VCD and Asthma: SLP Perspective. Jeff Searl, Ph.D., CCC-SLP Department of Communicative Sciences & Disorders Michigan State University

Transcription

1 VCD and Asthma: SLP Perspective Jeff Searl, Ph.D., CCC-SLP Department of Communicative Sciences & Disorders Michigan State University

2 The Name Issue 1983 Vocal Cord Dysfunction (VCD) coined by Christopher et al (much earlier descriptions of the condition back to 1842 usually associated with hysterical patients ) Since at least 40 different labels have been association Common nomenclature task force Inducible Laryngeal Obstruction (ILO) American College of Chest Physicians; European Respiratory Society; European Laryngological Society But not catching on as a universal term

3 The Name Issue from the SLP Perspective Generally use VCD to facilitate communication among the care team and with patients But in our hearts term is Non-specific to the condition Overlaps with a large swath of others who demonstrate various types of vocal cord dysfunction with whom we work Preference for Paradoxical Vocal Cord Motion (PVCM) Disorder

4 Clinical Presentation - broadly For years thought to be psychological Not so now broad patient base 65% > 19 years old Median ages Adults = 36 years Peds = 14 years Does seem to be female > male Sx: chronic in 85%, acute in 15% Wide range of patient report Air hunger, chest tightness, tension in throat, choking, trouble swallowing, throat clear, aphonia or dysphonia, cough, etc. Fear, anxiety, panic worsening of other Sx Triggers/associated conditions: exercise, URI, reflux, sinus drainage, stress, odors == laryngeal hypersensitivity Refractory asthma often part of the clinical picture [42% of those wih VCD misdx as asthma for average of 9 years; prob is 33% with VCD have concomitant asthma (Traister et al 2013)]

5 For SLPS, Clinical Presentation is such that SLP is NOT usually the first person that they go to General practitioners, Asthma and Allergy specialists, sometimes Ear, Nose, Throat docs SLPs often asked to contribute to diagnostic process Ruling in/out other possibilities Directly confirming the laryngeal behavior consistent with VCD Assessing stimulability for behavioral change

6 A Unified Underpinning Emerging? Low, Ruanne, Uddin (2017) People with vs. without asthma Focus on Susceptibility to the condition predisposing and augmenting factors Reflux, nasal drainage, etc. Psychological/psychiatric Exercise Etc. Model reinforces need for team diagnostic and treatment

7 SLP SLP + SLP + SLP SLP +

8 Diagnostically What the SLP Can Add Information on laryngeal Structure Function During voice During swallow During breathing Rest Activity

9 Diagnostically What the SLP Can Add Flexible laryngoscopy = visualization of the event itself Gold-standard to date (but with limits) Generally with VCD Vocal folds adduct anteriorly with glottal gap posteriorly During inspiration, possibly expiration, possibly both But subjective; not always able to catch them during symptom occurrence (challenge tests panting, exercise, methacholine, fast-extended talking) flexendosc_exercise based PVCM_non exercise based

10 attempting to What are we [SLP] ruling out? Structural issues Obstruction in larynx, supraglottic region Cysts, papilloma, malignancy Stenosis Laryngeal web Swellings Epiglottis Ingestion or inhalation trauma ETC.! Functional issues Inspiratory phonation Vocal fold paralysis Psychogenic (somatoform, conversion, malingering)

11 Some of the many things we can see during flex endoscopy that can create breathing problems

12 Multidisciplinary Team for Dx SLP has a part Pulmonology, Asthma, Allergy specialists ENT Psychology/Psychiatry GI Neurology Endocrinology Infectious Disease Athletic trainer, physical therapist

13 Treatment Approach multipronged and multidisciplinary Trigger/Irritant Control Asthma control (if appropriate) Physical- Trainer Medical Psych SLP Psychological support/counseling & Education Train breathing techniques: in the moment, retraining Address Associated laryngeal behaviors: cough, throat clear

14 SLP Treatment Education The condition normal physiology vs. their situation What seems to trigger it for them; ways to control triggers Good vocal hygiene Supportive counseling Reassurance Benign nature, self-limited

15 SLP Treatment No studies comparing 1 vs another for superiority A few approaches specific regimens vary Remove the focus on the larynx/neck during breathing Abdominal breathing Increased resistance at the lips/mouth ( sh, f, s ) ha + sniff pant Possibly use inspiratory muscle strength training case studies suggesting success in athletes with VCD

16 One Approach (Murry et al, 2010)

17 An Example Approach: cough control

18 Other foci of SLP Tx Relaxation of oropharyngeal musculature (Christopher et al, 1983) Patient education that behavior can be controlled (cognitivebehavioral therapy; Campainha et al, 2012) Visualization re: open throat breathing (Pinhoe et al, 1997) Biofeedback re: breathing (Altman et al, 2000) Multimodality with medical/psychological Tx - many

19 Concluding Thoughts Seems some combo of behavioral, cognitive, psychological, medical intervention can help assumes proper diagnosis Management of triggers is critical some are medical/physiological, others are environmental, still others are behavioral and psychololgical SLP treatment research seems we can be helpful; wanting more stringent assessment of protocols and comparison of approaches so we know what might work best for what patient.