Why Can t I breathe? Asthma vs. Vocal Cord Dysfunction (VCD) Lindsey Frohn, M.S., CCC-SLP Madonna Rehabilitation Hospital (Lincoln, NE)

Transcription

1 Why Can t I breathe? Asthma vs. Vocal Cord Dysfunction (VCD) Lindsey Frohn, M.S., CCC-SLP Madonna Rehabilitation Hospital (Lincoln, NE)

2 Objectives Examine Vocal Cord Dysfunction Examine Exercise Induced Asthma Differentiate Symptoms of Asthma and VCD for Differential Diagnosis Identify Potential Risk Factors and Triggers for VCD Appraise Referral Sources if VCD is Suspected Analyze the Role of Speech Pathologist for VCD Summary

3 Examining VCD: Historical Background Dunglison: hysteria William Osler: laryngeal muscle spasms during times of great distress Downing et al: factitious asthma Patterson et al: Munchhausen s stridor Christopher et al: vocal cord dysfunction Present - paradoxical vocal fold motion or vocal cord dysfunction still widely used

4 Examining VCD: Laryngeal Anatomy

5 Examining VCD: Normal Breathing Patterns In the normal larynx, the vocal folds abduct (open) during inspiration and partially adduct (close) during expiration (so all of your air isn t lost at once helps with efficient exhale). Abduction can also be induced by sniffing and panting Complete adduction of the vocal folds occurs with phonation, coughing, throat clearing, swallowing.

6 Examining VCD: Paradoxical Breathing Patterns Paradoxical vocal fold motion can be seen during inspiration, expiration, or both Vocal folds are adducted on inhalation (causing stridor) Vocal folds are abducted on exhalation (reduced efficiency, all air rushes out at once causing shortness of breath

7 Examining VCD: Other Names for VCD Paradoxical Vocal Fold Movement Episodic Paroxysmal Laryngospasm Munchausen s Stridor

8 Examining VCD: Demographics 3:1 female-to-male ratio Primarily young patients yrs Often in athletes, competitive personalities, high achieving individuals, anxiety is a common trait. Recent literature suggests an increase in prevalence in children and adolescents In infants it is often diagnosed as laryngospasms.

9 Examining Exercise Induced Asthma More accurate description is exerciseinduced bronchoconstriction (EIB). Constricting of the lungs, triggered typically by exercise Airway narrowing as a result of exercise. Managed best with medications. Can co-exist with asthma, and with VCD. Symptoms continue long after onset do not resolve very quickly.

10 Differential Diagnosis: Asthma vs. VCD Symptom Onset Recovery From Symptoms Perceptions of Tightness Sounds Involved Medication Effectiveness Vocal Cord Dysfunction 5 minutes within starting activity/presentation of trigger 5-10 minutes to fully recover from symptoms More in throat area, sometimes moving down to upper chest area Stridor, voicing on inhale Medications do not help symptoms Exercise Induced Asthma 10 minutes within starting activity minutes to fully recover from symptoms More in chest area Wheeze, chest sound Good response to medications

11 Differential Diagnosis: Worst Case Scenarios Worst Case for VCD: Pass out from reduced oxygen flow, but symptoms stop and resolve. Worst Case for Asthma: Death

12 Differential Diagnosis: What to Rule Out Asthma (can co-exist with VCD in anywhere of 40-60% of patients) Laryngospasm Infant and geriatric population, complete airway obstruction, limited time course (sec to min) Laryngeal angioedema (i.e. anaphylaxis) Bilateral vocal cord paralysis Glottic and subglottic stenosis Narrowing of larynx due to webbing, fibrosis, scarring requires dilation of the airway Foreign body obstruction

13 Risk Factors and Common Triggers: Prevalence Females more so than males Athletic individuals/super athletes Competitive personalities Voice abusers/over users

14 Triggers for VCD Asthma can often coexist Exercise predominantly in young female athletes Irritants - dust, smoke, chemicals GERD Postnasal drip due to allergens, irritants Neurologic injury after thyroid or C-spine surgery (rare)

15 Triggers Continued Stress commonly associated with prior psych illness (e.g. depression, generalized anxiety disorder, personality disorders, PTSD, sexual abuse) Emotional upset Post-extubation Changes in air temperature (really cold or hot and humid)

16 Appropriate Referrals if VCD is Suspected If VCD is suspected, a referral for further diagnosis is optimal: Primarily a referral to an Immunologist or an Otolaryngologist (ENT) is optimal. They can conduct Pulmonary Function testing and/or a flexible laryngoscopy for further insight into the respiratory system and vocal cord functioning. If VCD is indicated, typically the patient will then be referred for speech therapy.

17 Appropriate Referrals if VCD is Suspected Further potential appropriate referrals: If a psychological factor is suspected, a referral to a counselor or a sports psychologist may be warranted. University of Nebraska is a potential resource If reflux is a trigger, a diet or exercise coach can be considered.

18 Recap: What is VCD? Vocal Cord Dysfunction (VCD) is also known as paradoxical vocal fold movement (PVFM) Normal breathing pattern: Inhalation: vocal cords are open (abducted) to allow maximal intake of air. Exhalation: vocal cords remain slightly closed so as to maximize our exhale by not letting the air all rush out at once, leaving us short of breath. Paradoxical breathing pattern: Inhalation: vocal cords are closed (abducted) typically producing stridor and restricting airflow in.

19 Role of Speech Therapy in VCD Overall Goal of Therapy: To retrain the paradoxical breathing pattern To restore confidence, to teach that you are in control, it is not your breathing controlling you Therapy Objectives Education Respiratory/Relaxation techniques at rest during activity that typically triggers VCD attack Negative practice Home exercise program

20 Speech Therapy Objectives Education Aiding in visualization and understanding of laryngeal structures typically, and during a VCD attack. Use of pictures, videos, drawings, demonstrations Teaching voice terminology for further understanding

21 Speech Therapy Objectives Education Counseling Providing the knowledge to patients that they can be in control of their breathing rather than their breathing controlling them. Determining patient s motivation to improve Describing expectations of patient and role of speech-language pathologist

22 Speech Therapy Objectives Respiratory Techniques Aimed to take attention away from tightness in the laryngeal region and focus on the front of the face/mouth. Slowing the direction of the breath Fast inhale, prolonged exhale Sniff inhale, s sound exhale focusing more on the exhale, taking focus away from problem Focused on low abdominal breathing Diaphragmatic breathing, belly breathing Directing air downward pushing air down to fill the gas tank

23 Speech Therapy Objectives Relaxation Techniques Use of visualization to picture air going in This is where education portion of therapy becomes especially important Increases self-awareness of breathing sequence

24 Speech Therapy Objectives Home Program Purpose is to make exercises habitual so that patient can initiate techniques during onset of an attack. X times per day, Y number of repetitions each time Help patient identify regular intervals to fit exercises into daily schedule In the morning before getting up Before bed

25 Duration of VCD Therapy Varies with each patient A few sessions to 6-8 weeks. Duration is based on patient progress

26 Outcomes Discharge Decisions Can the patient demonstrate independence with breathing exercises? at rest within a setting where the attack typically occurs Is the patient completing exercises daily, a few times a day. Have patient utilize a log/journal for accountability. Have the attacks decreased in frequency? Is the patient reporting success with

27 Summary VCD (or PVFM) is an under-recognized disorder that can result from many different etiologies Most patients with PVFM are misdiagnosed as having asthma or anaphylaxis PVFM can co-exist with asthma, rendering the diagnosis even more challenging Spirometry/respiratory loop testing can be helpful but is neither sensitive or specific for PVFM Gold standard requires demonstration of abnormal adduction of the vocal folds on

28 Summary Speech therapy is the cornerstone of longterm management with excellent prognosis GERD, post nasal drip, and stress are common co-morbidities that may require treatment

29 About the presenters Lindsey Frohn has 4 years experience as a pediatric outpatient speech-language pathologist at Madonna Rehabilitation Hospital. Lindsey received her masters degree from the University of Nebraska-Lincoln. lfrohn@madonna.org,

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31 References Deckart, J. & Deckart, L. (2010) Vocal Cord Dysfunction. American Family Physician. Volume 81, Issue 2. Retrieved from: Koufman, J. A., & Block, C. (2008). Differential diagnosis of paradoxical vocal fold movement. American Journal of Speech- Language Pathology, 17(4), Parsons, J. P., Hallstrand, T. S., Mastronarde, J. G., Kaminsky, D. A., Rundell, K. W., Hull, J. H.,... & Anderson, S. D. (2013). An official American Thoracic Society clinical practice guideline: exercise-induced bronchoconstriction. American journal of respiratory and critical care medicine, 187(9), Ross, L. (2009). Vocal Cord Dysfunction: Something to Talk About. Allergy & Asthma Today. Volume 6, Issue 1. Retrieved from: Sandage, M. J., & Zelazny, S. K. (2004). Paradoxical vocal fold motion in children and adolescents. Language, Speech, and Hearing Services in Schools, 35(4),