Exaggeration of Asthma (Staticus Asthmaticus)

How they present when you are in their rooms.

A diagnosis sometimes observed in the clinical setting is an exaggeration of asthma (staticus wheezicus). These patients often have a diagnosis of asthma/ COPD, although often learn to play it to their advantage.

Clinical Presentation: You can observe them from the doorway, such as while they are sleeping, and they are fine. But as soon as you wake them up, they have a forced, expiratory, almost stridorous wheeze. It is often audible. They may appear fine as you enter their rooms, although as soon as you pull out your stethoscope they start forcibly exhaling. Heart rate may be elevated slightly. Oxygen saturation is usually within normal range. (This section was submitted to me by a reader here at the RT Cave, and published with permission. )

Differential diagnosis.  The RT Cave sponsored a committee of 20 respiratory therapists and five doctors. During a meeting on January 27, 2017, they came up with three mechanisms for establishing a diagnosis.  They are:

1. Doorway Observations. It's  beneficial to observe them while they are sleeping from the doorway. If they are sleeping comfortably you can rule out asthma and rule in staticus asthmaticus. 
2. Pursed Lip Trick. Have patient breathe through pursed lips. You cannot fake a wheeze through pursed lips. If you hear a wheeze while patient breathing through pursed lips you can diagnose asthma. If you do not hear a wheeze, then the diagnosis is staticus asthmaticus.  (Note: Those who have a long history of staticus wheezicus learn this trick and generally ignore requests for them to do it.) 
3. Denials. Similar to Munchausen syndrome, these patients will never admit what they are doing even when called on it by physicians and faced with evidence. Adamant denial, and claiming that they hate the doctor that called them on their bluff, is the most common sign indicative of staticus asthmaticus. 

How they present once they are admitted and alone. 

Treatment. Our committee concluded that they usually have an actual diagnosis of asthma, so QID Duonebs are usually indicated. They are usually given systemic corticosteroids just in case they might be telling the truth. They also insist on anxiolytics or pain relievers. They would benefit from psychological consults, although they usually refuse this. Even though their oxygen saturation is normal, they often insist upon supplemental oxygen, either the nasal cannula or oxygen masks. The best treatment is early diagnosis and calling them on their bluff. Just be open and honest with them. What makes this tricky is the fact that most healthcare providers have tons and tons of empathy. Plus, there is always the fear that they might be telling the truth. So, this often leads to overtreatment.

Etiology. Our committee decided that their fake bronchospasms are usually psychosomatically induced, meaning that it's all in their heads. The exact cause may be stress, such as annoying family members, work, or school. It may also be attention seeking induced in order to improve self-esteem. The theory here is that the attention and empathy received in the hospital setting boost self-esteem. Some may also be drug seeking, although this is never confirmed.

Discharge. Our committee decided that they usually do not want to be discharged. As soon as they learn you are thinking discharge, they go on a strong, self-induced coughing fit. They may be fine one minute, perhaps even involved in an interesting discussion. Then, out of the blue, they embark on a serious coughing fit, which sometimes results in true bronchospasm. An alternative to coughing is sudden onset chest pain.

Consequences. Our committee noted that they sometimes suffer from overtreatment, and what is referred to as the accelerated side effect-effect. This is where one medicine is used to treat fake symptoms, and this presents with side effects. A second medicine is given to treat the side effect of the first medicine, and this second medicine also has side effects. A third medicine is given to treat the side effect of the second medicine, and this medicine has side effects and so on and so on. This can often result in an endless cycle of long hospital stays and repeated re-admissions, making these patients very costly. This condition is extremely difficult to treat, making an early diagnosis of staticus asthmaticus extremely important.

Prognosis. With early diagnosis and proper treatment, the prognosis is good. However, diagnosis is usually missed until the patient becomes a repeat offender. Other than accelerated side effect-effect, a secondary complication results from the difficulty of empathetic healthcare providers to call these patients on their faux asthma. This often results in lengthy and expensive hospitals stays and the inability for these patients to gain the psychological consultation that they truly need. (Note: This prognosis was submitted by a Pulmonologist. He gave us permission to use his name. The RT Cave has decided to keep his name anonymous anyway for his own protection.)

Disclaimer. The above is a facetious characterization drawn by the readers of the RT Cave and on conclusions by our committee. Any resemblance to actual patients is merely coincidental. Mr. Frea is not responsible for the content of this post, as all he did here was compile together comments from our readers and our committee. 

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