Primary ciliary dyskinesia (PCD) is a rare disorder of motile cilia associated with situs abnormalities. At least 12% of patients with PCD have situs ambiguus (SA), including organ laterality defects falling outside normal arrangement (situs solitus [SS]) or mirror image inversion (situs inversus totalis [SIT]).

A 65-year-old man with a medical history of anxiety and depression came to the ED with concerns of coughing blood-tinged phlegm for the past 3 days. Four days before the presentation, the patient had a motor vehicle accident as a restrained driver with airbag deployment. The patient struck his chest against the steering wheel. He was evaluated at a level 1 trauma center and underwent a whole-body scan, including a CT scan of the chest, which showed no acute abnormalities. Apart from mild-to-moderate bruising and tenderness on the right side of his face, nose, and anterior chest, the patient was stable and was discharged the next day. After returning home, the patient started coughing blood-tinged phlegm, which became progressively bloodier for the next 3 days, achieving individual posttussive volumes of 1 T of frank blood. In the ED, the patient denied any similar symptoms in the past. He denied any recent or distant known history of malignancy, infections, or travel outside the United States. He lives by himself and previously worked various jobs. He endorsed active tobacco use and smoking 3 to 6 cigarettes per day for the past 20 years with 5 pack-year history. Patient reported consuming one to two alcohol drinks per month.

A 56-year-old man with a medical history of diabetes, no prior lung disease, and no tobacco exposure presented with exhaustion and a nonproductive cough 7 days after working in an old farmhouse in Vermont. His friend who worked with him exhibited similar symptoms. He was treated as an outpatient with doxycycline; however, his clinical condition deteriorated and necessitated hospitalization and subsequent intubation.

Respiratory failure is a common and potentially life-threatening complication of neuromuscular diseases. Prompt recognition and accurate diagnosis of new or worsening chronic neuromuscular disease have important clinical management and prognostic implications. In this article, we present an approach to the acute presentation of undifferentiated neuromuscular respiratory failure in the ICU and guidance for determination and respiratory management of the underlying disorder.