Exercise Induced Exercise Induced Paradoxical Vocal Cord DysfunctionParadoxical Vocal Cord Dysfunction
(EI-PVCD)(EI-PVCD)
Dale R. Gregore Dale R. Gregore
M.S., CCC-SLPM.S., CCC-SLPSpeech Language PathologistSpeech Language Pathologist
Clinical Rehabilitation Specialist - VoiceClinical Rehabilitation Specialist - Voice
NORMAL RespirationNORMAL Respiration 101 101
On inhalation, the vocal cords (folds) On inhalation, the vocal cords (folds) ABductABduct allowing air to flow into the allowing air to flow into the trachea, bronchial tubes, lungstrachea, bronchial tubes, lungs
On exhalation, the vocal folds may On exhalation, the vocal folds may close slightly, however should and do close slightly, however should and do remain remain ABductedABducted
Normal LarynxNormal Larynx
Vocal fold ABDUCTION occurs during respiration
Vocal fold ADDUCTION
Occurs during
swallowing, coughing, etc…
Strobe exam
Paradoxical Vocal Fold Movement Paradoxical Vocal Fold Movement (PVFM)(PVFM)
The cord function is The cord function is reversed reversed in that the in that the vocal folds ADDuct on vocal folds ADDuct on inspiration versus inspiration versus ABduct ABduct Leads to tightness or Leads to tightness or spasm in the larynxspasm in the larynxInspiratory wheeze Inspiratory wheeze evidentevident
Definition of EI-VCDDefinition of EI-VCD
““Inappropriate closure of the Inappropriate closure of the vocal folds upon inspiration vocal folds upon inspiration resulting in stridor, dyspnea resulting in stridor, dyspnea and shortness of breath (SOB) and shortness of breath (SOB) during strenuous activity”during strenuous activity”
– Matthers-Schmidt, 2001; Sandage Matthers-Schmidt, 2001; Sandage et al, 2004et al, 2004
PseudonymsPseudonyms
Vocal Cord Dysfunction (VCD)Vocal Cord Dysfunction (VCD)– Most common termMost common term
Munchausen’s StridorMunchausen’s Stridor
Emotional Laryngeal WheezingEmotional Laryngeal Wheezing
Pseudo-asthmaPseudo-asthma
Fictitious Asthma Fictitious Asthma
Episodic Laryngeal DyskinesiaEpisodic Laryngeal Dyskinesia
Patient description Patient description of VCD episodesof VCD episodes
– ““in the top of my throat I see a McDonalds in the top of my throat I see a McDonalds straw surrounded by darkness. The straw straw surrounded by darkness. The straw ends in a pool of thick, sticky liquid that is ends in a pool of thick, sticky liquid that is encased by a wall of rubber bands and encased by a wall of rubber bands and outside of the rubber bands is air that I outside of the rubber bands is air that I can’t access”.can’t access”.
– ““The top part of my throat is complete The top part of my throat is complete darkness, at the back part of the darkness darkness, at the back part of the darkness there are cotton balls. These are holding there are cotton balls. These are holding my fear”. my fear”.
PVFM VisualizedPVFM VisualizedAnterior portion of the Anterior portion of the vocal folds are vocal folds are ADDuctedADDucted
Only a small area of Only a small area of opening at the opening at the
Posterior aspect of Posterior aspect of the vocal foldsthe vocal folds
Diamond shaped Diamond shaped ‘CHINK’‘CHINK’
May be evident on May be evident on both inhalation and both inhalation and exhalationexhalation
Essential FeaturesEssential Features
Vocal fold adduct (close) during Vocal fold adduct (close) during respiration instead of abducting respiration instead of abducting (opening)(opening)
Laryngeal instability while patient is Laryngeal instability while patient is asymptomaticasymptomatic
– Treole,K. et. al. 1999Treole,K. et. al. 1999
Episodic respiratory distressEpisodic respiratory distress
SymptomsSymptoms
StridorStridor
Difficulty with inspiratory phaseDifficulty with inspiratory phase
Throat tightening > bronchial/ chestThroat tightening > bronchial/ chest
Dysphonia during/following an attackDysphonia during/following an attack
Abrupt onset and resolutionAbrupt onset and resolution
Little or NO response to medical Little or NO response to medical treatment (inhalers, bronchodilators)treatment (inhalers, bronchodilators)
Various EtiologiesVarious Etiologies
Laryngo-Pharyngeal Reflux (LPR)Laryngo-Pharyngeal Reflux (LPR)– Food/ liquid/ acid refluxes from the Food/ liquid/ acid refluxes from the
stomach up the esophagus into the stomach up the esophagus into the pharynx (throat)pharynx (throat)
– Can spill over and into the larynx Can spill over and into the larynx – causes coughing, choking, breathing and causes coughing, choking, breathing and
voice changes, swelling, irritation, voice changes, swelling, irritation, – Can be SILENT or sensed when it happensCan be SILENT or sensed when it happens– WATERBRASHWATERBRASH
LPR, continuedLPR, continued
Clinical characteristics can be Clinical characteristics can be observed using observed using videolaryngoscopic or videolaryngoscopic or stroboscopic visualization of stroboscopic visualization of the larynxthe larynx
Ideally, diagnosed by a 24-Ideally, diagnosed by a 24-hour pH. Probe or EGDhour pH. Probe or EGD
LPR and AthletesLPR and AthletesWell documented occurrence in weight Well documented occurrence in weight liftinglifting
Can be aggravated by bending, pushing/ Can be aggravated by bending, pushing/ resisting (tackling, etc…), tight clothing, resisting (tackling, etc…), tight clothing, even drinking water during a game/ meet/ even drinking water during a game/ meet/ matchmatch
Timing of meals before exercise is Timing of meals before exercise is importantimportant
Type of foods/ liquids should be monitoredType of foods/ liquids should be monitored
Laryngopharyngeal Reflux: Laryngopharyngeal Reflux: Clinical Signs Clinical Signs
Vocal Fold Edema
Lx Erythema
Interarytenoid Edema
Other potential causes of Other potential causes of Paradoxical Vocal Cord Paradoxical Vocal Cord
DysfunctionDysfunction
Allergic rhinitis or reactionAllergic rhinitis or reaction
Conversion disorder Conversion disorder
AnxietyAnxiety
Respiratory-type or drug-Respiratory-type or drug-induced laryngeal dystoniainduced laryngeal dystonia
Etiologies (cont.)Etiologies (cont.)
Asthma-associated Asthma-associated laryngeal dysfunctionlaryngeal dysfunction
Brainstem dysfunctionBrainstem dysfunctionCVA or injuryCVA or injury
Chronic laryngeal Chronic laryngeal instability, sensitivity & instability, sensitivity & tensiontension
Athlete Profile for EI-VCDAthlete Profile for EI-VCD
Onset between 11-18 Onset between 11-18
Females have a greater incidence Females have a greater incidence (generally 3:1) (generally 3:1)
High achievingHigh achieving
““Type A” personalitiesType A” personalities
High personal standards and/or High personal standards and/or social pressuressocial pressures
Intolerant to personal failureIntolerant to personal failure
Athlete Profile, cont…Athlete Profile, cont…CompetitiveCompetitive
Self demandingSelf demanding
Perceives family pressure to achieve a Perceives family pressure to achieve a high level of successhigh level of success
““Choke” under pressureChoke” under pressure
May have recently graduated to higher May have recently graduated to higher level of competition within their sport (JV level of competition within their sport (JV to Varsity: Rep to Travel team; college to Varsity: Rep to Travel team; college level sports, etc)level sports, etc)
EI-VCD versus AsthmaEI-VCD versus Asthma
Recalcitrant to asthma medicationsRecalcitrant to asthma medicationsi.e. does not respond to i.e. does not respond to Individuals with “asthma” after long Individuals with “asthma” after long term steroid use might not truly have term steroid use might not truly have asthma, but VCDasthma, but VCDIndividuals with significant anxiety: Individuals with significant anxiety: is it LIVE OR MEMOREX? Which is it LIVE OR MEMOREX? Which causes which?causes which?
Differential Diagnosis of EI-VCDDifferential Diagnosis of EI-VCDIncludes a detailed Case History Includes a detailed Case History
Pulmonary function StudiesPulmonary function Studies
Lab Test Lab Test
ENT/ Pulmonary/ Allergy evaluations ENT/ Pulmonary/ Allergy evaluations
Flexible Laryngoscopy/ videostroboscopyFlexible Laryngoscopy/ videostroboscopy
Speech-language pathology evaluation Speech-language pathology evaluation
Supplemental as needed: Supplemental as needed: Psychological evaluationPsychological evaluation
Differential Diagnosis of VCDDifferential Diagnosis of VCD Team Must Rule Out:Team Must Rule Out: – Mass ObstructionMass Obstruction– Bilateral vocal fold paralysisBilateral vocal fold paralysis– Anaphylactic laryngeal edemaAnaphylactic laryngeal edema– Extrinsic airway compressionExtrinsic airway compression– Foreign body aspirationForeign body aspiration– Infectious croupInfectious croup– LaryngomalaciaLaryngomalacia– Exercise Induced Asthma/ Exercise Induced Asthma/
AsthmaAsthma
Diagnosis of EI-VCDDiagnosis of EI-VCD
Often mistaken for asthmaOften mistaken for asthma
Diagnosis of EI-PVCD is by Diagnosis of EI-PVCD is by exclusionexclusion = when patient = when patient fails to respond to asthma fails to respond to asthma or allergy medication, then or allergy medication, then VCD is finally consideredVCD is finally considered
EI-VCD and AsthmaEI-VCD and Asthma
Can exist independently Can exist independently
Can also coexistCan also coexist– Patient may experience LPR which Patient may experience LPR which
causes Asthma flare-up and then causes Asthma flare-up and then laryngospasm (VCD) from coughinglaryngospasm (VCD) from coughing
– May experience chest (asthma) and/or May experience chest (asthma) and/or laryngeal (VCD) tightnesslaryngeal (VCD) tightness
EI-PVCD versusEI-PVCD versus Exercise Induced Asthma Exercise Induced Asthma
Feature PVCM EIAFemale Preponderance + -Chest Tightness +/- -Throat Tightness + -Stridor + -Usual onset of symptoms after beginning exercise (min) <5 >5-10Recovery period (min) 5-10 15-60Refractory period - +Late-phase response - +Response to beta-agonist - +
Typical Spirometry Findings for Typical Spirometry Findings for PVCDPVCD
AsymptomaticAsymptomatic– Flow-volume loops are normal Flow-volume loops are normal
Symptomatic: Symptomatic: – Blunted inspiratory curveBlunted inspiratory curve– Inspiratory curves highly varied Inspiratory curves highly varied – Expiratory portion may be bluntedExpiratory portion may be blunted– Ratio of forced expiratory to inspiratory Ratio of forced expiratory to inspiratory
flow at 50% VC can be greater than 1.0flow at 50% VC can be greater than 1.0
Inspiratory cut-off, flattening of the Inspiratory cut-off, flattening of the inspiratory limb (curve)inspiratory limb (curve)
NORMAL VCD
Case History QuestionsCase History Questions– Do you have more trouble breathing in Do you have more trouble breathing in
than out?than out?– Do you experience throat tightness?Do you experience throat tightness?– Do you have a sensation of choking or Do you have a sensation of choking or
suffocation?suffocation?– Do you have hoarseness?Do you have hoarseness?– Do you make a breathing-in noise Do you make a breathing-in noise
(stridor) when you are having (stridor) when you are having symptoms?symptoms?
Questions (cont.)Questions (cont.)– How soon after exercise starts do your How soon after exercise starts do your
symptoms begin?symptoms begin?– How quickly do symptoms subside?How quickly do symptoms subside?– Do symptoms recur to the same degree Do symptoms recur to the same degree
when you resume exercise?when you resume exercise?– Do inhaled bronchodilators prevent or Do inhaled bronchodilators prevent or
abort attacks?abort attacks?– Do you experience numbness and/or Do you experience numbness and/or
tingling in your hands or feet or around tingling in your hands or feet or around your mouth with attacksyour mouth with attacks
Questions (cont.)Questions (cont.)– Do symptoms ever occur during sleep?Do symptoms ever occur during sleep?– Do you routinely experience nasal Do you routinely experience nasal
symptoms (postnasal drip, nasal symptoms (postnasal drip, nasal congestion, runny nose, sneezing)?congestion, runny nose, sneezing)?
– Do you experience reflux symptoms?Do you experience reflux symptoms?
Videostroboscopic ExaminationVideostroboscopic ExaminationInstrumentationInstrumentation– Flexible fiberoptic laryngeal endoscope with Flexible fiberoptic laryngeal endoscope with
stroboscopic capabilitystroboscopic capability
ObservationsObservations– Movement of arytenoids during respiration Movement of arytenoids during respiration
at rest: Complete closure; Posterior at rest: Complete closure; Posterior diamonddiamond
– Signs of laryngopharyngeal reflux disorder Signs of laryngopharyngeal reflux disorder (LPR)(LPR)
– Degree of laryngeal instabilityDegree of laryngeal instability
Laryngeal Supraglottic Laryngeal Supraglottic HyperfunctionHyperfunction
arytenoid arytenoid compressioncompression
ventricular ventricular compressioncompression
Limited airway for Limited airway for phonationphonation
VCD appearance on direct VCD appearance on direct examinationexamination
Laryngeal Laryngeal Supraglottic Supraglottic HyperfunctionHyperfunction
Abnormal Abnormal ventricular ventricular compression compression during speech during speech
Laryngeal Supraglottic Laryngeal Supraglottic HyperfunctionHyperfunction
Sphincteric Sphincteric contraction of the contraction of the supraglottis during supraglottis during speech productionspeech production
PVCM VisualizedPVCM Visualized
Rounded arytenoids, but normal abduction
Posterior ‘chink’
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
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
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 systemiccorticosteroids
Acute Management of EI-VCD Acute Management of EI-VCD in the fieldin the field
Approach to the Approach to the patient is importantpatient is important
It is generally agreed It is generally agreed that patients do not that patients do not consciously consciously manipulate or control manipulate or control their upper airway their upper airway obstruction obstruction
Acute Management of EI-VCD Acute Management of EI-VCD
During an episode, they usually feel During an episode, they usually feel helpless and terrifiedhelpless and terrified
Implying that it is “in their head” is Implying that it is “in their head” is incorrect and counterproductive to incorrect and counterproductive to their recoverytheir recovery
Coach them through, help them outCoach them through, help them out
Be positiveBe positive
Acute Management of AttacksAcute Management of Attacks
– Offer reassurance and empathyOffer reassurance and empathy– Eliminate activity and people from Eliminate activity and people from
environmentenvironment– Prompt for EASY BREATHINGPrompt for EASY BREATHING– Elicit controlled ‘Panting’Elicit controlled ‘Panting’
Relaxed jawRelaxed jaw
Tongue on floor of mouth behind bottom Tongue on floor of mouth behind bottom teethteeth
Acute Management in the GameAcute Management in the Game
Visualize WIDE OPEN AIRWAY Visualize WIDE OPEN AIRWAY
6 lane highway with no roadblocks6 lane highway with no roadblocks
Air goes in and circles around, goes outAir goes in and circles around, goes out
Shoulders relaxedShoulders relaxed
Standing w/ open chest, hands on hips, Standing w/ open chest, hands on hips, or bent over/ hands on knees….which or bent over/ hands on knees….which position works best?position works best?
Quick Sniff TechniqueQuick Sniff Technique– Sniff then Blow….talk the athlete through this– Sniff in with focal emphasis at the tip of the
noseSniff = ABduction
– Then exhale with pursed lips on “ssssss” “shhhhhh” “ffffffff”“whhhhhhhh” = Back pressure respiration
ACUTE treatment, cont…ACUTE treatment, cont…– Breathing against pressure (hand on Breathing against pressure (hand on
abdomen)abdomen)Resistance and focus on pressure against / Resistance and focus on pressure against / in another body partin another body part
– HelioxHelioxAdministered by Paramedics or ER MDsAdministered by Paramedics or ER MDs
– Sedatives and psychotropic medicationsSedatives and psychotropic medicationsLast resortLast resort
Calming effectCalming effect
Eliminates tension/ constrictionEliminates tension/ constriction
Treatment: Speech TherapyTreatment: Speech Therapy
Patient counseling, education Patient counseling, education
Respiratory retrainingRespiratory retraining
Focal and whole body relaxationFocal and whole body relaxation
Phonatory retrainingPhonatory retraining
Monitor reflux Sx or anxietyMonitor reflux Sx or anxiety
Develop / outline a ‘Game Plan’ = Develop / outline a ‘Game Plan’ = practice when asymptomatic; practice when asymptomatic; implement at the onset of sximplement at the onset of sx
Therapeutic goals and methodsTherapeutic goals and methodsGoalGoal– Ability to Ability to
overcome fear overcome fear and helplessnessand helplessness
– Reduced tension Reduced tension in- extrinsic in- extrinsic laryngeal muscleslaryngeal muscles
– Diversion of Diversion of attention from attention from larynxlarynx
MethodMethod– Mastery of Mastery of
breathing breathing techniquestechniques
– Open throat Open throat breathing; breathing; resonant voice resonant voice techniquetechnique
– Diaphragmatic Diaphragmatic breathing and breathing and active exhalationactive exhalation
Therapeutic goals and methodsTherapeutic goals and methodsGoalGoal– Reduced tension Reduced tension
in neck, in neck, shoulders and shoulders and chestchest
– Ability to use Ability to use techniques to techniques to reduce severity reduce severity and frequency of and frequency of attacksattacks
MethodMethod– Movement, Movement,
stretching, stretching, progressive progressive relaxationrelaxation
– Increase Increase awareness of early awareness of early warning warning symptoms; symptoms; Rehearse action Rehearse action planplan
Speech TherapySpeech Therapy
Patient Counseling & EducationPatient Counseling & Education– Description of laryngeal eventsDescription of laryngeal events– Viewing of laryngoscopy tapeViewing of laryngoscopy tape– Relate parallels to other stress induced Relate parallels to other stress induced
disorders: migraine, irritable colon, disorders: migraine, irritable colon, muscle tension dysphonia, muscle tension dysphonia, GERefluxGEReflux
– Flexible endoscopic biofeedbackFlexible endoscopic biofeedback– Sensory biofeedback (sEMG)Sensory biofeedback (sEMG)
Speech TherapySpeech Therapy
Respiratory trainingRespiratory training– Low “diaphragmatic” breathing versus Low “diaphragmatic” breathing versus
“high” clavicular thoracic “high” clavicular thoracic – Rhythmic respiratory cyclesRhythmic respiratory cycles– Use resistance exhale (draw attention Use resistance exhale (draw attention
away from larynx and extend exhale)away from larynx and extend exhale)– Prevention and coping strategies during Prevention and coping strategies during
episodes = Action Planepisodes = Action Plan
Back Pressure BreathingBack Pressure Breathing
Nasal Sniff = OPEN cordsNasal Sniff = OPEN cords
Prolonged exhalation /w/, /f/, /sh/, /s/ Prolonged exhalation /w/, /f/, /sh/, /s/
Shoulders relaxedShoulders relaxed
Throat openThroat open
Implement when laying, sitting, Implement when laying, sitting, standing, walking, jogging, running, standing, walking, jogging, running, playing sports, etcplaying sports, etc
RelaxationRelaxation TrainingTraining
GoalGoal– Teach the patient to relax focal areas Teach the patient to relax focal areas
then the entire body during an episode then the entire body during an episode of respiratory distressof respiratory distress
MethodsMethods– Use progressive relaxation with guided Use progressive relaxation with guided
imageryimagery– Explore the patient’s visual concept of Explore the patient’s visual concept of
their disorder and altertheir disorder and alter
ST Duration: The CCHS ApproachST Duration: The CCHS Approach
2-8 sessions2-8 sessions
Average 4 sessionsAverage 4 sessions
Followed by clinical observation Followed by clinical observation during sport/ gameduring sport/ game
Followup phone / email contact: tell Followup phone / email contact: tell me how it is going? me how it is going?
Re-evaluation as necessary, if Re-evaluation as necessary, if symptoms reoccur (rarely)symptoms reoccur (rarely)
CASE DISCUSSIONCASE DISCUSSION
14 year old female14 year old female
Sports: field hockey, soccerSports: field hockey, soccer
Travel soccer U-17 team/ midfiledTravel soccer U-17 team/ midfiled
Initial symptoms: ‘throat closes’ ~5 Initial symptoms: ‘throat closes’ ~5 minutes in to game; hand on throat; minutes in to game; hand on throat; signals coach; pulled from game; 20 signals coach; pulled from game; 20 minute recovery: lying on sidelineminute recovery: lying on sideline
Therapy Focus and OutcomeTherapy Focus and Outcome5 sessions5 sessions
Breathing 101Breathing 101
Training from static to active movement/ Training from static to active movement/ runningrunning
Full coaching then observation of strategy Full coaching then observation of strategy implemetation in therapy and during gameimplemetation in therapy and during game
Outcome:Outcome: (-) sx during mile run; cool (-) sx during mile run; cool down routine implemented; 20-30 minute down routine implemented; 20-30 minute game play/ no EI-VCD w/ ‘game plan’ game play/ no EI-VCD w/ ‘game plan’
Case Discussion #2Case Discussion #2
14 year old female14 year old female
Sports: cross country; basketballSports: cross country; basketball
Initial Symptoms: ‘throat closed’ Initial Symptoms: ‘throat closed’ during CC trials; had to ‘drop out’during CC trials; had to ‘drop out’
Secondary Symptoms: inspiratory Secondary Symptoms: inspiratory stridor when wearing mouth guard/ stridor when wearing mouth guard/ basketball; felt ‘faint’basketball; felt ‘faint’
Therapy Focus and OutcomeTherapy Focus and Outcome
5 sessions5 sessionsGoals: establish ‘low’ AD breathing/ Goals: establish ‘low’ AD breathing/ eliminate shoulder elevation and CT eliminate shoulder elevation and CT respiration pattern; train in back respiration pattern; train in back pressure breathing w/ and w/out pressure breathing w/ and w/out mouthguard during activities of mouthguard during activities of progressive effort including walk; jog; progressive effort including walk; jog; stairs, treadmill; suicide drills; BB stairs, treadmill; suicide drills; BB drills; sprints, etcdrills; sprints, etc
OutcomeOutcomeSuccessful resolution of PVFM during Successful resolution of PVFM during 20 minute runs and when playing BB20 minute runs and when playing BBIncreased awareness of AD versus CT Increased awareness of AD versus CT respirationrespirationHabituated alternate use of sniff/ Habituated alternate use of sniff/ pant – blow, etc. pant – blow, etc. Increased perceived ‘control’ over Increased perceived ‘control’ over breathing and performancebreathing and performanceSpring Sport pending: soccerSpring Sport pending: soccer
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