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Exercise Induced Paradoxical Vocal Cord Dysfunction (EI-PVCD)

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.

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Exercise Induced Paradoxical Vocal Cord Dysfunction (EI-PVCD)

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  1. Exercise Induced Paradoxical Vocal Cord Dysfunction(EI-PVCD) Dale R. Gregore M.S., CCC-SLP Speech Language Pathologist Clinical Rehabilitation Specialist - Voice

  2. 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

  3. Normal Larynx

  4. Vocal fold ABDUCTION occurs during respiration

  5. Vocal fold ADDUCTION Occurs during swallowing, coughing, etc…

  6. Strobe exam

  7. 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

  8. 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

  9. Pseudonyms • Vocal Cord Dysfunction (VCD) • Most common term • Munchausen’s Stridor • Emotional Laryngeal Wheezing • Pseudo-asthma • Fictitious Asthma • Episodic Laryngeal Dyskinesia

  10. 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”.

  11. 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

  12. 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

  13. 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)

  14. 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

  15. 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

  16. 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

  17. Laryngopharyngeal Reflux: Clinical Signs Interarytenoid Edema Lx Erythema Vocal Fold Edema

  18. Other potential causes of Paradoxical Vocal Cord Dysfunction • Allergic rhinitis or reaction • Conversion disorder • Anxiety • Respiratory-type or drug-induced laryngeal dystonia

  19. Etiologies (cont.) • Asthma-associated laryngeal dysfunction • Brainstem dysfunction • CVA or injury • Chronic laryngeal instability, sensitivity & tension

  20. 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

  21. 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)

  22. 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?

  23. 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

  24. 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

  25. 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

  26. 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

  27. EI-PVCD versus Exercise Induced Asthma

  28. 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

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

  30. 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?

  31. 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

  32. 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?

  33. 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

  34. Laryngeal Supraglottic Hyperfunction • arytenoid compression • ventricular compression • Limited airway for phonation

  35. VCD appearance on direct examination • Laryngeal Supraglottic Hyperfunction • Abnormal ventricular compression during speech

  36. Laryngeal Supraglottic Hyperfunction • Sphincteric contraction of the supraglottis during speech production

  37. PVCM Visualized Posterior ‘chink’ Rounded arytenoids, but normal abduction

  38. Diagnostic Features PVFM Asthma • Flow-volume loop Inspiratory cut-off,Reduced expiratory • perhaps some expiratorylimb only • limb reduction * • Bronchial provocationNegativePositive • 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

  39. 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 Laryngealarea Chestarea • location • Timing of breathing Stridor on Wheezing on • noises inspiration exhalation

  40. Pattern of dyspneic Sudden onset and More gradual onset event relatively rapidlonger recoverycessation period • Nocturnal awakening Rarely Almost always • with symptoms • Response to broncho- No responseGood response • dilators and/or systemic • corticosteroids

  41. 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

  42. 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

  43. 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

  44. 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?

  45. 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

  46. 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

  47. 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

  48. 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

  49. 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 Therapeutic goals and methods

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