Aim. Differential diagnosis of vocal cord dysfunction (VCD) and asthma.Methods. 105 patients with partially controlled asthma were examined. We used specific examinations for VCD: psychological scales , questionnaires for monitoring symptoms of VCD, transnasal fiberoptic laryngoscopy, conventional and electronic lung auscultation with the analysis of the amplitude-frequency characteristics (AFC) of wheezing in the chest and in the region of the larynx on the left and right. Spirometry was performed using Vitalograph ALPHA spirometer (England). The patients were divided into three groups: group 1 included patients with asthma; group 2 included patients with asthma and VCD (asthma-plus syndrome); group 3 included patients with VCD.Results. Conventional auscultation revealed wheezing over the lungs with a decrease in its intensity on the neck surface in group 1. In groups 2 and 3, the maximal wheezing was observed on the anterior surface of the neck and less intense wheezing was heard over the lungs. Electronic auscultation found mid-tonal wheezing over the lungs and over the larynx in group 1; high-pitched wheezing over the larynx and mid-tonal wheezing over the lungs in groups 2 and 3. Score of dyspnea according to the Borg scale was highest in the asthma-plus group – 4,8 (5,2 – 6,5) points, and lowest in the 1st group – 4,2 (3,7 – 4,9) points. The sensation of wheezing is maximal in VCD – 7,1 (6,5 – 7,9) points. The scores of symptoms of VCD were strongly correlated with the intensity of wheezing, dyspnea, and AFC of wheezing. Spirometry was close to normal in the group of patients with VCD; obstructive disorders were noted in groups 1 and 2. Transnasal laryngoscopy demonstrated paradoxical movement of the vocal cords during inspiration in groups 2 and 3. The triggers of episodes of VCD in the subjects were numerous; vocal loads predominated. Specific treatment of VCD in groups 2 and 3 improved the respiratory performance significantly.Conclusion. The primary diagnosis of asthma cannot be made without an examination for VCD. Psychological questionnaires and VCD questionnaires should be used. It is important to use electronic auscultation over the larynx for diagnosis. Correction of treatment in accordance with VCD in patients with asthma can significantly reduce the doses of inhaled and oral corticosteroids.

Diaphragm dysfunction is a rare cause of respiratory distress with a variety of clinical manifestations that complicate diagnosis and treatment. The given clinical case demonstrates the possibility of detecting bilateral diaphragm paralysis using available general clinical and instrumental diagnostic methods. Among the physical data, high standing of the lower borders of the lungs with limited mobility and paradoxical movement of the diaphragm during the Mueller test have a high diagnostic value. Chest X-ray demonstrates the high standing of both domes of the diaphragm and subsegmental atelectasis in the basal parts of the lungs. Severe hypoxemia developed: oxygen saturation in clino- and orthostasis was 72 and 96%, respectively. The tests of pulmonary function showed significant restrictive impairments, a decrease in the vital capacity of the lungs was also determined. Ultrasound examination of the diaphragm revealed hyperechogenicity, lack of inspiratory thickening, and respiratory mobility of the domes of the diaphragm. Electromyography confirmed gross right and left phrenic nerve axonopathy. An idiopathic variant of diaphragm dysfunction can be assumed based on the patient stabilization during CPAP therapy, physiotherapy exercises, chest massage, followed by the disappearance of signs of bilateral diaphragm paralysis. Conclusion. The presented case demonstrates the difficulties of diagnosing bilateral diaphragm paralysis. The final diagnosis was made through the use of specific research methods recommended for suspected diaphragm dysfunction. The prognosis of the idiopathic variant of bilateral diaphragm paralysis, as in this case, is favorable. Spontaneous remission was observed.

Федеральное государственное бюджетное образовательное учреждение высшего образования «Рязанский государственный медицинский университет имени академика И.П.Павлова» Министерства здравоохранения Российской Федерации: 390026, Россия, Рязань, ул. Высоковольтная, 9 РезюмеЦелью исследования явилось изучение «языка» свистящих хрипов у пациентов с бронхиальной астмой (БА), взаимосвязь вербальных и амплитудно-частотных характеристик (АЧХ) хрипов с выраженностью бронхиальной обструкции и одышки. Материалы и методы. Обследованы пациенты (n = 72) с частично контролируемой БА. Больные описывали свистящее дыхание методом сравнения, оценивалась степень интенсивности звуковых характеристик хрипов и одышки по шкале Борга CR-10. Спирометрия с бронходилатационным тестом и одновременной записью легочных звуков при помощи электронного стетоскопа Littmann 3200 осуществлялась по правилам Американского торакального (American Thoracic Society -ATS) и Европейского респираторного (European Respiratory Society -ERS) обществ при помощи спирометра Vitalograph ALPHA (Великобритания). Результаты. По словесным характеристикам свистящих хрипов выделены 2 группы пациентов: у больных 1-й группы (n = 38) выслушивались хрипы высокотональных АЧХ хрипов (576 ± 33 Гц; интенсивность хрипов -6,5 ± 0,7 балла, степень выраженности одышки -4,8 ± 1,2 балла по шкале Борга); у пациентов 2-й группы (n = 34)хрипы средне-и низкотональных АЧХ хрипов (368 ± 40,2 Гц; интенсивность хрипов -3,8 ± 0,6 балла, степень выраженности одыш ки -3,7 ± 0,5 балла по шкале Борга). Получены разнообразные «языковые» характеристики свистящих хрипов. Выявлена прямая корреляционная зависимость между степенью обструктивных нарушений и субъективными ощущениями свистящего дыхания. У больных 1-й группы отмечена среднетяжелая и тяжелая степень обструктивных нарушений (объем форсированного выдоха за 1-ю секунду (ОФВ1) < 50 %), 2-й -легкая и средняя степень бронхиальной обструкции (50 < ОФВ1 < 80 %). В 1-й группе положительные результаты бронходилатационного теста фиксировались в 100 % случаев, во 2-й -в 37 %. У пациентов обеих групп отмечены сравнимые значения постбронходилатационных показателей АЧХ. Уменьшение интенсивности хрипов приводило к снижению выраженности одышки. Одышка не влияла на интенсивность субъективного восприятия хрипов. Заключение. Приведены словесные характеристики свистящего дыхания у пациентов с БА. Выявлена прямая сильная корреляционная связь восприятия хрипов с тяжестью бронхиальной обструкции и слабая обратная связь между интенсивностью восприятия хрипов и одышки до применения бронхолитического препарата, прямая умеренной силы корреляционная связь после бронходилатационного теста. Выраженность бронхиальной обструкции у пациентов с БА играет первостепенную роль в возникновении свистящих хрипов высокотональных АЧХ хрипов. У данных пациентов следует ожидать хороший медикаментозный ответ на ингаляционную терапию β2-агонистами. Ключевые слова: бронхиальная астма, свистящее дыхание, тональность хрипов, бронхиальная обструкция. Конфликт интересов. Конфликт интересов отсутс...

INTRODUCTION: The clinical presentation of aortic dissection (AD) is diverse. Along with the classic signs, there are many “masks” that create difficulties in differential diagnosis with diseases having similar symptoms. The difficulties in the diagnosis of AD include rare incidence of the pathology, atypism of the clinical symptoms which can be interpreted as ischemic heart disease, hypertensive crisis, pulmonary embolism, aortic heart disease, neurological pathology, acute surgical pathology, renal colic. In the reported cases, there were symptoms that should have put the doctor on the alert for AD. So, in the first case there were an acute onset with a sharp rise in blood pressure, unusual irradiation of anginal pain to the lumbar region, asymmetry of the pulse and blood pressure on the extremities, development of gangrene of the right leg. In the second case, the symptomatology of degenerative-dystrophic lesion of the spine prevailed, for which the appropriate treatment was given for ten days. Symptoms suggestive of AD: expansion of the abdominal aorta on magnetic resonance imaging of the spine that could suggest involvement of the thoracic aorta in the pathological process, the presence of anemia. The third case — symptomatically classic variant of AD: severe anginal status, pulse and blood pressure asymmetry. Such symptoms as nausea, vomiting, diarrhea, and most importantly, short duration of the observation, did not permit to make a correct diagnosis on admission. In all clinical observations, the analysis of complaints, history, physical and instrumental data ultimately permitted to diagnose AD. CONCLUSION: For the timely diagnosis of AD, it is important to use available methods of instrumental diagnostics, from routine to high-tech ones. Before routing a patient to the department of vascular surgery, it is necessary to provide medical care aimed at slowing down AD, stabilization of hemodynamics, and anesthesia.