Download Paradoxical Vocal Cord Dysfunction

Exercise Induced
Paradoxical Vocal Cord Dysfunction
(EI-PVCD)
Dale R. Gregore
M.S., CCC-SLP
Speech Language Pathologist
Clinical Rehabilitation Specialist - Voice
NORMAL Respiration 101
On inhalation, the vocal cords (folds)
ABduct allowing air to flow into the
trachea, bronchial tubes, lungs
On exhalation, the vocal folds may
close slightly, however should and do
remain ABducted
Normal Larynx
Vocal fold
ABDUCTION occurs
during respiration
Vocal fold ADDUCTION
Occurs during
swallowing, coughing, etc…
Strobe exam
Paradoxical Vocal Fold Movement
(PVFM)
The cord function is
reversed in that the
vocal folds ADDuct on
inspiration versus
ABduct
Leads to tightness or
spasm in the larynx
Inspiratory wheeze
evident
Definition of EI-VCD
“Inappropriate closure of the
vocal folds upon inspiration
resulting in stridor, dyspnea
and shortness of breath (SOB)
during strenuous activity”
– Matthers-Schmidt, 2001;
Sandage et al, 2004
Pseudonyms
Vocal Cord Dysfunction (VCD)
– Most common term
Munchausen’s Stridor
Emotional Laryngeal Wheezing
Pseudo-asthma
Fictitious Asthma
Episodic Laryngeal Dyskinesia
Patient description
of VCD episodes
– “in the top of my throat I see a
McDonalds straw surrounded by
darkness. The straw ends in a pool of
thick, sticky liquid that is encased by a
wall of rubber bands and outside of the
rubber bands is air that I can’t access”.
– “The top part of my throat is complete
darkness, at the back part of the
darkness there are cotton balls. These
are holding my fear”.
PVFM Visualized
Anterior portion of the
vocal folds are
ADDucted
Only a small area of
opening at the
Posterior aspect of
the vocal folds
Diamond shaped
‘CHINK’
May be evident on
both inhalation and
exhalation
Essential Features
Vocal fold adduct (close) during
respiration instead of abducting
(opening)
Laryngeal instability while patient is
asymptomatic
– Treole,K. et. al. 1999
Episodic respiratory distress
Symptoms
Stridor
Difficulty with inspiratory phase
Throat tightening > bronchial/ chest
Dysphonia during/following an attack
Abrupt onset and resolution
Little or NO response to medical
treatment (inhalers, bronchodilators)
Various Etiologies
Laryngo-Pharyngeal Reflux (LPR)
– Food/ liquid/ acid refluxes from the
stomach up the esophagus into the
pharynx (throat)
– Can spill over and into the larynx
– causes coughing, choking, breathing
and voice changes, swelling, irritation,
– Can be SILENT or sensed when it
happens
– WATERBRASH
LPR, continued
Clinical characteristics can be
observed using
videolaryngoscopic or
stroboscopic visualization of
the larynx
Ideally, diagnosed by a 24hour pH. Probe or EGD
LPR and Athletes
Well documented occurrence in weight
lifting
Can be aggravated by bending, pushing/
resisting (tackling, etc…), tight clothing,
even drinking water during a game/ meet/
match
Timing of meals before exercise is
important
Type of foods/ liquids should be monitored
Laryngopharyngeal Reflux:
Clinical Signs
Interarytenoid Edema
Lx Erythema
Vocal Fold Edema
Other potential causes of
Paradoxical Vocal Cord
Dysfunction
Allergic rhinitis or reaction
Conversion disorder
Anxiety
Respiratory-type or druginduced laryngeal dystonia
Etiologies (cont.)
Asthma-associated
laryngeal dysfunction
Brainstem dysfunction
CVA or injury
Chronic laryngeal
instability, sensitivity &
tension
Athlete Profile for EI-VCD
Onset between 11-18
Females have a greater incidence
(generally 3:1)
High achieving
“Type A” personalities
High personal standards and/or
social pressures
Intolerant to personal failure
Athlete Profile, cont…
Competitive
Self demanding
Perceives family pressure to achieve a
high level of success
“Choke” under pressure
May have recently graduated to higher
level of competition within their sport (JV
to Varsity: Rep to Travel team; college
level sports, etc)
EI-VCD versus Asthma
Recalcitrant to asthma medications
i.e. does not respond to
Individuals with “asthma” after long
term steroid use might not truly have
asthma, but VCD
Individuals with significant anxiety:
is it LIVE OR MEMOREX? Which
causes which?
Differential Diagnosis of EI-VCD
Includes a detailed Case History
Pulmonary function Studies
Lab Test
ENT/ Pulmonary/ Allergy evaluations
Flexible Laryngoscopy/ videostroboscopy
Speech-language pathology evaluation
Supplemental as needed:
Psychological
evaluation
Differential Diagnosis of VCD
Team Must Rule Out:
– Mass Obstruction
– Bilateral vocal fold paralysis
– Anaphylactic laryngeal edema
– Extrinsic airway compression
– Foreign body aspiration
– Infectious croup
– Laryngomalacia
– Exercise Induced Asthma/
Asthma
Diagnosis of EI-VCD
Often mistaken for asthma
Diagnosis of EI-PVCD is by
exclusion = when patient
fails to respond to asthma
or allergy medication, then
VCD is finally considered
EI-VCD and Asthma
Can exist independently
Can also coexist
– Patient may experience LPR which
causes Asthma flare-up and then
laryngospasm (VCD) from coughing
– May experience chest (asthma) and/or
laryngeal (VCD) tightness
EI-PVCD versus
Exercise Induced Asthma
Feature
Female Preponderance
Chest Tightness
Throat Tightness
Stridor
Usual onset of symptoms after beginning exercise (min)
Recovery period (min)
Refractory period
Late-phase response
Response to beta-agonist
PVCM
+
+/+
+
<5
5-10
-
EIA
>5-10
15-60
+
+
+
Typical Spirometry Findings for
PVCD
Asymptomatic
– Flow-volume loops are normal
Symptomatic:
– Blunted inspiratory curve
– Inspiratory curves highly varied
– Expiratory portion may be blunted
– Ratio of forced expiratory to inspiratory
flow at 50% VC can be greater than 1.0
Inspiratory cut-off, flattening of the
inspiratory limb (curve)
NORMAL
VCD
Case History Questions
– Do you have more trouble breathing in
than out?
– Do you experience throat tightness?
– Do you have a sensation of choking or
suffocation?
– Do you have hoarseness?
– Do you make a breathing-in noise
(stridor) when you are having
symptoms?
Questions (cont.)
– How soon after exercise starts do your
symptoms begin?
– How quickly do symptoms subside?
– Do symptoms recur to the same degree
when you resume exercise?
– Do inhaled bronchodilators prevent or
abort attacks?
– Do you experience numbness and/or
tingling in your hands or feet or around
your mouth with attacks
Questions (cont.)
– Do symptoms ever occur during sleep?
– Do you routinely experience nasal
symptoms (postnasal drip, nasal
congestion, runny nose, sneezing)?
– Do you experience reflux symptoms?
Videostroboscopic Examination
Instrumentation
– Flexible fiberoptic laryngeal endoscope
with stroboscopic capability
Observations
– Movement of arytenoids during respiration
at rest: Complete closure; Posterior
diamond
– Signs of laryngopharyngeal reflux disorder
(LPR)
– Degree of laryngeal instability
Laryngeal Supraglottic
Hyperfunction
arytenoid
compression
ventricular
compression
Limited airway for
phonation
VCD appearance on direct
examination
Laryngeal
Supraglottic
Hyperfunction
Abnormal
ventricular
compression
during speech
Laryngeal Supraglottic
Hyperfunction
Sphincteric
contraction of the
supraglottis during
speech production
PVCM Visualized
Posterior ‘chink’
Rounded arytenoids, but normal
abduction
Diagnostic Features PVFM
Asthma
Flow-volume loop
Inspiratory cut-off,
Reduced expiratory
perhaps some expiratory limb only
limb reduction *
Bronchial provocation
test
Negative
Laryngoscopic
observations
Inspiratory adduction
of anterior 2/3 of vocal
folds; posterior diamondshaped chink; perhaps
medialization of ventricular
folds; inspiratory adduction
may carry over to expiration
Positive
Vocal folds may
adduct during
exhalation
Diagnostic Features PVFM
Precipitators (triggers)
Asthma
Exercise, extreme
Exercise, extreme
temperatures, airway temperatures,
irritants, emotional
airway irritants,
stressors
emotional stressors,
allergens
Number of triggers
Usually one
Usually multiple
Breathing obstruction
location
Laryngeal area
Chest area
Timing of breathing
noises
Stridor on
inspiration
Wheezing on
exhalation
Pattern of dyspneic
event
Sudden onset and
relatively rapid
cessation
Nocturnal awakening
with symptoms
Rarely
Response to bronchodilators and/or systemic
corticosteroids
No response
More gradual onset
longer recovery
period
Almost always
Good response
Acute Management of EI-VCD
in the field
Approach to the
patient is important
It is generally agreed
that patients do not
consciously
manipulate or control
their upper airway
obstruction
Acute Management of EI-VCD
During an episode, they usually feel
helpless and terrified
Implying that it is “in their head” is
incorrect and counterproductive to
their recovery
Coach them through, help them out
Be positive
Acute Management of Attacks
– Offer reassurance and empathy
– Eliminate activity and people from
environment
– Prompt for EASY BREATHING
– Elicit controlled ‘Panting’
Relaxed jaw
Tongue on floor of mouth behind bottom
teeth
Acute Management in the Game
Visualize WIDE OPEN AIRWAY
6 lane highway with no roadblocks
Air goes in and circles around, goes
out
Shoulders relaxed
Standing w/ open chest, hands on
hips, or bent over/ hands on
knees….which position works best?
Quick Sniff Technique
– Sniff then Blow….talk the athlete through this
– Sniff in with focal emphasis at the tip of the
nose
Sniff = ABduction
– Then exhale with pursed lips on
“ssssss”
“shhhhhh”
“ffffffff”
“whhhhhhhh”
= Back pressure respiration
ACUTE treatment, cont…
– Breathing against pressure (hand on
abdomen)
Resistance and focus on pressure against /
in another body part
– Heliox
Administered by Paramedics or ER MDs
– Sedatives and psychotropic medications
Last resort
Calming effect
Eliminates tension/ constriction
Treatment: Speech Therapy
Patient counseling, education
Respiratory retraining
Focal and whole body relaxation
Phonatory retraining
Monitor reflux Sx or anxiety
Develop / outline a ‘Game Plan’ =
practice when asymptomatic;
implement at the onset of sx
Therapeutic goals and methods
Goal
– Ability to
overcome fear
and helplessness
– Reduced tension
in- extrinsic
laryngeal
muscles
– Diversion of
attention from
larynx
Method
– Mastery of
breathing
techniques
– Open throat
breathing;
resonant voice
technique
– Diaphragmatic
breathing and
active exhalation
Therapeutic goals and methods
Goal
– Reduced tension
in neck,
shoulders and
chest
– Ability to use
techniques to
reduce severity
and frequency of
attacks
Method
– Movement,
stretching,
progressive
relaxation
– Increase
awareness of
early warning
symptoms;
Rehearse action
plan
Speech Therapy
Patient Counseling & Education
– Description of laryngeal events
– Viewing of laryngoscopy tape
– Relate parallels to other stress induced
disorders: migraine, irritable colon,
muscle tension dysphonia, GEReflux
– Flexible endoscopic biofeedback
– Sensory biofeedback (sEMG)
Speech Therapy
Respiratory training
– Low “diaphragmatic” breathing versus
“high” clavicular thoracic
– Rhythmic respiratory cycles
– Use resistance exhale (draw attention
away from larynx and extend exhale)
– Prevention and coping strategies during
episodes = Action Plan
Back Pressure Breathing
Nasal Sniff = OPEN cords
Prolonged exhalation /w/, /f/, /sh/,
/s/
Shoulders relaxed
Throat open
Implement when laying, sitting,
standing, walking, jogging, running,
playing sports, etc
Relaxation Training
Goal
– Teach the patient to relax focal areas
then the entire body during an episode
of respiratory distress
Methods
– Use progressive relaxation with guided
imagery
– Explore the patient’s visual concept of
their disorder and alter
ST Duration: The CCHS Approach
2-8 sessions
Average 4 sessions
Followed by clinical observation
during sport/ game
Followup phone / email contact: tell
me how it is going?
Re-evaluation as necessary, if
symptoms reoccur (rarely)
CASE DISCUSSION
14 year old female
Sports: field hockey, soccer
Travel soccer U-17 team/ midfiled
Initial symptoms: ‘throat closes’ ~5
minutes in to game; hand on throat;
signals coach; pulled from game; 20
minute recovery: lying on sideline
Therapy Focus and Outcome
5 sessions
Breathing 101
Training from static to active movement/
running
Full coaching then observation of strategy
implemetation in therapy and during game
Outcome: (-) sx during mile run; cool
down routine implemented; 20-30 minute
game play/ no EI-VCD w/ ‘game plan’
Case Discussion #2
14 year old female
Sports: cross country; basketball
Initial Symptoms: ‘throat closed’
during CC trials; had to ‘drop out’
Secondary Symptoms: inspiratory
stridor when wearing mouth guard/
basketball; felt ‘faint’
Therapy Focus and Outcome
5 sessions
Goals: establish ‘low’ AD breathing/
eliminate shoulder elevation and CT
respiration pattern; train in back
pressure breathing w/ and w/out
mouthguard during activities of
progressive effort including walk;
jog; stairs, treadmill; suicide drills;
BB drills; sprints, etc
Outcome
Successful resolution of PVFM during
20 minute runs and when playing BB
Increased awareness of AD versus
CT respiration
Habituated alternate use of sniff/
pant – blow, etc.
Increased perceived ‘control’ over
breathing and performance
Spring Sport pending: soccer
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