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. swallowing, coughing, etc…
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) Munchausen’s Stridor
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

16. 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

17. 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

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

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

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

21. 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

22. 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)

23. 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?

24. 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

25. 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

26. 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

27. 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

28. EI-PVCD versus Exercise Induced Asthma

29. 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

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

31. 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?

32. 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

33. 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?

34. 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

35. Laryngeal Supraglottic Hyperfunction
arytenoid compression
ventricular compression
Limited airway for phonation

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

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

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

39. 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

40. 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

41. Pattern of dyspneic Sudden onset and More gradual onset event
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 systemic
corticosteroids

42. 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

43. 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

44. 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

45. 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?

46. 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

47. 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

48. 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

49. Therapeutic goals and methods
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

50. Therapeutic goals and methods
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

51. Speech Therapy Patient Counseling & Education
Description of laryngeal events
Viewing of laryngoscopy tape
Relate parallels to other stress induced disorders: migraine, irritable colon, muscle tension dysphonia, GEReflux
Flexible endoscopic biofeedback
Sensory biofeedback (sEMG)

52. Speech Therapy Respiratory training
Low “diaphragmatic” breathing versus “high” clavicular thoracic
Rhythmic respiratory cycles
Use resistance exhale (draw attention away from larynx and extend exhale)
Prevention and coping strategies during episodes = Action Plan

53. Back Pressure Breathing
Nasal Sniff = OPEN cords
Prolonged exhalation /w/, /f/, /sh/, /s/
Shoulders relaxed
Throat open
Implement when laying, sitting, standing, walking, jogging, running, playing sports, etc

54. Relaxation Training Goal Methods
Teach the patient to relax focal areas then the entire body during an episode of respiratory distress
Methods
Use progressive relaxation with guided imagery
Explore the patient’s visual concept of their disorder and alter

55. ST Duration: The CCHS Approach
2-8 sessions
Average 4 sessions
Followed by clinical observation during sport/ game
Followup phone / contact: tell me how it is going?
Re-evaluation as necessary, if symptoms reoccur (rarely)

56. CASE DISCUSSION 14 year old female Sports: field hockey, soccer
Travel soccer U-17 team/ midfiled
Initial symptoms: ‘throat closes’ ~5 minutes in to game; hand on throat; signals coach; pulled from game; 20 minute recovery: lying on sideline

57. Therapy Focus and Outcome
5 sessions
Breathing 101
Training from static to active movement/ running
Full coaching then observation of strategy implemetation in therapy and during game
Outcome: (-) sx during mile run; cool down routine implemented; minute game play/ no EI-VCD w/ ‘game plan’

58. Case Discussion #2 14 year old female
Sports: cross country; basketball
Initial Symptoms: ‘throat closed’ during CC trials; had to ‘drop out’
Secondary Symptoms: inspiratory stridor when wearing mouth guard/ basketball; felt ‘faint’

59. Therapy Focus and Outcome
5 sessions
Goals: establish ‘low’ AD breathing/ eliminate shoulder elevation and CT respiration pattern; train in back pressure breathing w/ and w/out mouthguard during activities of progressive effort including walk; jog; stairs, treadmill; suicide drills; BB drills; sprints, etc

60. Outcome
Successful resolution of PVFM during 20 minute runs and when playing BB
Increased awareness of AD versus CT respiration
Habituated alternate use of sniff/ pant – blow, etc.
Increased perceived ‘control’ over breathing and performance
Spring Sport pending: soccer

61. REFERENCES
Brugman, S. M., & Newman, K. (1993). Vocal cord dysfunction. Medical/Scientific Update
Christopher, K. L., WoodII, R. P., Eckert, R. C., Blager, F. B., Raney, R. A., & Souhrada, J. F. (1983). Vocal-cord dysfunction presenting as asthma. The New England Journal of Medicine
Gavin, L. A., Wamboldt, M., Brugman, S., Roesler, T. A., & Wamboldt, F. (1998). Psychological and family characteristics of adolescents with vocal cord dysfunction. Journal of Asthma
Martin, R. J., Blager, F. B., Gay, M. L., & WoodII, R. P. (1987). Paradoxic vocal cord motion in presumed asthmatics. Seminars in Respiratory Medicine

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Sandage et. al. Paradoxical vocal fold motion in children and adolescents. Lang. Speech Hear. Serv. Sch. 2004: 35 (4)
Vlahakis NE, Patel AM, Maragos NE, Beck KC. Diagnosis of Vocal Cord Dysfunction: The Utility of Spirometry and Plethysmography. Chest 2002; 122:
Nastasi, K. J., Howard, D. A., Raby, R. B., Lew, D. B., & Blaiss, M. S. (1997). Airway fluoroscopic diagnosis of vocal cord dysfunction syndrome. Annals of Allergy, Asthma, Immunology

63. Powell DM, Karanfilov BI, Beechler KB, Treole K, Trudeau MD, Forrest L
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