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Pulmonary hamartomas are abnormal growths of mature cell or tissue types, including cartilage, epithelium, fat or muscle. Although most cases are benign, asymptomatic and often incidentally discovered, these masses may provoke significant complications via predisposition to obstruction, ischaemia or infection. Pulmonary hamartomas located within the tracheal lumen are exceedingly rare clinical entities which produce symptoms of dyspnoea, cough, stridor, wheezing or angina. Significant clinical consequences include airway obstruction and cardiovascular collapse. Most cases of tracheal hamartoma are initially diagnosed as obstructive pulmonary disease. We present a structured case report of a tracheal hamartoma identified in a patient with recent coronary artery bypass grafting who was initially evaluated for persistent ischaemic pathology, resulting in delay of diagnosis. By review of limited literature of this disorder, we emphasise the need for clinicians to be aware of this indolent and rare entity., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

An early adolescent girl presented to the emergency department (ED) of her local hospital following a syncopal episode after a warm bath on a background of increasing breathlessness for 1-year duration. On examination, she was fully alert, no pain or injuries from her syncope, she was warm and well perfused, her respiratory rate at rest was normal and she showed no signs of respiratory distress, there were no signs of seizure activity such as incontinence or tongue biting, she had a raised Jugular Venous Pressure (JVP), a loud pansystolic murmur, there was no cyanosis and no oedema. She was referred for a chest radiograph due to her history of breathlessness and for an ECG based on the examination findings of a murmur. Her ECG showed marked right axis deviation with tall T waves in V1 and P waves in lead II. Therefore, she was referred for an outpatient echocardiogram which demonstrated severely dilated right ventricular (RV) with impaired RV function. She was diagnosed with primary pulmonary hypertension.Her history included red flag symptoms including worsening breathlessness and syncope. Syncopal episodes are common and mostly benign, that is, vasovagal, but attention to a detailed history including constitutional symptoms and examination is crucial to ensure appropriate investigations and management. While causes are commonly benign in paediatrics, it is important to ensure that there are no features of an underlying cause. This includes ruling out commonly seen paediatric presentations that could present as an unwitnessed syncopal episode and this should include seizures, anaemia, arrhythmias, hypotension, hypoglycaemia and pain. If other causes are not ruled out, it can lead to an incorrect diagnosis as found in this patient when she presented a further three times to ED while waiting for her tertiary appointment., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

A male patient in his 50s presented to the emergency department with a three-day history of shortness of breath, New York Heart Association class IV, and oxygen desaturation. His physical examination revealed a large volume radial pulse with bibasal crepitation in the lungs and a soft diastolic murmur in the aortic area on auscultation of his heart. He was managed on the line of decompensated heart failure. Transthoracic echocardiography showed a dissection flap in the ascending aorta with acute severe aortic regurgitation. A subsequent urgent CT angiography of the whole aorta confirmed a complex type A aortic dissection with an aneurysmal ascending aorta. An emergency type A aortic dissection repair (modified Bentall's procedure) was done. The patient made a good recovery, was discharged successfully 2 weeks after the procedure and was doing well on postoperative follow-up., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

A female of reproductive age presents to the emergency department with progressive dyspnoea due to pneumothorax. She has a history of lymphangioleiomyomatosis (LAM) diagnosed by lung biopsy 15 years ago following incidental finding of pneumothorax. Despite various procedural and medicinal treatments, she continued to have recurrent pneumothorax, with three hospital admissions over the preceding 3 months. LAM is a rare cystic lung disease affecting the lymphatic system, which most commonly affects women of childbearing age. It can be diagnosed via imaging or tissue biopsy (gold standard). Treatment can be difficult, and it often requires highly specialised care by pulmonologists and often confers significant limitations to patients' independence and quality of life. Family physicians are often part of multidisciplinary team to provide care to patients with rare chronic conditions., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

A man in his early 50s with previously treated pulmonary tuberculosis (TB) presented with a 3-month history of cough, expectoration and progressive breathlessness, accompanied by significant weight loss. Examination revealed tachycardia, tachypnoea, hypoxaemia and unilateral diminished breath sounds. Investigations showed anaemia, leucocytosis and a homogeneous opacity on the left side of the CXR. ECG and echocardiography suggested pulmonary thromboembolism (PTE). A CT pulmonary angiogram confirmed a chronic embolus and a severely fibrosed left lung. A comprehensive thrombophilia workup yielded normal results and the PTE was attributed to his history of TB. Sputum analysis confirmed reactivated TB, leading to the initiation of antitubercular therapy. The patient improved clinically with plans for a repeat CT pulmonary angiography to assess the need for pulmonary thromboendarterectomy after completing TB treatment. This case highlights the possible association of TB and PTE, its management and why it should be considered as a differential diagnosis in patients with a history of TB presenting with exacerbated breathlessness., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

The differential diagnosis of dysphagia and dyspnoea with cervicofacial oedema is wide and includes diseases with variable prognosis that may require an urgent approach. This article presents the case of a middle-aged man who came to the emergency room referring to the symptoms described, with a history of central venous access established approximately 4 years ago. The patient was diagnosed with superior vena cava syndrome and treated with anticoagulants and removal of the catheter. After a week of admission with anticoagulation, the patient clinically improved with a considerable decrease in thrombus and pharyngolaryngeal and subcutaneous mucosal oedema. In the differential diagnosis of dysphagia and dyspnoea, we must also consider systemic diseases, and more specifically, these symptoms such as those described, and think about this entity because of its severity., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Fibrotic hypersensitivity pneumonitis (HP) has a poor prognosis when no antigen is identified, which occurs in many cases. We present a case of HP due to foam exposure in bedding, an unrecognised cause of HP. A woman was referred for dyspnoea and cough. High-resolution chest computed tomography (HRCT) showed a three-density pattern with gas trapping. Pulmonary function tests (PFTs) revealed restriction and reduced diffusing capacity. Bronchoalveolar lavage showed lymphocytosis (43%) and lung cryobiopsy showed fibrosis, lymphocytic infiltration and multinucleated giant cells. She had foam in mattress and pillows but no other exposures. Her symptoms, PFTs, and imaging improved after avoiding foam in her bedding. After re-exposure to a foam pillow, her symptoms, PFTs, and HRCT worsened. Microbiological analysis of the foam pillow reported Penicillium spp , known to cause HP. Foam exposure is a novel cause of HP, and foam avoidance can prevent disease progression and death., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

This case report presents the diagnostic journey of a man in his mid-70s who experienced shortness of breath, cough, recurrent episodes of fever, weight loss, pruritic erythroderma, uveitis and macrocytic anaemia. The initial diagnosis of cryptogenic organising pneumonia was made based on antibiotic refractory infiltrates seen in the lung CT scan. The patient initially responded favourably to immunosuppression but experienced a recurrence of symptoms when the corticosteroid dose was tapered. Despite ongoing systemic inflammation and refractory symptoms, it took nearly a year to establish the diagnosis of VEXAS (vacuoles, E1 enzyme, X-linked, autoinflammatory and somatic) syndrome. This case highlights the challenges in diagnosing and managing VEXAS syndrome due to its recent discovery and limited awareness in the medical community, as well as the need to consider this syndrome as a rare differential diagnosis of therapy-refractory pulmonary infiltrates., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

We describe an unusual case of bilateral pulmonary venous thrombosis in a pregnant woman in her mid 30s, who presented at 34 weeks of gestation with symptoms of sudden onset chest pain, shortness of breath and near syncope attacks. The patient was treated with enoxaparin and made an excellent clinical and hemodynamic recovery., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Intracardiac lymphomas are exceedingly rare accounting for only 1% of all primary cardiac tumours. Historically, due to their insidious development and non-specific clinical presentation, the diagnosis has been challenging with most cases being confirmed on post-mortem examination. Our case report details the experience of a previously fit and active woman in her 60s who presented with gradual onset exertional dyspnoea. Through a series of multimodal imaging tools (including echocardiogram, cardiac MRI, CT and positron emission tomography-CT) and biopsy, we confirmed the diagnosis of intracardiac diffuse large B-cell lymphoma. Our patient was managed with chemotherapy and went on to demonstrate excellent radiological response with near-complete resolution of the intracardiac mass. Subjectively, our patient reported significant improvement in exercise tolerance within weeks of commencing treatment., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

A woman in her 70s presented with anasarca and exertional dyspnoea. Investigation showed severe hypoalbuminaemia with no urinary or gastrointestinal protein losses. CT thorax reported lung consolidations, and transbronchial lung biopsy demonstrated organising pneumonia. Autoimmune myositis serology was positive for anti-Jo-1, anti-Ro-52, and anti-PM/Scl-100 antibodies. She was diagnosed with anti-synthetase syndrome with organising pneumonia. She was treated with oral prednisolone and oral mycophenolate mofetil with a good clinical response., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

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We report the case of a man in his late 30s who presented with a history of breathlessness and cough with haemoptysis. Complete blood counts revealed pancytopenia. High-resolution CT showed diffuse bilateral ground glass opacities. Sequential bronchoalveolar lavage confirmed alveolar haemorrhage. Bone marrow aspiration showed vacuoles in erythroid and myeloid precursor cells. The genome was sequenced, and the UBA1 gene revealed a c.121 A>G mutation (p.Met41Val), confirming vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic syndrome. The patient was managed with high-dose prednisolone pulse therapy. He improved with the complete resolution of the alveolar haemorrhage and an improvement in lung function and cytopenias., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

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Objective: Chest discomfort and shortness of breath (SOB) are key symptoms in patients with acute coronary syndrome (ACS). It is, however, unknown whether SOB is valuable for recognising ACS during telephone triage in the out-of-hours primary care (OHS-PC) setting., Methods: A cross-sectional study performed in the Netherlands. Telephone triage conversations were analysed of callers with chest discomfort who contacted the OHS-PC between 2014 and 2017, comparing patients with SOB with those who did not report SOB. We determine the relation between SOB and (1) High urgency allocation, (2) ACS and (3) ACS or other life-threatening diseases., Results: Of the 2195 callers with chest discomfort, 1096 (49.9%) reported SOB (43.7% men, 56.3% women). In total, 15.3% men (13.2% in those with SOB) and 8.4% women (9.2% in those with SOB) appeared to have ACS. SOB compared with no SOB was associated with high urgency allocation (75.9% vs 60.8%, OR: 2.03; 95% CI 1.69 to 2.44, multivariable OR (mOR): 2.03; 95% CI 1.69 to 2.44), but not with ACS (10.9% vs 12.0%; OR: 0.90; 95% CI 0.69 to 1.17, mOR: 0.91; 95% CI 0.70 to 1.19) or 'ACS or other life-threatening diseases' (15.0% vs 14.1%; OR: 1.07; 95% CI 0.85 to 1.36, mOR: 1.09; 95% CI 0.86 to 1.38). For women the relation with ACS was 9.2% vs 7.5%, OR: 1.25; 95% CI 0.83 to 1.88, and for men 13.2% vs 17.4%, OR: 0.72; 95% CI 0.51 to 1.02. For 'ACS or other life-threatening diseases', this was 13.0% vs 8.5%, OR: 1.60; 95% CI 1.10 to 2.32 for women, and 7.5% vs 20.8%, OR: 0.81; 95% CI 0.59 to 1.12 for men., Conclusions: Men and women with chest discomfort and SOB who contact the OHS-PC more often receive high urgency than those without SOB. This seems to be adequate in women, but not in men when considering the risk of ACS or other life-threatening diseases., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: Characterise inhalational exposures during deployment to Afghanistan and Southwest Asia and associations with postdeployment respiratory symptoms., Methods: Participants (n=1960) in this cross-sectional study of US Veterans (Veterans Affairs Cooperative Study 'Service and Health Among Deployed Veterans') completed an interviewer-administered questionnaire regarding 32 deployment exposures, grouped a priori into six categories: burn pit smoke; other combustion sources; engine exhaust; mechanical and desert dusts; toxicants; and military job-related vapours gas, dusts or fumes (VGDF). Responses were scored ordinally (0, 1, 2) according to exposure frequency. Factor analysis supported item reduction and category consolidation yielding 28 exposure items in 5 categories. Generalised linear models with a logit link tested associations with symptoms (by respiratory health questionnaire) adjusting for other covariates. OR were scaled per 20-point score increment (normalised maximum=100)., Results: The cohort mean age was 40.7 years with a median deployment duration of 11.7 months. Heavy exposures to multiple inhalational exposures were commonly reported, including burn pit smoke (72.7%) and VGDF (72.0%). The prevalence of dyspnoea, chronic bronchitis and wheeze in the past 12 months was 7.3%, 8.2% and 15.6%, respectively. Burn pit smoke exposure was associated with dyspnoea (OR 1.22; 95% CI 1.06 to 1.47) and chronic bronchitis (OR 1.22; 95% CI 1.13 to 1.44). Exposure to VGDF was associated with dyspnoea (OR 1.29; 95% CI 1.14 to 1.58) and wheeze (OR 1.18; 95% CI 1.02 to 1.35)., Conclusion: Exposures to burn pit smoke and military occupational VGDF during deployment were associated with an increased odds of chronic respiratory symptoms among US Veterans., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Competing Interests: Competing interests: MN has received a grant and payment from the Department of Advanced Clinical and Translational Immunology, Osaka University Graduate School of Medicine, which is collaborating with Chugai Pharmaceutical. AK has received a grant and payment for lectures from Chugai Pharmaceutical.

Competing Interests: Competing interests: None declared.

Congenital pulmonary airway malformation (CPAM) is the most common among a rare group of congenital anomalies of the lower respiratory tract. It has variable presentation depending on its subtype and the patient's age. It may lead to respiratory distress in neonates. It can be a particularly challenging diagnosis in children born asymptomatic but present with complications later in life such as haemoptysis, recurrent chest infections, breathlessness and pneumothorax. Prenatal ultrasound, chest X-ray, CT scan and MRI are helpful in making a radiological diagnosis.A woman in her late teens presented with shortness of breath and right pleuritic chest pain. CT's chest showed a number of bullae of varying sizes on the right, including one huge bulla compressing all three lobes. She underwent lung volume reduction surgery via video-assisted thoracoscopy, and the histology specimen confirmed the diagnosis of CPAM type 1., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

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Tracheobronchomalacia (TBM) is a progressive weakening of the airways, leading to collapse and dyspnoea. TBM can be misdiagnosed when multiple chronic conditions accompany it. Tracheobronchoplasty (TBP) is indicated for severe symptomatic TBM, diagnosed by bronchoscopy and CT thorax. We report the case of a patient who underwent tracheal resection and reconstruction for continuing dyspnoea post argon therapy, TBP and a failure to tolerate extracorporeal membrane oxygenation-assisted Y-stent insertion. Relevant background history includes asthma, sleep apnoea, reflux, cardiomyopathy and a high body mass index. Bronchoscopy postreconstruction showed patent airways. Airway reconstruction was a viable management option for this patient's TBM. TBP is a treatment option for TBM. In this case, tracheal resection was required to sustain benefit. In addition, surveillance bronchoscopies will be carried out every year., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

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Background: Serial point-of-care ultrasound (PoCUS) can potentially improve acute patient care through treatment adjusted to the dynamic ultrasound findings. The objective was to investigate if treatment guided by monitoring patients with acute dyspnoea with serial cardiopulmonary PoCUS and usual care could reduce the severity of dyspnoea compared with usual care alone., Methods: This was a randomised, controlled, blinded-outcome trial conducted in three EDs in Denmark between 9 October 2019 and 26 May 2021. Patients aged ≥18 years admitted with a primary complaint of dyspnoea were allocated 1:1 with block randomisation to usual care, which included a single cardiopulmonary PoCUS within 1 hour of arrival (control group) or usual care (including a PoCUS within 1 hour of arrival) plus two additional PoCUS performed at 2 hours interval from the initial PoCUS (serial ultrasound group). The primary outcome was a reduction of dyspnoea measured on a verbal dyspnoea scale (VDS) from 0 to 10 recorded at inclusion and after 2, 4 and 5 hours., Results: There were 206 patients recruited, 102 in the serial ultrasound group and 104 in the control group, all of whom had complete follow-up. The mean difference in VDS between patients in the serial ultrasound and the control group was -1.09 (95% CI -1.51 to -0.66) and -1.66 (95% CI -2.09 to -1.23) after 4 and 5 hours, respectively. The effect was more pronounced in patients with a presumptive diagnosis of acute heart failure (AHF). A larger proportion of patients received diuretics in the serial ultrasound group., Conclusion: Therapy guided by serial cardiopulmonary PoCUS may, together with usual care, facilitate greater improvement in the severity of dyspnoea, especially in patients with AHF compared with usual care with a single PoCUS in the ED. Serial PoCUS should therefore be considered for routine use to aid the physician in stabilising the patient faster., Trial Registration Number: NCT04091334., Competing Interests: Competing interests: MDA received funding from the Department of Emergency Medicine, Slagelse Hospital, Naestved, Slagelse and Ringsted Hospitals’ Research Fund, Research Fund of Region Zealand and Region of Southern Denmark, and the University of Southern Denmark. ATL received royalties from Munksgaard and Gyldendal as an author of book chapters. PHG was in the advisory board of Boeringer Ingelheim and AstraZeneca. CF received a fee from AstraZeneca for a presentation on lung ultrasound at a pulmonologist expert meeting. IRS received grants from AstraZeneca, Novartis and personal fees from Teva and AstraZeneca for presentations. CBL received royalties from Munksgaard as an author of book chapters and fees from AstraZeneca for lectures at courses, educational events and symposia held by AstraZeneca. SWG, HØP and SP declare no competing interests., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Idiopathic hypereosinophilic syndrome is characterised by the overproduction of eosinophils with tissue infiltration, leading to multiorgan dysfunction. Its heterogenous presentation makes the diagnosis challenging and easy to miss. A woman in her 70s was admitted with chest pain and shortness of breath. Diagnostic testing showed elevated cardiac enzymes, an ejection fraction of 45% and pericardial effusion. Pericardiocentesis helped her symptoms significantly. Cardiac catheterisation revealed patent coronary arteries. She was diagnosed with myopericarditis and discharged on non-steroidal anti-inflammatory drugs. She returned the following week with worsening chest pain, dyspnoea and diarrhoea. Chest imaging showed bilateral infiltrates. Diagnostic testing showed eosinophilic predominance in peripheral blood (59%), pericardial fluid (37%) and bronchoalveolar lavage (31%). After a negative infectious workup, she was started on glucocorticoids and responded favourably. She was discharged on steroids. Mepolizumab was initiated outpatient, and steroids were discontinued. Mepolizumab was discontinued after 2 years while monitoring her symptoms and eosinophil counts., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: For the treatment of breathlessness in heart failure (HF), most textbooks advocate the use of opioids. Yet, meta-analyses are lacking., Methods: A systematic review was performed for randomised controlled trials (RCTs) assessing effects of opioids on breathlessness (primary outcome) in patients with HF. Key secondary outcomes were quality of life (QoL), mortality and adverse effects. Cochrane Central Register of Controlled Trials, MEDLINE and Embase were searched in July 2021. Risk of bias (RoB) and certainty of evidence were assessed by the Cochrane RoB 2 Tool and Grading of Recommendations Assessment, Development and Evaluation criteria, respectively. The random-effects model was used as primary analysis in all meta-analyses., Results: After removal of duplicates, 1180 records were screened. We identified eight RCTs with 271 randomised patients. Seven RCTs could be included in the meta-analysis for the primary endpoint breathlessness with a standardised mean difference of 0.03 (95% CI -0.21 to 0.28). No study found statistically significant differences between the intervention and placebo. Several key secondary outcomes favoured placebo: risk ratio of 3.13 (95% CI 0.70 to 14.07) for nausea, 4.29 (95% CI 1.15 to 16.01) for vomiting, 4.77 (95% CI 1.98 to 11.53) for constipation and 4.42 (95% CI 0.79 to 24.87) for study withdrawal. All meta-analyses revealed low heterogeneity (I 2 in all these meta-analyses was <8%)., Conclusion: Opioids for treating breathlessness in HF are questionable and may only be the very last option if other options have failed or in case of an emergency., Prospero Registration Number: CRD42021252201., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

A man in his 60s with biopsy-proven pulmonary sarcoidosis, not on treatment, presented with 6 weeks of dyspnea to the emergency department. ECG showed first-degree atrioventricular block and CT thorax demonstrated progressive pulmonary sarcoidosis with new multifocal consolidation. Antibiotics were initiated.A brain natriuretic peptide was elevated at 2024 ng/L and echocardiogram showed global left ventricular systolic dysfunction. Coronary angiogram revealed normal coronary arteries, and cardiac positron emission tomography and MRI demonstrated patterns compatible with cardiac sarcoidosis. The patient significantly improved with diuresis; he was started on prednisone, methotrexate and standard heart failure therapies.We outline the difficulties of attributing cardiac causes of dyspnoea in a patient with known pulmonary sarcoidosis given the rarity of cardiac involvement. We review proposed diagnostic criteria for cardiac sarcoidosis using enhanced imaging techniques without requiring invasive myocardial biopsy. This case discussion also highlights nuances in managing cardiac sarcoidosis based on the best available evidence and expert consensus., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

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Cardiac amyloidosis (CA) is challenging to diagnose due to its non-specific clinical manifestations early in the disease process. We report the case of a patient who presented with dyspnoea, abdominal distension and leg swelling. Medical history was notable for hypertension, recurrent vulvar squamous cell carcinoma and polysubstance abuse. Over 1 year before the official diagnosis of CA, the patient had multiple hospital readmissions for dyspnoea. Our case illustrates the importance of having a high index of clinical suspicion for an early diagnosis of CA. Furthermore, it highlights the need to re-evaluate a presumed diagnosis when a patient's symptoms recur or do not respond to appropriate treatment and to consider the influence of social factors on diagnostic processes., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

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Primary adenoid cystic carcinoma (ACC) of the trachea is a rare entity, with a 5-year survival between 50% and 80% for resectable cases and 30% in case of unresectable disease. We report a case of a primary ACC on a woman in her 70s that presented with a drawn-out history of dyspnoea. She was diagnosed with an unresectable obstructive tumour of the trachea, which required the placement of a Y-shaped stent. The patient underwent concomitant chemoradiotherapy, with partial response, and is still in follow-up, without evidence of disease progression., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

The emerging entity, long COVID -19 is characterised by long-lasting dyspnoea, fatigue, cognitive dysfunction and other symptoms. Cardiac involvement manifested as conduction abnormalities, left ventricle mechanical dyssynchrony, dyspnoea, palpitation and postural orthostatic tachycardia syndrome (POTS) are common in long COVID-19. The direct viral damage to the myocardium or immune-mediated inflammation are postulated mechanisms. A woman in her forties presented with a 2-month history of chest pain, functional dyspnoea, palpitation and an episode of syncope after having been home-isolated for mild COVID infection. During clinical workup, a clustering of ECG and echocardiographic abnormalities including left bundle branch block, septal flash, and presystolic wave on spectral Doppler echocardiography, and POTS were detected. The echocardiographic findings together with POTS and persistent dyspnoea indicated the presence of a long COVID-19 state. The prevalence and clinical significance of these finding, as well as the impact on long-term prognosis, should be investigated in future studies., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

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We describe a 56-year-old female patient hospitalised with COVID-19 in April 2020 who had persistent respiratory symptoms after radiographic and microbiologic recovery. X-ray of the chest demonstrated an elevated right hemidiaphragm while fluoroscopy confirmed unilateral diaphragmatic paralysis. Symptoms resolved gradually, concurrent with restoration of right hemidiaphragm function. Thus, we describe a rare cause of postacute sequelae of COVID-19 dyspnoea., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Platypnea-orthodexia syndrome (POS) is a rare but well-characterised condition where hypoxaemia and breathlessness occur while upright but resolve once recumbent. Early recognition can result in excellent outcomes for patients and can prevent unnecessary investigations for patients, especially if they present repeatedly to hospital after missed diagnosis. We present a case of a 75-year-old woman with a chronic history of breathlessness who was picked up after observations at a routine outpatient clinic. Early recognition of the POS allowed for appropriate investigations to take place identifying a patent foramen ovale (PFO). She was referred to the tertiary centre for closure of her PFO with complete resolution of her symptoms., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

A 62-year-old man presents with breathlessness 6 months following right pneumonectomy for lung adenocarcinoma. Previous investigations had not yielded a diagnosis and his symptoms were progressing. The patient described worsened symptoms when stood up (platypnoea), with profound hypoxia until laid supine (orthodeoxia). Platypnoea-orthodeoxia syndrome due to a right-to-left interatrial shunt was diagnosed on contrast-enhanced transoesophageal echocardiography with the patient undergoing successful percutaneous patent foramen ovale closure. Patent foramen ovale is often asymptomatic with a population prevalence of around 20%-30%. Anatomical shifts postpneumonectomy can open, or worsen a previously closed interatrial communication leading to right-to-left shunting of blood. Platypnoea-orthodeoxia is under-recognised, impairing quality of life and patient outcome. Investigations can be falsely reassuring, or poorly sensitive for the causative pathology. Percutaneous closure is safe with high success rates and this case highlights the need for a high index of suspicion for shunts, particularly in postpneumonectomy patients., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

A defect in one part of the immune system may affect the whole system. As a result, there may be a myriad of immunological diseases, which are often masked with the one disease that has the most prominent symptoms. This case report presents a patient with long-lasting allergic rhinitis who recently developed dyspnoea in exertion with suspected asthma development. After extensive diagnostic processing, asthma was dismissed, and diagnosis of selective IgA deficiency and coeliac disease with consequential iron deficiency anaemia was established. The patient was treated with parenteral iron and a gluten-free diet, which corrected her anaemia and led to the disappearance of dyspnoea. This paper aims to show the interplay between different immunological disorders and the possible causal connection between them., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Intracardiac platypnea-orthodeoxia syndrome (POS) is a pathological condition that leads to a reduction in oxygenation in the sitting position. The detection rate of patent foramen ovale that causes POS increases with Valsalva manoeuvre and cough. We report the case of a 92-year-old woman with POS, which could not be diagnosed in the sitting position. The Valsalva manoeuvre could not be performed because of dementia, and POS was diagnosed on the forward-bending position and abdominal compression. It was assumed that forward-bending increases the right atrial pressure by compressing the right ventricle along with elongation of the aorta, and abdominal compression increases the shunt volume by increasing the venous return. If POS is suspected in patients with dementia which cannot be diagnosed in the sitting position, forward-bending and abdominal compression, instead of the Valsalva manoeuvre, might be useful., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Pulmonary rehabilitation is a cornerstone of management for patients after lung transplantation (LT), but the benefits of inspiratory muscle training (IMT) after LT in children are unclear. Therefore, we examined whether IMT can improve respiratory function and dyspnoea in a paediatric patient after LT.The patient was a 13-year-old boy who underwent double LT. However, mild physical activity such as walking triggered dyspnoea for the patient. The patient underwent IMT with the intensity of approximately 30% of his maximal inspiratory pressure (MIP) for 2 months.The patient's MIP was increased by approximately 60% after 2 months, and his forced vital capacity as a percent of the predicted normal value increased from 74.6% to 83.4%, with improvement of dyspnoea.IMT may help improve dyspnoea after LT in children with respiratory muscle weakness and a decline in respiratory function., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

A short cut review was carried out to establish the diagnostic characteristics of alveolar dead space fraction (AVDSf) in the diagnosis of pulmonary embolism (PE). This is calculated from the arterial and end-tidal CO 2 Three papers were selected to answer the clinical question. The author, study type, relevant outcomes, results and weaknesses are tabulated. It is concluded that there is good evidence to support the use of AVDSf within a clinical prediction model to exclude a PE in patients when there is a low pretest probability. However, the specificity is not sufficient to support it as a 'rule in' test., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

A 76-year-old Korean woman presented with intermittent episodes of exertional hypoxia at the rehabilitation facility after a recent admission for ischaemic stroke. Clinical and diagnostic investigation confirmed the presence of platypnea-orthodeoxia syndrome (POS). Transoesophageal echocardiogram revealed a patent foramen ovale and hyperdynamic interatrial septum with right-to-left intracardiac shunt. Further diagnostic workup did not reveal right atrial hypertension, cirrhosis, pulmonary hypertension or any other extracardiac causes of right-to-left shunt. Positional preferential blood flow from inferior vena cava to the left atrium due to counterclockwise displacement of interatrial septum with age and posture was postulated to explain the atrial right-to-left shunt and the resultant POS. Closure was performed using a cribriform amplatzer occluder which improved her symptoms., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Neurological complications are well described in SARS-CoV-2, but for the first time we report a case of unilateral diaphragm paralysis occurring early in mechanical ventilation for respiratory failure due to such an infection. The patient subsequently required tracheostomy and ventilator support for 37 days, and had increased breathlessness and an elevated diaphragm at clinic review 9 months later. Dynamic chest radiography demonstrated persistent diaphragm paralysis with an accompanying postural change in lung volumes, and he subsequently underwent surgical plication. This case demonstrates that although persistent dyspnoea is a common feature following SARS-CoV-2 infection and is usually due to deconditioning or persistent parenchymal involvement, it can be due to other causes and needs to be investigated appropriately., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Platypnoea-orthodeoxia syndrome (POS) is a rare condition characterised by the association of dyspnoea and arterial oxygen desaturation induced by standing and relieved by recumbency. The precise mechanism remains poorly understood, but it appears to involve both anatomical and functional components producing a significant right-to-left shunting under certain postural conditions. This syndrome is associated with either intracardiac or extracardiac aetiologies, and the diagnosis depends on high clinical suspicion. Intracardiac shunt is the most common cause of POS and can be identified through echocardiography with bubble study. We report the case of a patient with POS secondary to a paradoxical shunt through the patent foramen oval, whose definitive diagnosis was only possible with contrasted transthoracic echocardiography in the sitting and standing positions., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Competing Interests: Competing interests: None declared.

Platypnoea-orthodeoxia syndrome (POS) is a rare entity characterised by respiratory distress and/or hypoxia developing in the sitting/upright posture, which is relieved in the supine posture. It is caused by cardiac, pulmonary and non-cardiopulmonary diseases. COVID-19 can have varying respiratory manifestations including acute respiratory distress syndrome (ARDS) and sequelae-like pulmonary fibrosis. POS has been rarely reported in patients with COVID-19. Here we report a case of POS in a patient recovering from severe COVID-19 ARDS. As he was gradually mobilised after his improvement, he had worsening dyspnoea in the sitting position with significant relief on assuming a supine posture. He was diagnosed with POS after ruling out other causes of POS. He was treated with oxygen support in upright posture and chest physiotherapy was continued, to which he showed improvement. POS is a rare manifestation of COVID-19 which needs awareness as it can be diagnosed easily and can respond to continued supportive care., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2021. No commercial re-use. See rights and permissions. Published by BMJ.)