Differential Diagnosis for Severe Dyspnea

A recent call came in as severe difficulty breathing. Upon arrival the patient was tripoding, with rapid, shallow breaths and expiratory wheezes audible from 5 feet away. Rescue had placed the patient on O2, and her pulse ox was in the mid 80’s. When I listened to her chest and back, I heard diminished breath sounds in the lower lobes, and clear wheezes on expiration. We were 3 minutes to the hospital from where we stood, so I started albuterol, and got an EKG (normal sinus without ectopy) and IV enroute. The patient reported significant improvement in her dyspnea with the albuterol treatment, and her pulse ox was quickly into the high 90’s.

While the above fit a nice picture for me, there were some issues that have me pondering. First, the patient had no asthma hx, though most of her family has asthma. Second, at one point she was complaining of tingling in her extremities. Third, the albuterol, which was preceded by my telling her it would provide significant relief, worked VERY quickly. Fourth, the patient required no additional treatments in the ED, and her lung sounds were clear there. If it weren’t for the low pulse ox and the wheezes, I’d argue this patient was hyperventilating and/or having a panic attack. I’m left wondering what exactly I had on my hands and if I handled it properly.