Review Question - QID 104198

This patient is likely suffering from asthma exacerbated by recent NSAID use. Pulsus paradoxus is a finding that can be seen in severe asthma and COPD, presenting as a decrease in systolic blood pressure of greater than 10 mmHg with inspiration.

Pulsus paradoxus may also be seen in many other conditions, including COPD, croup, and cardiac tamponade. In the absence of disease, systolic blood pressure decreases less than 10 mmHg with inspiration; this is also accompanied by an increase in heart rate. In pulsus paradoxus, the magnitude of the decrease is greater than 10 mmHg; this may result in the 'paradoxical finding' of absent radial pulse on palpation with normal auscultation of the cardiac rhythm. Aspirin Exacerbated Respiratory Disease (AERD/Samter's Triad) consists of asthma, recurrent sinusitis with nasal polyps, and aspirin or NSAID sensitivity.

Zoorob et al. review the work-up and management of acute dyspnea. Causes most commonly include respiratory and cardiac disorders, but additional etiologies may include airway obstruction, metabolic acidosis, psychogenic disorder, or neuromuscular conditions. The first step in management is determining if the patient is stable or unstable and the corresponding need for supplemental oxygen and/or intubation with mechanical ventilation.

Hamzaoui et al. discuss the mechanism of pulsus paradoxus in asthma. Both the decrease of LV stroke volume and the decrease in intrathoracic pressure that accompany inspiration contribute to the occurrence of pulsus paradoxus. Monitoring pulsus paradoxus can be used to assess both the severity and response to therapy of acute asthma.

Incorrect Answers:
Answer 1: Pulsus paradoxus is not commonly seen in pulmonary hypertension.
Answer 2: Pulsus paradoxus is not commonly seen in interstitial fibrosis.
Answer 4: Although pulsus paradoxus may manifest with a pulmonary embolism, this patient's history and presentation is more consistent with a diagnosis of asthma.
Answer 5: Although pulsus paradoxus may manifest in the setting of a pericardial effusion or cardiac tamponade, this patient's history and presentation is more consistent with a diagnosis of asthma.