Anita Gheller-Rigoni, DO, FACAAI Allergist-Immunologist. Exercise-Induced Vocal Cord Dysfunction

Transcription

1 Anita Gheller-Rigoni, DO, FACAAI Allergist-Immunologist Exercise-Induced Vocal Cord Dysfunction

2 Objectives 1. Understand the concept of vocal cord dysfunction 2. Recognize the difference between exercised induced bronchospasm and exercise induced vocal cord dysfunction 3. Identify acute treatment interventions for exercise induced vocal cord dysfunction 4. Understand the long term management of vocal cord dysfunction

3 Normal Respiration On inhalation, the vocal cords (folds) ABduct allowing air to flow into the lungs On exhalation, the vocal folds may close slightly, however mainly remain ABducted

4 Definition Vocal Cord Dysfunction A disorder of the upper airway in which the vocal folds ADduct during inspiration, exhalation, or both. This can result in inspiratory stridor and respiratory distress.

5 Vocal Cord Anatomy

6 Vocal fold ABDuction - respiration Vocal fold ADDuction - speech

7 Vocal fold ADDUCTION Occurs during swallowing, coughing, etc

8 Pseudonyms Paradoxical vocal fold motion (PVFM) Vocal cord dysfunction (VCD) Psychogenic stridor Munchausen s stridor Emotional laryngeal wheezing Pseudo-asthma Fictitious asthma Episodic laryngeal dyskinesia

9 Clinical Presentation Stridor (particularly on inhalation) Audible wheeze Choking sensation Acute episodic shortness of breath Voice weakness or loss Tightness in throat with substernal chest pain Globus Sensation Difficulty getting air in

10 Triggers Exercise Chemical odors Cigarette smoke Perfumes Cold air Stress Respiratory tract infections

11 Comorbidities Asthma Allergic rhinitis Gastroesophageal reflux disease Anxiety Neurological issues Overuse (singers, speakers, etc.)

12 Clinical Presentation Athletes SOB out of proportion to level of physical endurance Complain that they can t get enough air in Throat tightening > bronchial/ chest Abrupt onset and resolution (with rest) Little or NO response to medical treatment (inhalers, bronchodilators)

13 VCD vs EIB VCD Onset: at rest or later Sxs: throat/substernal Sx increased w/inspiration Quick onset & resolution Most inhalers do NOT help EIB Onset: early in activity Sxs: whole chest Sx increased w/expiration Can persist 30 min to hours Albuterol helps Other co-morbidities: hx of asthma, allergies, pneumonia

14 VCD vs EIB Overlap of the two is common and up to 50% of individuals with VCD also have some type of asthma. Other causes of laryngeal obstruction - bilateral vocal fold paralysis - laryngeal stenosis

15 Diagnosis - VCD

16 Diagnosis - VCD Rule out all other causes Direct laryngoscopic visualization of the vocal cords - After intense exercise - After methacholine bronchoprovacation testing

17 Diagnostic Evaluation Laryngoscopic Examination alternatively phonate and sniff, rapidly take deep breaths cough, throat clear, chuckle count to fifty, rapidly and loudly read a written passage in a loud voice sing

18 Direct Visualization

19 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 Facilitative diaphragmatic breathing - belly breathing Coach them through, help them out - breath through it

20 Acute Management of EI-VCD - 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 = Back pressure respiration

21 Long Term Management Treat underlying causes - Medications for acid reflux or allergies - Behavioral health Speech and language pathology Physical therapy Atrovent (ipratropium) inhaler before activity

22 Conclusions VCD is a family of syndromes In order to diagnose and treat VCD effectively a thorough history is important All relevant contributing factors should be addressed A psychogenic component does not rule out other organic etiologies A team approach is important