Module 4 Vocal Cord Dysfunction Flashcards
What is Vocal Cord Dysfunction [VCD]?
Abnormal adduction of vocal cords producing airflow obstruction at larynx
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Hyper-functional and inappropriate laryngeal closure reflex
What is VCD also known as
Paradoxical vocal fold motion
What factors can lead to VCD?
Repeated stimulation and excitation by noxious intrinsic and extrinsic irritants can cause nerve fibres to become hyper excitable and hyper responsive.
i.e think irritation (inflammation) and tension (leads to collaspe) in the chords
VCD is mistaken for what respiratory disease?
Refractory asthma; asthma that is unresponsive to therapy
(no improvement with bronchodilators and steroids)
How can VCD be managed/treated?
- Generally: breathing techniques and speech therapy to help control/relax muscles
- If possible, identify and try to avoid triggers.
- w/Inhaled or systemic corticosteroids, bronchodilators to help relieve symptoms (min affect)
Extreme cases:
hospitalizations, and intubation and tracheostomies
True or False:
VCD can co-exist w/asthma
True
When do VCD attacks occur?
generally during the day
What demographic is most affected by VCD?
Healthcare professionals
usually in adult females
Typical age of onset for VCD?
Age of onset is 3+ years, often between 20 - 40 years of age
Vocal cord physiology:
What part of the body helps keep the upper airways open?
The Larynx’s helps keep the lungs expanded;sorta of like valve
(provides PEEP during exhalation)
what factors affect glottis size?
Both laryngeal and respiratory motor neurons; and as a result vagal reflex activity arising from pulmonary and laryngeal receptors
What regulates the function of the larynx?
larynx innervation and vocal cord movement are regulated by the activation of striated muscles are both under voluntary and reflexive control
How do cases of VCD generally get triggered?
Exposure to irritates or allergen
-2nd exposures are more aggressive
Psychogenic factors in adults are rare
(stress or trauma)
Etiology of VCD:
Once exposed to irritants/allergens, what happens to airways?
Function ceases; leading to intermittent episodes of functional airway obstruction
Clinical manifestations of VCD?
Sudden episodes of SOB w/signs/symptoms similar to asthma exacerbations
VCD is symptoms/signs
Dyspnea on exertion / SOB
Inspiratory difficulty / Barking cough
Wheezing, Stridor
Sore throat/ hoarseness/ tightness
Dysphonia and voice changes
Dysphagia
Tachypnea and associated paresthesia
Retractions, chest tightness/burning pain
Dizziness/low LOC
Is VCD responsive to bronchodilators and corticosteroids?
No
- Have min affect unless VCD is paired with asthma
Are physical exams a good indicator of VCD?
Nah
What do Pulmonary Function Test for VCD reflect on a patient at rest?
Nothing; they’re asymptomatic (normal)
Normal lung volumes,
- no bronchodilator response
- high residual volumes
What do Pulmonary Function Test for VCD reflect on a patient during attack?
Flattened inspiratory limb w/variable extrathoracic or fixed, anatomical obstruction
Spirometers only suggestive, not diagnostic
What is the gold standard for diagnosing a symptomatic patient of VCD?
Laryngoscopy during acute attack visualizing vocal cords
Adduction of anterior 2/3 of vocal cords w/posterior chinking creating diamond shape primarily during inspiration but may occur during expiration
Diagnosing a asymptomatic patient
Normal laryngoscopy in asymptomatic patients
what do vocal cords act like for Asymptomatic patients?
vocal cord abduction suggest no VCD
What can induce VCD in asymptomatic patients?
Exercise or bronchial challenge
Differential diagnosis for VCD?
Basically any causes for upper airway obstruction.
-Bilateral vocal cord paralysis = most common
-Larngomalacia
-CNS disorders
-irritants/infections,asthma
-neoplasms
etc.
Early treatment for VCD?
- Speech therapy
- Breathing exercises
What is the first line of treatment for VCD and why is it important?
Speech therapy; teaches pts relaxation and breathing techniques for their vocal cords
Important bc:
-Decreases muscle tone by focusing on expiration instead of inspiration
What is sniff lung?
A breathing exercise that resembles shallow panting.
When are breathing exercise practiced for VCD?
When asymptomatic need during an attack.
2 main breathing exercises for VCD?
Abdominal breathing
Sniff lung
How does the breathing exercise known as abdominal breathing work?
EDIT - Refer to slide 18
slows inhalation via relaxed throat by placing tongue on floor of mouth behind lower from teeth while partially closing lips as abdomen expands.
Exhalation w/gentle “s” sound as abdomen contracts.
- main Treatments for VCD
- Relaxation techniques
- Heliox Therapy
- CPAP therapy
- Intubation or tracheostomy (severe cases)
- Inhaled anticholinergic agent
- Botulinum toxin
- Topical Lidocaine
- Counselling
- Antidepressants and anxiolytics (not typical)
When would you use the following treatment plans for VCD:
Relaxation techniques
Used for neck, shoulder, chest, and oropharyngeal muscles when they’re tight/spamming/shut
When would you use the following treatment plans for VCD?
Heliox therapy
Improves oxygen delivery and utilization during dynamic exercise in patients with chronic obstructive pulmonary disease.
- Breathing He-O2 increases ventilation but does not decrease the work of breathing during exercise.*
Heliox Therapy is the admin of a mixture of helium and oxygen optimally effective at a 70 : 30 mixture.
Why do we do this?
Heliox may be useful in acute severe asthma refractory to conventional treatment.
Shown to improve the delivery and deposition of nebulized albuterol.
Caveat:
If a patient requires more than 30% oxygen, it cannot be used.
when would you use CPAP as a therapy for VCD?
If person also suffers from sleep apnea
What is a common inhaled anticholinergic agent?
why is it important?
Atrovent
May be helpful in exercise induced VCD
What is the purpose of Botulinum toxin, give a example of it.
Blocks Ach release, creating laryngeal muscle weakness (experimental)
I.E
-Botox - intralaryngeal inj
What does a Topical lidocaine treatment look like for VCD?
Breaks cycle of hyperactive glottal and supraglottal muscle contractions
Asthma vs VCD
edit
Insert slide 23
They have similar symptoms, but w/inverse/opposite affects.
i.e
Asthma = usually expiratory difficulty
VCD = usually inspiratory dyspnea
Why is it important to to relieve asthma before VCD if signs of both are prevalent?
Relive asthma may allow the pt to relax enough to control their VCD.
Reversing VCD should also, in kind, resolve the pts asthma
The vagus nerve (cranial nerve X) plays a role in regulation of glottic size, What does the glottis do?
- why is it important?
The glottis is the opening between the vocal cords in the larynx.
Importance:
- The vagus nerve can cause the constriction of the opening. It protects airways and controls airflow. (its the flap).
Recall:
The larynx which allows air to pass through during breathing and sound production.
All the following could cause adduction of the vocal cords on inspiration except?
a. dust
b. stress.
c. GERD
d. Air trapping
Air trapping
- interesting note, GERD can cause VCD because of acid/digestive enzyme flow back up into the throat causing irritation -> VCD
