchus, as seen above. Bronchoscopy revealed an endobronchial lesion (shown below) that obliterated the left main-stem bronchus, causing a ball-valve effect leading to hyperinflation of the left lung. The cytologic appearance of a brush biopsy specimen of the lesion was consistent with squamous cell carcinoma. The patient received chest radiotherapy.

Because this patient's presentation of wheezing led to the initial misdiagnosis of bronchial asthma, write Drs Navin Verma and Terence M. Brady of Flushing, NY, always consider other conditions that can cause wheezing-particularly if there is no response to bronchodilator therapy. Included in the differential diagnosis are endobronchial obstructing lesions, congestive heart failure, and pulmonary embolism. In lung carcinoma, wheezing usually occurs when there is a central endobronchial lesion; in rare cases, a ball-valve effect of the obstructing tumor may cause distal air trapping and distal hyperinflation of the lung. Bronchoscopic examination is definitive and provides anatomic and pathologic diagnosis.