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VCD and Asthma: SLP PerspectiveJeff Searl, Ph.D., CCC-SLPDepartment of Communicative Sciences & DisordersMichigan State University
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 -2015 –
• Inducible Laryngeal Obstruction (ILO)• American College of Chest Physicians; European Respiratory Society;
European Laryngological Society• But not catching on as a universal term
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
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 wihVCD misdx as asthma for average of 9 years; probis 33% with VCD have concomitant asthma (Traister et al 2013)]
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
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
Diagnostically – What the SLP Can Add
• Information on laryngeal …• Structure• Function
• During voice• During swallow• During breathing
– Rest– Activity
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
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)
attempting to
Multidisciplinary Team for Dx – SLP has a part
• Pulmonology, Asthma, Allergy specialists• ENT• Psychology/Psychiatry• GI• Neurology• Endocrinology• Infectious Disease• Athletic trainer, physical therapist
Treatment Approach – multipronged and multidisciplinary
Trigger/Irritant Control
Psychological support/counseling
& Education
Address Associated laryngeal behaviors: cough, throat clear
Train breathing techniques: in the
moment, retraining
Asthma control (if appropriate)
Medical
Psych
SLP
Physical-Trainer
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
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
Other foci of SLP Tx• Relaxation of oropharyngeal musculature (Christopher et al, 1983)
• Patient education that behavior can be controlled (cognitive-behavioral 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
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.