Chronic cough in Vocal Cord Dysfunction: Description of a clinical entity

Measurement of respiratory-swallowing coordination using an oronasal facemask in healthy individuals

Respiratory-swallowing coordination (RSC) is well established as an essential airway-protective mechanism. Previous studies have used nasal airflow and/or kinematic rib cage and abdominal measures to assess respiration surrounding swallowing, meaning that the direct influence of oral respiration on RSC remains unknown. This study used a partitioned oronasal facemask to compare respiratory phase patterns measured using isolated nasal airflow with those measured using combined oronasal airflow during non-ingestive and ingestive swallowing tasks. Twenty-four healthy individuals with no respiratory or swallowing disorders were assessed at rest and during cued dry, 10 mL water, continuous drinking and cracker swallowing tasks. Respiratory phase patterns were determined for discrete swallows using the nasal and combined oronasal channels separately. There was variable agreement between respiratory phase patterns according to the nasal and oronasal channels across swallowing conditions. The frequency of exhale-swallow-exhale, inhale-swallow-exhale and exhale-swallow-inhale patterns increased by 2%-3% each with the addition of oral flow data to nasal data, whereas the prevalence of inhale-swallow-inhale and ambiguous patterns decreased. This suggests that estimates of respiratory phase patterns are altered minimally by inclusion of oral respiratory estimates in a healthy sample. There were several additional findings of note, including lower within-participant, within-session trial consistency (test-retest reliability) than expected, suggesting high variability in respiratory phase patterns across trials. Additionally, data showed evidence of swallowing non-respiratory flow at the beginning and end of the respiratory-swallowing pause, moving in both inward and outward directions, potentially expanding current understanding of swallowing non-respiratory flow. Further in-depth physiological investigations are required to improve understanding of these findings.

Awareness and practices of Speech Language Pathologists (SLPs) working with chronic cough in India: a call for action

OBJECTIVE

A cough persisting beyond eight weeks is referred as chronic cough (CC) and is a common symptom of many respiratory conditions and non-respiratory conditions. The role of a speech language pathologist (SLP) in CC is emerging and this study aimed to profile the awareness and practice patterns of SLPs practicing in India.

STUDY DESIGN

Cross-sectional study.

METHOD

An online survey was used to profile the assessment, treatment and counselling practices in CC among SLPs working in India. It sought to identify the awareness levels among SLPs regarding their role and availability of behavioural interventions for CC. Only SLPs who dealt with CC could complete the entire survey while other SLPs, filled regarding awareness and availability of behavioural interventions.

RESULTS

127 eligible responses obtained from SLPs working across clinical settings in India were analysed. 75.59% (n=96) of them had not seen patients with CC in their career. 47.24% (n=60) of them were aware that behavioural interventions were available for CC. Thirty-one SLPs completed the entire survey and their practice patterns indicated that few clinicians used cough-specific protocols while largely relying on voice and swallowing related assessment and treatment for CC.

CONCLUSION

This survey the lack of awareness of SLPs' role in CC and that their practices are dominated by existing procedures for voice and swallowing disorders. Increasing the awareness of SLP's role in CC may increase the caseload of patients referred and expand the SLP's scope of practice. Development of guidelines in CC practice and inclusion in coursework/curriculum are future considerations.

Dysfunctional Breathing in Children: A Literature Review

Dysfunctional breathing (DB) describes a respiratory condition that is mainly characterized by abnormal breathing patterns, affecting both children and adults, often leading to intermittent or chronic complaints and influencing physiological, psychological, and social aspects. Some symptoms include breathlessness; dizziness; palpitations; and anxiety, while its classification lies in breathing pattern disorders and upper airway involvement. Its prevalence among the pediatric population varies with a female overrepresentation, while the existence of comorbidities in DB, such as asthma, gastro-esophageal reflux, nasal diseases, and anxiety/depression, frequently leads to misdiagnosis or underdiagnosis and complicates therapeutic approaches. The basic diagnostic tools involve a detailed history, physical examination, and procedures such as structured light plethysmography, cardiopulmonary exercise testing, and laryngoscopy when a laryngeal obstruction is present. The management of DB presumes a multidimensional approach encompassing breathing retraining, disease-specific advice through speech and language therapy in the presence of laryngeal obstruction, psychotherapy for fostering self-efficacy, and surgical therapy in a structural abnormality. The current review was developed to provide a summary of classifications of DB and epidemiological data concerning the pediatric population, comorbidities, diagnostic tools, and therapeutic approaches to enhance the comprehension and management of DB in children.

Living With Asthma and Vocal Cord Dysfunction/Inducible Laryngeal Obstruction: "I Just Can't Get Air In"

BACKGROUND

Asthma and vocal cord dysfunction (VCD), also known as inducible laryngeal obstruction (ILO), may coexist, resulting in worse outcomes for patients. The experience of people with VCD/ILO and coexisting asthma is unknown.

OBJECTIVE

We sought to determine whether coexistent VCD/ILO and asthma have deleterious impacts on quality of life.

METHODS

We undertook a descriptive qualitative study using one-to-one semistructured interviews with 30 purposively recruited adult participants with a prior confirmed doctor asthma diagnosis and laryngoscopy-confirmed VCD/ILO. A thematic and content analysis was conducted to explore the data.

RESULTS

Participants were mostly female (63%), mean ± SD age 63 ± 12 years. Four themes were identified: trapped voice, altered life, knowledge about VCD/ILO, and looking for solutions. Participants reported their voice being trapped in their throat or the voice being suddenly cut off when talking or singing. Self-reported VCD/ILO symptoms including throat tightness and breathlessness were highlighted by participants. The second theme described how patients struggle to communicate or tended to shorten conversations. Insufficient knowledge and existing confusion regarding whether asthma was causing the breathlessness was described in the third theme. Looking for solutions depicted participants' diagnostic journey and how they sought an explanation for the symptoms.

CONCLUSIONS

People with asthma and coexisting VCD/ILO experience a substantial burden affecting the quality of life. These data describe the impact on patients with coexisting conditions and should be used to increase clinician awareness of the experience of VCD/ILO from patients' perspectives to support a personalized approach to care.

Clinical Parameters of the Speech-Language Pathology Assessment of the Chronic Cough: A Scoping Review

OBJECTIVE

to map the clinical parameters used in the speech-language pathology assessment of the chronic cough.

METHODS

a scoping review was performed to answer the clinical question: "What are the clinical parameters included in the speech-language pathology assessment of patients with chronic cough?" Evidence was searched by electronic and manual search. The electronic search included: MEDLINE, Cochrane Library, EMBASE, Web of Science, SCOPUS, and LILACS. Each database had a specific search strategy. The manual search included Journal of Voice, Chest, and Thorax, Brazilian Library of Theses and Dissertations, Open Grey, and Clinical Trials, in addition to scanning the references of the included studies. The extracted data considered information regarding the publication, sample, assessment, and measures used when assessing chronic cough.

RESULTS

the electronic search found 289 studies; the manual search found 1036 studies; 12 were selected for the present study. The most used assessments were: self-assessment (75%), aerodynamic analysis (66.67%), the perceptual auditory judgment of the voice quality (58.33%), acoustic analysis of the voice (41.67%), cough frequency, and cough threshold (41.67%) and electroglottography (25%).

CONCLUSIONS

the subjective instruments were used more frequently, while specific objective instruments, which are recent, were used less frequently. Complementary assessments such as vocal assessment, have been frequently used, also, with no other parameter. A lack of homogeneity was identified in the speech-language pathology assessment and measures of patients with chronic cough, thus, the comparison among studies and clinical analysis is difficult.

State of the Art for Refractory Cough: Multidisciplinary Approach

Chronic cough is a common problem that can be refractory to medical treatment. Nonpharmaceutical management of chronic cough has an important role in well selected patients. This review article outlines the history of chronic cough management, current approaches to speech pathology management of the condition and new modalities of nonpharmaceutical treatment. There is a need for further research into nonpharmaceutical options with well described randomised control trials.

Multidisciplinary management of inducible laryngeal obstruction and breathing pattern disorder

We provide an overview of the assessment and management of inducible laryngeal obstruction and breathing pattern disorder. We highlight the multidisciplinary team members involved and their essential roles within a complex breathlessness service. We discuss treatments initiated by physiotherapy and speech and language therapy, the importance of joint working, and discuss the high incidence of comorbidities and the association with other respiratory disorders.

Educational aims

Inducible laryngeal obstruction and breathing pattern disorder are common causes of breathlessness.Inducible laryngeal obstruction is an inappropriate, transient, reversible narrowing of the laryngeal area that causes breathlessness and laryngeal symptoms.Breathing pattern disorder is an alteration in the normal biomechanical patterns of breathing that results in intermittent or chronic symptoms, which may be respiratory and/or non-respiratory.People with inducible laryngeal obstruction or breathing pattern disorder often have other comorbidities that will also need addressing.Multidisciplinary assessment and treatment is essential for comprehensive workup and holistic care.Timely assessment and diagnosis can prevent unnecessary medication use and hospital admissions and facilitate effective management of the condition using reassurance, advice, education, breathing retraining and vocal exercises.

Applying behaviour change theory to speech and language therapy intervention for inducible laryngeal obstruction

BACKGROUND

Speech and language therapists (SLTs) provide interventions for inducible laryngeal obstruction (ILO) despite a current lack of evidence to inform intervention delivery. This study is the first step to develop an evidence-based intervention for ILO, using behaviour change theory and the Behaviour Change Technique Taxonomy version 1 (BCTTv1). Outcomes will inform the early development stage of a complex speech and language therapy intervention for ILO, enabling more precise reporting of ILO intervention studies, as per CONSORT guidelines.

AIMS

(1) To identify whether the BCTTv1 is a useful tool for characterising speech and language therapy interventions for ILO, based on existing literature, current practice and patient interviews. (2) To identify key behaviour change techniques (BCT) used within existing complex speech and language therapy interventions for ILO METHODS AND PROCEDURES: A five-phase study was conducted: (1) a systematic literature search of six electronic databases (Medline, EMBASE, CINAHL (EBSCO), Scopus, Trip, Web of Science) and grey literature between 2008 and 2020; (2) observations of six speech and language therapy intervention sessions; (3) a semi-structured interview with an SLT to validate the observed BCTTs; (4) consensus from four national expert SLTs regarding application of synthesised BCTT data to their own experiences of ILO interventions; and (5) patient engagement to review and comment on findings.

OUTCOMES AND RESULTS

Forty-seven BCTs in total were coded across all three sources. Thirty-two BCTs were identified in clinical observations; 31 in interviews with SLTs and 18 in the literature. Only six BCT were identified in all three sources. Expert SLTs confirmed clinical application and relevance. Patients reported finding the concept of BCT challenging but highlighted the value of psychoeducation to support their understanding of symptoms and in turn to understand the rationale behind speech and language therapy intervention recommendations.

CONCLUSION

This study indicates that the BCTTv1 is a suitable framework to identify and describe intervention components used within speech and language therapy interventions for ILO. A practice-research gap exists, reinforcing that existing literature does not capture the complexity of speech and language therapy intervention for ILO. Further research is needed to develop our understanding of the BCTs that support optimal behaviour change for this patient group.

WHAT THIS PAPER ADDS

What is already known on the subject There is growing recognition for the value of speech and language therapists (SLTs) in delivering complex interventions for patients with inducible laryngeal obstruction (ILO), including evidence to suggest that their intervention can improve quality of life for patients and reduce excessive healthcare use. There are, however, no randomised controlled trials in this field; thus it is unclear what constitutes the most effective intervention. What this study adds This study demonstrates the complexity of speech and language therapy interventions for ILO and highlights the practice-research gap. It identifies a range of behaviour change techniques that are used in existing practice and captures patient views relating to the components identified within this study. What are the clinical implications of this work? Findings highlight the value of providing education about factors that might be driving ILO symptoms and in turn the importance of sharing with patients the rationale for treatment recommendations that necessitate a change in their behaviours. Identified behaviour change techniques can be used when developing and implementing SLT interventions for ILO.

Vocal cord dysfunction/inducible laryngeal obstruction-2022 Melbourne Roundtable Report

Vocal cord dysfunction/inducible laryngeal obstruction (VCD/ILO), is a common condition characterized by breathlessness associated with inappropriate laryngeal narrowing. Important questions remain unresolved, and to improve collaboration and harmonization in the field, we convened an international Roundtable conference on VCD/ILO in Melbourne, Australia. The aims were to delineate a consistent approach to VCD/ILO diagnosis, appraise disease pathogenesis, outline current management and model(s) of care and identify key research questions. This report summarizes discussions, frames key questions and details recommendations. Participants discussed clinical, research and conceptual advances in the context of recent evidence. The condition presents in a heterogenous manner, and diagnosis is often delayed. Definitive diagnosis of VCD/ILO conventionally utilizes laryngoscopy demonstrating inspiratory vocal fold narrowing >50%. Computed tomography of the larynx is a new technology with potential for swift diagnosis that requires validation in clinical pathways. Disease pathogenesis and multimorbidity interactions are complex reflecting a multi-factorial, complex condition, with no single overarching disease mechanism. Currently there is no evidence-based standard of care since randomized trials for treatment are non-existent. Recent multidisciplinary models of care need to be clearly articulated and prospectively investigated. Patient impact and healthcare utilization can be formidable but have largely escaped inquiry and patient perspectives have not been explored. Roundtable participants expressed optimism as collective understanding of this complex condition evolves. The Melbourne VCD/ILO Roundtable 2022 identified clear priorities and future directions for this impactful condition.

Vocal cord dysfunction/inducible laryngeal obstruction: novel diagnostics and therapeutics

INTRODUCTION

Vocal cord dysfunction/inducible laryngeal obstruction (VCD/ILO) is an important medical condition but understanding of the condition is imperfect. It occurs in healthy people but often co-exists with asthma. Models of VCD/ILO pathophysiology highlight predisposing factors rather than specific mechanisms and disease expression varies between people, which is seldom appreciated. Diagnosis is often delayed, and the treatment is not evidence based.

AREAS COVERED

A unified pathophysiological model and disease phenotypes have been proposed. Diagnosis is conventionally made by laryngoscopy during inspiration with vocal cord narrowing >50% Recently, dynamic CT larynx was shown to have high specificity (>80%) with potential as a noninvasive, swift, and quantifiable diagnostic modality. Treatment entails laryngeal retraining with speech pathology intervention and experimental therapies such as botulinum toxin injection. Multidisciplinary team (MDT) clinics are a novel innovation with demonstrated benefits including accurate diagnosis, selection of appropriate treatment, and reductions in oral corticosteroid exposure.

EXPERT OPINION

Delayed diagnosis of VCD/ILO is pervasive, often leading to detrimental treatments. Phenotypes require validation and CT larynx can reduce the necessity for laryngoscopy, thereby fast-tracking diagnosis. MDT clinics can optimize management. Randomized controlled trials are essential to validate speech pathology intervention and other treatment modalities and to establish international standards of care.

The Impact of Functional Laryngoscopy on the Diagnosis of Laryngeal Hypersensitivity Syndromes

BACKGROUND

Chronic cough and vocal cord dysfunction are manifestations of laryngeal hypersensitivity syndrome.

OBJECTIVE

The aim of the study was to determine the clinical utility of functional transnasal laryngoscopy in patients with laryngeal hypersensitivity syndromes.

METHODS

This study was a prospective observational cross-sectional study design of 71 participants with laryngeal hypersensitivity syndrome referred for functional transnasal laryngoscopy. Participants had a clinical assessment with a speech pathologist after which a provisional diagnosis of chronic cough, suspected vocal cord dysfunction, suspected muscle tension dysphonia, or a combination was made. A laryngoscopy with provocation was performed and the diagnosis revised after which the provisional and revised diagnoses were compared.

RESULTS

The diagnosis changed in 67% of participants after laryngoscopy. Vocal cord dysfunction was diagnosed in an additional 17 cases when not expected clinically but discounted when suspected clinically in 12 participants. Muscle tension dysphonia was diagnosed in an additional 31 cases when not suspected clinically and not confirmed when suspected in 2.

CONCLUSION

This study demonstrated that conditions such as muscle tension dysphonia and vocal cord dysfunction cannot be diagnosed based on symptoms alone. In addition to diagnostic accuracy, functional laryngoscopy enhances treatment planning and provides immediate feedback regarding laryngeal movement during respiration and phonation.

Peripheral and central mechanisms of cough hypersensitivity

Chronic cough is a difficult to treat symptom of many respiratory and some non-respiratory diseases, indicating that varied pathologies can underpin the development of chronic cough. However, clinically and experimentally it has been useful to collate these different pathological processes into the single unifying concept of cough hypersensitivity. Cough hypersensitivity syndrome is reflected by troublesome cough often precipitated by levels of stimuli that ordinarily don't cause cough in healthy people, and this appears to be a hallmark feature in many patients with chronic cough. Accordingly, a strong argument has emerged that changes in the excitability and/or normal regulation of the peripheral and central neural circuits responsible for cough are instrumental in establishing cough hypersensitivity and for causing excessive cough in disease. In this review, we explore the current peripheral and central neural mechanisms that are believed to be involved in altered cough sensitivity and present possible links to the mechanism of action of novel therapies that are currently undergoing clinical trials for chronic cough.