Module 4 Vocal Cord Dysfunction

Question 1

What is Vocal Cord Dysfunction [VCD]?

Answer 1

Abnormal adduction of vocal cords producing airflow obstruction at larynx

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Hyper-functional and inappropriate laryngeal closure reflex

Question 2

What is VCD also known as

Answer 2

Paradoxical vocal fold motion

Question 3

What factors can lead to VCD?

Answer 3

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

Question 4

VCD is mistaken for what respiratory disease?

Answer 4

Refractory asthma; asthma that is unresponsive to therapy

(no improvement with bronchodilators and steroids)

Question 5

How can VCD be managed/treated?

Answer 5

• 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

Question 6

True or False:
VCD can co-exist w/asthma

Answer 6

True

Question 7

When do VCD attacks occur?

Answer 7

generally during the day

Question 8

What demographic is most affected by VCD?

Answer 8

Healthcare professionals

usually in adult females

Question 9

Typical age of onset for VCD?

Answer 9

Age of onset is 3+ years, often between 20 - 40 years of age

Question 10

Vocal cord physiology:

What part of the body helps keep the upper airways open?

Answer 10

The Larynx’s helps keep the lungs expanded;sorta of like valve

(provides PEEP during exhalation)

Question 11

what factors affect glottis size?

Answer 11

Both laryngeal and respiratory motor neurons; and as a result vagal reflex activity arising from pulmonary and laryngeal receptors

Question 12

What regulates the function of the larynx?

Answer 12

larynx innervation and vocal cord movement are regulated by the activation of striated muscles are both under voluntary and reflexive control

Question 13

How do cases of VCD generally get triggered?

Answer 13

Exposure to irritates or allergen
-2nd exposures are more aggressive

Psychogenic factors in adults are rare
(stress or trauma)

Question 14

Etiology of VCD:
Once exposed to irritants/allergens, what happens to airways?

Answer 14

Function ceases; leading to intermittent episodes of functional airway obstruction

Question 15

Clinical manifestations of VCD?

Answer 15

Sudden episodes of SOB w/signs/symptoms similar to asthma exacerbations

Question 16

VCD is symptoms/signs

Answer 16

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

Question 17

Is VCD responsive to bronchodilators and corticosteroids?

Answer 17

No

• Have min affect unless VCD is paired with asthma

Question 18

Are physical exams a good indicator of VCD?

Answer 18

Nah

Question 19

What do Pulmonary Function Test for VCD reflect on a patient at rest?

Answer 19

Nothing; they’re asymptomatic (normal)

Normal lung volumes,
- no bronchodilator response
- high residual volumes

Question 20

What do Pulmonary Function Test for VCD reflect on a patient during attack?

Answer 20

Flattened inspiratory limb w/variable extrathoracic or fixed, anatomical obstruction

Spirometers only suggestive, not diagnostic

Question 21

What is the gold standard for diagnosing a symptomatic patient of VCD?

Answer 21

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

Question 22

Diagnosing a asymptomatic patient

Answer 22

Normal laryngoscopy in asymptomatic patients

Question 23

what do vocal cords act like for Asymptomatic patients?

Answer 23

vocal cord abduction suggest no VCD

Question 24

What can induce VCD in asymptomatic patients?

Answer 24

Exercise or bronchial challenge

Question 25

Differential diagnosis for VCD?

Answer 25

Basically any causes for upper airway obstruction. -Bilateral vocal cord paralysis = most common -Larngomalacia -CNS disorders -irritants/infections,asthma -neoplasms etc.

Question 26

Early treatment for VCD?

Answer 26

1. Speech therapy 2. Breathing exercises

Question 27

What is the first line of treatment for VCD and why is it important?

Answer 27

Speech therapy; teaches pts relaxation and breathing techniques for their vocal cords Important bc: *-Decreases muscle tone by focusing on expiration instead of inspiration*

Question 28

What is sniff lung?

Answer 28

A breathing exercise that resembles shallow panting.

Question 29

When are breathing exercise practiced for VCD?

Answer 29

When asymptomatic need during an attack.

Question 30

2 main breathing exercises for VCD?

Answer 30

Abdominal breathing Sniff lung

Question 31

How does the breathing exercise known as abdominal breathing work? *EDIT - Refer to slide 18*

Answer 31

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.

Question 32

9. main Treatments for VCD

Answer 32

1. Relaxation techniques 2. Heliox Therapy 3. CPAP therapy 4. Intubation or tracheostomy (severe cases) 5. Inhaled anticholinergic agent 6. Botulinum toxin 7. Topical Lidocaine 8. Counselling 9. Antidepressants and anxiolytics (not typical)

Question 33

When would you use the following treatment plans for VCD: Relaxation techniques

Answer 33

Used for neck, shoulder, chest, and oropharyngeal muscles when they’re tight/spamming/shut

Question 34

When would you use the following treatment plans for VCD? Heliox therapy

Answer 34

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.*

Question 35

Heliox Therapy is the admin of a mixture of helium and oxygen optimally effective at a 70 : 30 mixture. Why do we do this?

Answer 35

*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.

Question 36

when would you use CPAP as a therapy for VCD?

Answer 36

If person also suffers from sleep apnea

Question 37

What is a common inhaled anticholinergic agent? why is it important?

Answer 37

Atrovent May be helpful in exercise induced VCD

Question 38

What is the purpose of Botulinum toxin, give a example of it.

Answer 38

Blocks Ach release, creating laryngeal muscle weakness (experimental) I.E -Botox - intralaryngeal inj

Question 39

What does a Topical lidocaine treatment look like for VCD?

Answer 39

Breaks cycle of hyperactive glottal and supraglottal muscle contractions

Question 40

Asthma vs VCD *edit* Insert slide 23

Answer 40

They have similar symptoms, but w/inverse/opposite affects. i.e Asthma = usually expiratory difficulty VCD = usually inspiratory dyspnea

Question 41

Why is it important to to relieve asthma before VCD if signs of both are prevalent?

Answer 41

Relive asthma may allow the pt to relax enough to control their VCD. Reversing VCD should also, in kind, resolve the pts asthma

Question 42

The vagus nerve (cranial nerve X) plays a role in regulation of glottic size, What does the glottis do? - why is it important?

Answer 42

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.

Question 43

All the following could cause adduction of the vocal cords on inspiration except? a. dust b. stress. c. GERD d. Air trapping

Answer 43

Air trapping - interesting note, GERD can cause VCD because of acid/digestive enzyme flow back up into the throat causing irritation -> VCD