Title: Exercise Induced Paradoxical Vocal Cord Dysfunction (EI-PVCD)
1Exercise Induced Paradoxical Vocal Cord
Dysfunction (EI-PVCD)
- Dale R. Gregore
- M.S., CCC-SLP
- Speech Language Pathologist
- Clinical Rehabilitation Specialist - Voice
2NORMAL 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
3Normal Larynx
4Vocal fold ABDUCTION occurs during respiration
5Vocal fold ADDUCTION Occurs during swallowing,
coughing, etc
6Strobe exam
7Paradoxical 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
8Definition 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
9Pseudonyms
- Vocal Cord Dysfunction (VCD)
- Most common term
- Munchausens Stridor
- Emotional Laryngeal Wheezing
- Pseudo-asthma
- Fictitious Asthma
- Episodic Laryngeal Dyskinesia
10Patient 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 cant 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.
11PVFM 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
12Essential 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
13Symptoms
- Stridor
- Difficulty with inspiratory phase
- Throat tightening gt bronchial/ chest
- Dysphonia during/following an attack
- Abrupt onset and resolution
- Little or NO response to medical treatment
(inhalers, bronchodilators)
14Various 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
15(No Transcript)
16LPR, continued
- Clinical characteristics can be observed using
videolaryngoscopic or stroboscopic visualization
of the larynx - Ideally, diagnosed by a 24-hour pH. Probe or EGD
17LPR 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
18Laryngopharyngeal Reflux Clinical Signs
Interarytenoid Edema
Lx Erythema
Vocal Fold Edema
19Other potential causes of Paradoxical Vocal Cord
Dysfunction
- Allergic rhinitis or reaction
- Conversion disorder
- Anxiety
- Respiratory-type or drug-induced laryngeal
dystonia
20Etiologies (cont.)
- Asthma-associated laryngeal dysfunction
- Brainstem dysfunction
- CVA or injury
- Chronic laryngeal instability, sensitivity
tension
21Athlete Profile for EI-VCD
- Onset between 11-18
- Females have a greater incidence (generally 31)
- High achieving
- Type A personalities
- High personal standards and/or social pressures
- Intolerant to personal failure
22Athlete 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)
23EI-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?
24Differential 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
25Differential 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
26Diagnosis 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
27EI-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
28EI-PVCD versus Exercise Induced Asthma
29Typical 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
30Inspiratory cut-off, flattening of the
inspiratory limb (curve)
NORMAL
VCD
31Case 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?
32Questions (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
33Questions (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?
34Videostroboscopic 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
35Laryngeal Supraglottic Hyperfunction
- arytenoid compression
- ventricular compression
- Limited airway for phonation
36VCD appearance on direct examination
- Laryngeal Supraglottic Hyperfunction
- Abnormal ventricular compression during speech
37Laryngeal Supraglottic Hyperfunction
- Sphincteric contraction of the supraglottis
during speech production
38PVCM Visualized
Posterior chink
Rounded arytenoids, but normal abduction
39Diagnostic Features PVFM Asthma
- Flow-volume loop Inspiratory cut-off,
Reduced expiratory - perhaps some
expiratory limb only - limb
reduction - Bronchial provocation Negative
Positive - test
- Laryngoscopic Inspiratory
adduction Vocal folds may observations
adduct during - of anterior
2/3 of vocal exhalation - folds
posterior diamond- - shaped
chink perhaps -
medialization of ventricular - folds
inspiratory adduction - may carry
over to expiration -
-
40Diagnostic Features PVFM Asthma
- Precipitators (triggers) Exercise, extreme
Exercise, extreme
temperatures, airway temperatures,
irritants, emotional airway irritants,
stressors emotional
stressors, allergens - Number of triggers Usually one
Usually multiple - Breathing obstruction Laryngeal area
Chest area - location
- Timing of breathing Stridor on
Wheezing on - noises inspiration exhalation
41- Pattern of dyspneic Sudden onset and
More gradual onset event
relatively rapid longer recovery
cessation period -
- Nocturnal awakening Rarely
Almost always - with symptoms
- Response to broncho- No response
Good response - dilators and/or systemic
- corticosteroids
42Acute 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
43Acute 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
44Acute 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
45Acute 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?
46Quick 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
47ACUTE 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
48Treatment 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
49Therapeutic 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
50Therapeutic 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
51Speech 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)
52Speech 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
53Back 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
54Relaxation 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 patients visual concept of their
disorder and alter
55ST 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)
56CASE 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
57Therapy 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
58Case 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
59Therapy 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
60Outcome
- 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
61REFERENCES
- Brugman, S. M., Newman, K. (1993). Vocal cord
dysfunction. Medical/Scientific Update. 11. 5.
1-5. - Christopher, K. L., WoodII, R. P., Eckert, R. C.,
Blager, F. B., Raney, R. A., Souhrada, J. F.
(1983). Vocal-cord dysfunction presenting as
asthma. The New England Journal of Medicine. 308.
1556-1570. - Gavin, L. A., Wamboldt, M., Brugman, S., Roesler,
T. A., Wamboldt, F. (1998). Psychological and
family characteristics of adolescents with vocal
cord dysfunction. Journal of Asthma. 35. 409-417. - Martin, R. J., Blager, F. B., Gay, M. L.,
WoodII, R. P. (1987). Paradoxic vocal cord motion
in presumed asthmatics. Seminars in Respiratory
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