Mysterious breathing difficulties solved through expert collaboration

June 2nd, 2020
Aunjane holding her had to her trachea where she was experiencing breathing difficulties.
Once the root of her breathing difficulties had been identified, Aunjane Ayers faced serious surgery. Her UCHealth team fortunately had uncommon experience with such cases. Photos by Cyrus McCrimmon for UCHealth.

Irma Ayers had gotten her daughter Aunjane into kickboxing. The child was on her own sometimes because Irma was a single mom working full-time, and being able to protect yourself is a good thing. Aunjane found that she liked the intensity of the sessions and learning what she called “cool stuff” to the point that she even got into mixed martial arts training. But soon, she found her workouts cut short by shortness of breath.

The culprit, more than one doctor concluded, was exercise-induced asthma. When Aunjane’s inhaler had no effect at all, anxiety became the prevailing theory. Aunjane neither felt particularly anxious nor seemed so to others. Her breathing difficulties led her to abandon combat sports, and over time less and less exertion led to labored breathing. This went on, and grew gradually worse, for years, to the point that walking to the bus stop had her gasping for air. Finally, she arrived at the Multidisciplinary Complex Airway Clinic, part of the Comprehensive Lung and Breathing Program at UCHealth University of Colorado Hospital on the Anschutz Medical Campus.

Breathing difficulties

Aunjane’s was a case that very good doctors had not cracked. This UCHealth clinic also had very good doctors – not to mention speech-language pathologists and experienced nurses and other staff. But even the elite surgeons who would lead Aunjane’s care admit that they wouldn’t have figured out and ultimately fixed the very real problem that ailed Aunjane if they and other specialists had not collaborated closely, thought creatively, and been determined not to leave her without an answer yet again.

Stairs as medical device

Aunjane’s first stop was with Dr. Matthew Clary, a University of Colorado School of Medicine ear, nose, and throat surgeon at UCHealth. Clary specializes in voice, airway, and swallowing disorders. He looked at her chart and recognized a patient who had been dealing with worsening symptoms for a solid decade, “bouncing around from one doc to another, into the ER and out of the ER, with nobody talking to each other.”

Aunjane Ayers, at a park, waited for a long time for what turned out to be a very tricky diagnosis for her breathing difficulties.
Aunjane Ayers waited for a long time for what turned out to be a very tricky diagnosis for her breathing difficulties. (Photos by Cyrus McCrimmon for UCHealth)

With a flexible laryngoscope – used to examine the vocal cords and adjacent windpipe – Clary saw nothing out of the ordinary. He wondered if the problem wasn’t something called paradoxical vocal fold movement (also called vocal cord dysfunction), in which the vocal cords close rather than open when one breathes. He sent Aunjane straight to Juliana Litts, a UCHealth speech language pathologist, to check on that. Aunjane took the Anschutz Outpatient Pavilion stairs on the way. She was having a hard time breathing by the time she got there.

Dr. Juliana Litts

But when Litts examined Aunjane, she concluded that the vocal cords weren’t the culprit. When she got back to Clary’s office a bit later, he realized that, if the stairs were triggering symptoms, he could employ them as an impromptu medical device. Together with a nurse, Aunjane jogged up and down a hospital stairwell a few times, which triggered symptoms that were clear as day when she walked back into the exam room. Clary performed another flexible laryngoscopy.

This time, there it was. Once the scope was back out, they checked out the video together.

“Whoa,” Clary said.

“See – I knew it!” Aunjane said.

The next step was with Dr. Robert Meguid, a CU School of Medicine and UCHealth cardiothoracic surgeon with whom Clary works closely. With Aunjane under anesthesia, Meguid checked her airway with a bronchoscope, which reaches past the larynx and into the lower windpipe and, if need be, the lungs.

women showing her muscles, glad to be back to working out after her breathing difficulties were fixed.
Her trachea now stable and her breathing difficulties over, Aunjane is back at work, back in the gym, and taking classes with the ultimate aim of becoming a doctor herself one day.

Without the stress imparted by the stairs, the trachea looked fine. Afterward, Meguid called Clary. “I don’t see anything I can correlate with her symptoms,” he told his colleague. They agreed that an awake bronchoscopy would be the next step. A few days later, Aunjane took to the stairs again, then Clary performed an awake bronchoscopy on Aunjane with local anesthesia in his clinic.

Clary met with Meguid shortly thereafter so they could check out the bronchoscope video together. A section of Aunjane’s trachea just below her voice box twisted and collapsed with each breath. The weak section was less than an inch long, and, unusually, on the side rather than the front or back of her windpipe. After so many years, Aunjane’s condition had been discovered..

Dr. Robert Meguid

Challenging surgery

There were a couple of ways to fix it. The first was to use a laser to scar the inside of the trachea, thereby firming it up and, ideally, preventing its collapse. Clary tried this minimally invasive procedure first; it didn’t take. Aunjane faced a big decision.

The way forward now would be a surgery involving the resection of the damaged part of the windpipe and anastomosis of the now-separated trachea. In other words, Meguid and Clary would cut out the problem section and sew the resulting open ends back together. They have done many of these surgeries together and are counted among the few U.S. surgeons with such experience. With complicated cases like Aunjane’s, they’ve found that they can get better outcomes when they work together.

It’s a challenging procedure, and there are risks, Clary says. The nerves that control the voice box can be damaged. With time, the point of repair can narrow into tracheal stenosis. The freshly sewn airway can come partially undone, possibly leading to, as Meguid put it, “life-threatening complications and tracheostomy.”

voice disorders specialist Dr. Matthew Clary
UCHealth laryngologist Dr. Matthew Clary removed a vocal cord cyst that seriously impaired Vidal’s ability to speak. Photo by UCHealth.

By now it was early 2019. Aunjane was 22 and had exhausted all other options. Her mom Irma worried about the risks but left it up to Aunjane. She decided to have the surgery.

Before the March procedure, Clary and Meguid met with Aunjane and Irma. The surgeons walked through what would happen, the possible complications, and the recovery process. They then asked if there were any questions.

Meguid and Clary performed the surgery together, and it went well. Its last step was simple and strange: Meguid temporarily sutured Aunjane’s chin to her chest – necessary to help ensure the trachea’s healing. At one point, while walking around the inpatient unit, Aunjane stopped at a vending machine. A medical student observed her chin-to-chest posture and asked, “Are you alright?”

“Yeah, I just want my Snickers,” Aunjane replied.

Her breathing was far better. Irma was relieved.

Aunjane’s chin was freed again after a week. It was three months before Aunjane was working again as an endoscopy technician at a local hospital. By November, she was back at the gym, though lifting weights rather than kickboxing – at least for now. “I feel good. I’m pretty sure I can probably get back into it again,” Aunjane said.

She’s busy between work and taking college classes with the ultimate aim of being a doctor herself. If she does so, one would expect her to embrace multidisciplinary collaboration. She’s a living case study of the benefits it can bring, and she’s grateful to the team at UCHealth that has her breathing deeply again.

“They’re awesome,” she said. “They’re the people that listened to me.”

 

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About the author

Since 2008, Todd Neff has written hundreds of stories for University of Colorado Hospital and UCHealth. He covered science and the environment for the Daily Camera in Boulder, Colorado, and has taught narrative nonfiction at the University of Colorado. He was a 2007-2008 Ted Scripps Fellowship recipient in Environmental Journalism at CU.

His latest book, "The Laser That’s Changing the World," tells the story of the inventors and innovators who saw, and ultimately realized, the potential of lidar to help solve problems ranging from smokestack-pollution detection, ice-sheet mapping, disaster recovery, and, ultimately, autonomous-vehicle guidance, among many other uses. His first book, "From Jars to the Stars," recounts how Ball Aerospace evolved from an Indiana jar company - and a group of students in a University of Colorado basement - to an organization that managed to blast a sizable crater in the comet 9P/Tempel 1. "Jars" won the Colorado Book Award for History in 2012.

Todd graduated with a business degree from the University of Michigan, where he played soccer, and with a master’s degree from the Fletcher School of Law and Diplomacy at Tufts University. Before becoming a journalist at the turn of the millennium, he was an IT and strategy consultant. He once spoke fluent Japanese and still speaks fluent German.

When not writing, he spends time with teenage daughters and wife Carol, plays soccer, and allows himself to be bullied by a puggle he outweighs by a factor of seven.