Exercise Induced Paradoxical Vocal Cord Dysfunction (EI-PVCD)

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Exercise Induced Paradoxical Vocal Cord
Dysfunction (EI-PVCD)

• Dale R. Gregore
• M.S., CCC-SLP
• Speech Language Pathologist
• Clinical Rehabilitation Specialist - Voice

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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

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Normal Larynx
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Vocal fold ABDUCTION occurs during respiration
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Vocal fold ADDUCTION Occurs during swallowing,
coughing, etc
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Strobe exam
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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

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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

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Pseudonyms

• Vocal Cord Dysfunction (VCD)
• Most common term
• Munchausens Stridor
• Emotional Laryngeal Wheezing
• Pseudo-asthma
• Fictitious Asthma
• Episodic Laryngeal Dyskinesia

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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 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.

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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

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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

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Symptoms

• 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)

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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

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LPR, continued

• Clinical characteristics can be observed using
  videolaryngoscopic or stroboscopic visualization
  of the larynx
• Ideally, diagnosed by a 24-hour pH. Probe or EGD

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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

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Laryngopharyngeal Reflux Clinical Signs
Interarytenoid Edema
Lx Erythema
Vocal Fold Edema
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Other potential causes of Paradoxical Vocal Cord
Dysfunction

• Allergic rhinitis or reaction
• Conversion disorder
• Anxiety
• Respiratory-type or drug-induced laryngeal
  dystonia

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Etiologies (cont.)

• Asthma-associated laryngeal dysfunction
• Brainstem dysfunction
• CVA or injury
• Chronic laryngeal instability, sensitivity
  tension

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Athlete 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

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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)

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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?

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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
  

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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

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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

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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

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EI-PVCD versus Exercise Induced Asthma
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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

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Inspiratory cut-off, flattening of the
inspiratory limb (curve)
NORMAL
VCD
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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?

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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

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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?

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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

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Laryngeal Supraglottic Hyperfunction

• arytenoid compression
• ventricular compression
• Limited airway for phonation

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VCD appearance on direct examination

• Laryngeal Supraglottic Hyperfunction
• Abnormal ventricular compression during speech

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Laryngeal Supraglottic Hyperfunction

• Sphincteric contraction of the supraglottis
  during speech production

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PVCM Visualized
Posterior chink
Rounded arytenoids, but normal abduction
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Diagnostic 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

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Diagnostic 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

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• 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

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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

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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

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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

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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?

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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

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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

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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

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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

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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

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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)

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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

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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

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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 patients visual concept of their
  disorder and alter

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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)

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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

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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

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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

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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

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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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REFERENCES

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• 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.,
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  in presumed asthmatics. Seminars in Respiratory
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