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Sarkar M, Madabhavi IV, Mehta S, Mohanty S. Use of flow volume curve to evaluate large airway obstruction. Monaldi Arch Chest Dis 2022; 92. [DOI: 10.4081/monaldi.2022.1947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 01/16/2022] [Indexed: 11/23/2022] Open
Abstract
The flow volume loop (FVL) is a graphic display of airflow against lung volumes at different levels obtained during the maximum inspiratory and expiratory maneuver. It is a simple and reproducible method of lung function assessment. A narrative review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. PubMed, EMBASE, Ovid MEDLINE and CINAHL databases were queried and reviewed for studies pertinent to the various FVLs abnormalities and their mechanisms from January 2020 to December 2020. We used the following search terms; flow-volume loop, upper airway obstruction, Obstructive airway disease, and spirometry. Assessing the shape of the flow-volume loop is particularly helpful in diagnosing and localizing upper airway obstruction. They are also helpful in identifying bronchodilator response to treatment. Characteristic FVLs is also seen in patients with obstructive or restrictive lung disorders. Spirometry should be interpreted using the absolute values for flows and volumes as well as the flow volume and volume time curves.
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Johnston KL, Bradford H, Hodges H, Moore CM, Nauman E, Olin JT. The Olin EILOBI Breathing Techniques: Description and Initial Case Series of Novel Respiratory Retraining Strategies for Athletes with Exercise-Induced Laryngeal Obstruction. J Voice 2017; 32:698-704. [PMID: 29050661 DOI: 10.1016/j.jvoice.2017.08.020] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Revised: 08/13/2017] [Accepted: 08/18/2017] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Exercise-induced laryngeal obstruction (EILO), the condition previously known as paradoxical vocal fold motion and vocal cord dysfunction, is characterized by inappropriate glottic or supraglottic obstruction during high-intensity exercise, causing exertional dyspnea, frequently with stridor. EILO is definitively diagnosed through upper-airway visualization during a characteristic episode. Although respiratory retraining is a primary therapy for EILO, many patients report symptom persistence despite adequate performance of traditional techniques. This report describes three novel breathing techniques for EILO, the Olin EILOBI (EILO biphasic inspiratory) breathing techniques. We include a teaching process and case series with patient-reported assessments. MATERIALS AND METHODS Following descriptions of the techniques and teaching process, we present data from a questionnaire offered to all patients who learned at least one of the techniques between September 2015 and March 2017. Subjects evaluated (1) expectation setting, (2) teaching processes, (3) their ability to implement the techniques during high-intensity exercise, and (4) perceived clinical effectiveness. RESULTS Ninety-five percent of eligible patients participated, a primarily young, female, and Caucasian sample. Over 50% of subjects competed at the high school varsity level. Sixty-two percent of subjects perceived reasonable expectations, and 82% positively evaluated the teaching process. Seventy-nine percent were able to employ their technique in the high-intensity activity of choice, and 66% perceived clinical effectiveness with the techniques. CONCLUSIONS The Olin EILOBI breathing techniques are novel respiratory retraining techniques for use in high-intensity exercise. Case series subjects reported reasonable expectations, a helpful teaching process, the ability to use these techniques during high-intensity exercise, and perceived clinical effectiveness.
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Affiliation(s)
- Kristina L Johnston
- Department of Rehabilitation Medicine, National Jewish Health, Denver, Colorado
| | - Hannah Bradford
- Department of Pediatrics, National Jewish Health, Denver, Colorado
| | - Heather Hodges
- Department of Rehabilitation Medicine, National Jewish Health, Denver, Colorado
| | - Camille M Moore
- Division of Biostatistics & Bioinformatics, National Jewish Health, Denver, Colorado
| | - Emily Nauman
- Department of Rehabilitation Medicine, National Jewish Health, Denver, Colorado
| | - J Tod Olin
- Department of Pediatrics, National Jewish Health, Denver, Colorado.
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Garcia-Neuer M, Lynch DM, Marquis K, Dowdall J, Castells M, Sloane DE. Drug-Induced Paradoxical Vocal Fold Motion. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2017; 6:90-94. [PMID: 29037819 DOI: 10.1016/j.jaip.2017.08.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Revised: 07/20/2017] [Accepted: 08/08/2017] [Indexed: 10/18/2022]
Abstract
Vocal cord dysfunction, also known as paradoxical vocal fold motion (PVFM), is a disorder characterized by abnormal vocal cord adduction during inspiration. PVFM is commonly misdiagnosed as asthma because of the similarity of symptoms: cough, wheezing, chest pain, and dyspnea. We present the clinical vignette of a 36-year-old woman with juvenile rheumatoid arthritis and multiple adverse drug reactions who presented with recurrent episodes of unrecognized PVFM during skin testing for drug allergy, omalizumab treatment, and tocilizumab desensitization. Before the diagnosis of PVFM, these episodes were treated as anaphylaxis, including the administration of epinephrine. Once diagnosed and treated for PVFM, the patient did not present any further events and continued treatment for drug allergy. PVFM may be underreported in hypersensitivity reactions because of the similarity to Type 1-mediated respiratory symptoms and comorbid asthma.
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Affiliation(s)
- Marlene Garcia-Neuer
- Division of Rheumatology, Allergy and Immunology, Brigham and Women's Hospital, Boston, Mass
| | - Donna Marie Lynch
- Division of Rheumatology, Allergy and Immunology, Brigham and Women's Hospital, Boston, Mass
| | | | - Jayme Dowdall
- Division of Otolaryngology, Department of Surgery, Brigham and Women's Hospital, Boston, Mass; Harvard Medical School, Boston, Mass
| | - Mariana Castells
- Division of Rheumatology, Allergy and Immunology, Brigham and Women's Hospital, Boston, Mass; Harvard Medical School, Boston, Mass
| | - David Edward Sloane
- Division of Rheumatology, Allergy and Immunology, Brigham and Women's Hospital, Boston, Mass; Harvard Medical School, Boston, Mass.
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Denipah N, Dominguez CM, Kraai EP, Kraai TL, Leos P, Braude D. Acute Management of Paradoxical Vocal Fold Motion (Vocal Cord Dysfunction). Ann Emerg Med 2017; 69:18-23. [PMID: 27522309 DOI: 10.1016/j.annemergmed.2016.06.045] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Revised: 06/27/2016] [Accepted: 06/28/2016] [Indexed: 11/25/2022]
Abstract
Paradoxical vocal fold motion disorder, also commonly termed vocal cord dysfunction, is a poorly understood cause of acute upper airway obstruction. Patients with paradoxical vocal fold motion frequently present to the emergency department (ED) with acute respiratory distress and stridor. Lack of familiarity with this disorder may lead to delayed diagnosis or misdiagnosis and unnecessary intubations or surgical airway procedures. Although long-term management of paradoxical vocal fold motion is well described, there is a paucity of information about acute evaluation and management. This article aims to summarize the ED presentation and management of paradoxical vocal fold motion.
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Affiliation(s)
- Nizhoni Denipah
- Department of Surgery, Division of Otolaryngology Head and Neck Surgery, University of New Mexico Health Sciences Center, Albuquerque, NM
| | - Christopher M Dominguez
- Division of General Surgery, University of New Mexico Health Sciences Center, Albuquerque, NM
| | - Erik P Kraai
- Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM
| | - Tania L Kraai
- Department of Surgery, Division of Otolaryngology Head and Neck Surgery, University of New Mexico Health Sciences Center, Albuquerque, NM
| | - Paul Leos
- Department of Speech Pathology, University of New Mexico Health Sciences Center, Albuquerque, NM
| | - Darren Braude
- Departments of Emergency Medicine and Anesthesiology, University of New Mexico Health Sciences Center, Albuquerque, NM.
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Taher H, Samuelson M, Gehlbach B, Gross T. A young man with dyspnoea and audible expiration: the loops never lie. Breathe (Sheff) 2016; 12:159-63. [PMID: 27408634 PMCID: PMC4933619 DOI: 10.1183/20734735.007015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Spirometry provides clues to solving this puzzle of dyspnoea and wheeze in a young nonsmoker-the loops never lie! http://ow.ly/YC9zI A 10 s recording of expiratory sounds from this case can be found at: http://ow.ly/UVVu300moD1.
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Affiliation(s)
- Hisham Taher
- Dept of Internal Medicine, Carver College of Medicine and the University of Iowa, Iowa City, IA, USA
| | - Megan Samuelson
- Dept of Pathology, Carver College of Medicine and the University of Iowa, Iowa City, IA, USA
| | - Brian Gehlbach
- Dept of Internal Medicine, Carver College of Medicine and the University of Iowa, Iowa City, IA, USA
| | - Thomas Gross
- Dept of Internal Medicine, Carver College of Medicine and the University of Iowa, Iowa City, IA, USA
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Christensen PM, Heimdal JH, Christopher KL, Bucca C, Cantarella G, Friedrich G, Halvorsen T, Herth F, Jung H, Morris MJ, Remacle M, Rasmussen N, Wilson JA. ERS/ELS/ACCP 2013 international consensus conference nomenclature on inducible laryngeal obstructions. Eur Respir Rev 2015; 24:445-50. [DOI: 10.1183/16000617.00006513] [Citation(s) in RCA: 96] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Individuals reporting episodes of breathing problems caused by re-occurring variable airflow obstructions in the larynx have been described in an increasing number of publications, with more than 40 different terms being used without consensus on definitions. This lack of an international consensus on nomenclature is a serious obstacle for the development of the area, as knowledge from different centres cannot be matched, pooled or readily utilised by others. Thus, an international Task Force has been created, led by the European Respiratory Society/European Laryngological Society/American College of Chest Physicians. This review describes the methods used to reach an international consensus on the subject and the resulting nomenclature, the 2013 international consensus conference nomenclature.
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Marcinow AM, Thompson J, Forrest LA, deSilva BW. Irritant-Induced Paradoxical Vocal Fold Motion Disorder. Otolaryngol Head Neck Surg 2015; 153:996-1000. [DOI: 10.1177/0194599815600144] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Accepted: 07/22/2015] [Indexed: 11/17/2022]
Abstract
Objectives To review our experience with the diagnosis and treatment of irritant-induced paradoxical vocal fold motion disorder (IPVFMD). Study Design Retrospective chart review. Setting Tertiary academic referral center. Subjects and Methods Thirty-four cases that met IPVFMD criteria and 76 cases of non-IPVFMD were selected from a database of patients with paradoxical vocal fold motion disorder—the diagnosis of which was made on the basis of flexible fiberoptic laryngoscopy and augmented by an odor challenge. Clinical charts were reviewed to document history of environmental allergies, pulmonary disease, gastroesophageal reflux, psychiatric disorder, fibromyalgia, tobacco use, alcohol use, dysphonia, cough, dysphagia, and treatment outcomes. Results There were no statistical differences between the IPVFMD and non-IPVFMD groups. Of the patients who were assigned and attended laryngeal control therapy, 13 (65%) reported improvement of symptoms. Symptom improvement increased to 100% in those patients who attended at least 2 laryngeal control therapy sessions. Conclusions IPVFMD should be considered in patients presenting with respiratory symptoms after irritant exposure. Sensitivity of diagnosis can be improved via a standardized approach consisting of a careful history and physical examination, including laryngoscopy in the presence of triggers. Laryngeal control therapy is a well-tolerated and effective method of managing IPVFMD.
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Affiliation(s)
- Anna M. Marcinow
- Department of Otolaryngology, Group Health, Cincinnati, Ohio, USA
| | - Jennifer Thompson
- Department of Speech and Language Pathology, Wexner Medical Center at The Ohio State University, Columbus, Ohio, USA
| | - L. Arick Forrest
- Department of Otolaryngology–Head and Neck Surgery, Wexner Medical Center at The Ohio State University, Columbus, Ohio, USA
| | - Brad W. deSilva
- Department of Otolaryngology–Head and Neck Surgery, Wexner Medical Center at The Ohio State University, Columbus, Ohio, USA
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Patel RR, Venediktov R, Schooling T, Wang B. Evidence-Based Systematic Review: Effects of Speech-Language Pathology Treatment for Individuals With Paradoxical Vocal Fold Motion. AMERICAN JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2015; 24:566-584. [PMID: 25836980 DOI: 10.1044/2015_ajslp-14-0120] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Accepted: 03/27/2015] [Indexed: 06/04/2023]
Abstract
PURPOSE In this article, our goal was to determine the state of the evidence and the effect of speech-language pathology (SLP) treatment for individuals with paradoxical vocal fold motion (PVFM). METHOD The American Speech-Language-Hearing Association's National Center for Evidence-Based Practice in Communication Disorders searched 22 electronic databases using key words related to PVFM, speech or voice treatment, and behavioral intervention for articles published through July 2013. Identified articles were systematically evaluated to assess the quality of the evidence using a modification of the American Speech-Language-Hearing Association's critical appraisal scheme. RESULTS Sixty-five articles met the search criteria. Only 2 out of the 65 articles were judged to contain adequate evidence to evaluate the effect of SLP treatment for PVFM. All 65 articles exemplify the state of the evidence for SLP treatment for PVFM. CONCLUSION The state of the evidence for the use of SLP treatment is in its infancy, with a majority of articles in the exploratory stage of research. Consequently, few clinical implications can be drawn at this time. SLP treatment for PVFM is promising; however, there is clearly a pressing need for systematic experimental studies that involve a control group to further the evidence base.
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Abstract
Paradoxical Vocal Fold Movement Disorder (PVFMD) is a cause of dyspnea that can mimic or occur alongside asthma or other pulmonary disease. Treatment with Laryngeal Control Therapy is very effective once the entity is properly diagnosed and contributing comorbidities are managed appropriately. In understanding the etiology of PVFMD, focus has broadened beyond psychiatric factors alone to include the spectrum of laryngeal irritants (laryngopharyngeal reflux, allergic and sinus disease, sicca, and possibly obstructive sleep apnea). The following is a discussion of the history, terminology, epidemiology, diagnosis, comorbid conditions, and treatment of this entity.
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Affiliation(s)
- Laura Matrka
- Department of Otolaryngology - Head and Neck Surgery, The Ohio State University Wexner Medical Center, Eye and Ear Institue, Suite 4000, 915 Olentangy River Road, Columbus, OH 43212, USA; JamesCare Voice and Swallowing Disorders Clinic, Stoneridge Medical Center, 4019 West Dublin-Granville Road, Dublin, OH 43017, USA.
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Abstract
Vocal cord dysfunction (VCD), generally characterized by paradoxical closure of the vocal cords during inspiration, is a common mimicker of asthma and of other conditions that cause upper airway obstruction. As a result, it is frequently overlooked and often misdiagnosed, resulting in administration of excessive medications or other unnecessary interventions, with resultant morbidity. This article explores the clinical features, proposed causes, diagnostic considerations, and management of VCD, as well as some differences between VCD and asthma that can aid in differentiating these two diagnoses in the clinical setting.
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Affiliation(s)
- Flavia C L Hoyte
- Division of Allergy and Immunology, Department of Medicine, National Jewish Health, 1400 Jackson Street, Denver, CO 80206, USA.
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Grüber C, Lehmann C, Weiss C, Niggemann B. Somatoform respiratory disorders in children and adolescents-proposals for a practical approach to definition and classification. Pediatr Pulmonol 2012; 47:199-205. [PMID: 21905261 DOI: 10.1002/ppul.21533] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2011] [Accepted: 07/20/2011] [Indexed: 01/31/2023]
Abstract
Somatoform respiratory disorders represent conditions with dysfunctional breathing unexplained by structural abnormalities. This heterogeneous group includes disorders with neural dysregulation of respiration (vocal cord dysfunction) or with dysregulation of the respiratory pattern (hyperventilation, sighing dyspnea), psychogenic disorders such as unjustified anxiety of suffocation, and stereotype conditions such as throat clearing or habit cough. Many symptoms are nonspecific and largely overlap with respiratory disease symptoms of somatic etiology. Most patients will present in a nonspecialized clinical setting. This article provides symptom-based criteria for the definition of somatoform respiratory disorders and their differentiation from somatic disease. Emphasis is put on clinical criteria which can be easily integrated in a routine setting. Owing to the multifaceted etiology of somatoform respiratory disorders therapeutic approaches integrating somatic medicine, respiratory therapy and psychology are crucial. The introduction of defined clinical criteria may facilitate the discrimination of somatoform respiratory disorders from somatic disorders in routine patient encounters and avoid therapeutic detours.
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Affiliation(s)
- Christoph Grüber
- Department of Pediatrics, Klinikum Frankfurt (Oder), Frankfurt (Oder), Germany.
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Morris MJ, Christopher KL. Diagnostic criteria for the classification of vocal cord dysfunction. Chest 2011; 138:1213-23. [PMID: 21051397 DOI: 10.1378/chest.09-2944] [Citation(s) in RCA: 130] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Vocal cord dysfunction (VCD) is a syndrome characterized by paroxysms of glottic obstruction due to true vocal cord adduction resulting in symptoms such as dyspnea and noisy breathing. Since first described as a distinct clinical entity in 1983, VCD has inadvertently become a collective term for a variety of clinical presentations due to glottic disorders. Despite an increased understanding of laryngeal function over the past 25 years, VCD remains a poorly understood and characterized entity. Disparities in the literature regarding etiology, pathophysiology, and management may be due to the historic approach to this patient population. Additionally, disorders clearly not due to paroxysms of true vocal cord adduction, such as laryngomalacia, vocal cord paresis, and CNS causes, need to be differentiated from VCD. Although a psychologic origin for VCD has been established, gastroesophageal reflux disease (GERD), nonspecific airway irritants, and exercise have also been associated with intermittent laryngeal obstruction with dyspnea and noisy breathing. VCD has been repeatedly misdiagnosed as asthma; however, the relationship between asthma and VCD is elusive. There are numerous case reports on VCD, but there is a paucity of prospective studies. Following an in-depth review of the medical literature, this article examines the available retrospective and prospective evidence to present an approach for evaluation of VCD including: (1) evaluation of factors associated with VCD, (2) differential diagnosis of movement disorders of the upper airway, and (3) clinical, spirometric, and endoscopic criteria for the diagnosis.
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Affiliation(s)
- Michael J Morris
- Department of Medicine (MCHE-MD), 3851 Roger Brooke Dr, Brooke Army Medical Center, Ft. Sam Houston, TX 78234-6200, USA.
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Varney V, Parnell H, Evans J, Cooke N, Lloyd J, Bolton J. The successful treatment of vocal cord dysfunction with low-dose amitriptyline - including literature review. J Asthma Allergy 2009; 2:105-10. [PMID: 21437148 PMCID: PMC3048598 DOI: 10.2147/jaa.s6673] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2009] [Indexed: 11/23/2022] Open
Abstract
Vocal cord dysfunction is an asthma mimic. Diagnosis of this condition requires a high index of suspicion if unnecessary treatments are to be avoided. We describe the findings from our case series of 62 patients (age range 18 to 90 years) in whom the diagnosis was confirmed. Our findings show low-dose amitriptyline to be very effective in 90% of cases, with rapid benefit for those patients whose symptoms had been present for less than 12 months. This treatment, in conjunction with psycho-therapeutic and behavioral therapies may reduce unnecessary hospital admissions. Future studies may show whether this treatment regimen may reduce demands on the speech and language therapists.
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Echternach M, Verse T, Delb W, Richter B. [Expiratory vocal cord dysfunction? Case report and review of the literature]. HNO 2008; 57:68-72. [PMID: 19099272 DOI: 10.1007/s00106-008-1848-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Wood and Milgrom defined vocal cord dysfunction (VCD) as paradoxical adduction of the vocal folds during inspiration or during inspiration and expiration. We describe the case of a patient with attacks of dyspnea with an isolated expiratory paradoxical adduction of the vocal folds. A review of the literature reveals many factors associated with VCD. Because of the similar risk factors and order of events concerning VCD, we believe that even expiratory laryngeal dysfunctions could be denoted as subtypes of VCD.
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Affiliation(s)
- M Echternach
- Freiburger Institut für Musikermedizin, Universitätsklinik, Breisacherstrasse 60, 79106, Freiburg.
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Hicks M, Brugman SM, Katial R. Vocal Cord Dysfunction/Paradoxical Vocal Fold Motion. Prim Care 2008; 35:81-103, vii. [DOI: 10.1016/j.pop.2007.09.005] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Ibrahim WH, Gheriani HA, Almohamed AA, Raza T. Paradoxical vocal cord motion disorder: past, present and future. Postgrad Med J 2007; 83:164-72. [PMID: 17344570 PMCID: PMC2599980 DOI: 10.1136/pgmj.2006.052522] [Citation(s) in RCA: 88] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Paradoxical vocal cord motion disorder (PVCM), also called vocal cord dysfunction, is an important differential diagnosis for asthma. The disorder is often misdiagnosed as asthma leading to unnecessary drug use, very high medical utilisation and occasionally tracheal intubation or tracheostomy. Laryngoscopy is the gold standard for diagnosis of PVCM. Speech therapy and psychotherapy are considered the cornerstone of management of this disorder. The aim of this article is to increase the awareness of PVCM among doctors, highlighting the main characteristics that distinguish it from asthma and discuss the recent medical achievements and the possible future perspectives related to this disorder.
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Affiliation(s)
- Wanis H Ibrahim
- Pulmonary Section, Department of Medicine, Hamad General Hospital, PO Box 3050, Doha, Qatar.
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Nolan PK, Chrysler M, Phillips G, Goodman D, Rusakow LS. Pulse oximetry coupled with spirometry in the emergency department helps differentiate an asthma exacerbation from possible vocal cord dysfunction. Pediatr Pulmonol 2007; 42:605-9. [PMID: 17514748 DOI: 10.1002/ppul.20621] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
PURPOSE Spirometry performed by adolescents with refractory wheeze or stridor and respiratory distress, with normal room air oxygen saturation, may differentiate subjects not having an acute asthma exacerbation (AE-) from those who are (AE+). A subpopulation may also be identified that has flow volume loop (FVL) patterns consistent with vocal cord dysfunction (VCD). METHODS Spirometry was performed by adolescents who presented to a pediatric emergency department (ED) with respiratory distress attributed to an acute AE who, after therapy, were still symptomatic and had room air oxygen saturation > or = 97%. Spirometry findings were classified as: (a) consistent with an acute AE, (b) variable extrathoracic airway obstruction pattern consistent with VCD, (c) a combination of the two, or (d) normal airflow. RESULTS Of 2,073 adolescent visits for asthma seen in the ED in 2005, 20 encounters among 17 adolescents were examined during the period of 0700-2200 on weekdays when an investigator was available, of which, 15 encounters were classified as AE-. In the AE- group, nine had FVL evidence of variable extrathoracic airway obstruction consistent with VCD, and six had normal spirometry. Three of the five encounters that were AE+ had FVL evidence consistent with VCD. CONCLUSIONS Spirometry, performed on therapy-resistant wheezing or stridorous adolescent patients in respiratory distress with oxygen saturation > or =97%, may help differentiate patients who are not having an acute AE from those who are. In those subjects not having an acute AE, respiratory distress may prove to be due to VCD.
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Affiliation(s)
- Paul K Nolan
- Department of Pediatrics, Texas Tech University HSC, Amarillo, TX 79106, USA.
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Huggins JT, Kaplan A, Martin-Harris B, Sahn SA. Eucalyptus as a specific irritant causing vocal cord dysfunction. Ann Allergy Asthma Immunol 2004; 93:299-303. [PMID: 15478393 DOI: 10.1016/s1081-1206(10)61505-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Vocal cord dysfunction (VCD) is a well-recognized clinical entity that frequently mimics asthma and is characterized by inappropriate adduction of the vocal cords during inspiration. The pathogenesis of VCD has not yet been defined. The only previous report suggested that respiratory irritants may trigger paradoxical motion of the vocal cords. OBJECTIVE To report the case of a 46-year-old woman with VCD precipitated by eucalyptus exposure. METHODS A masked flexible fiberoptic nasolaryngoscopy was performed to confirm whether VCD occurred with eucalyptus and not with other known respiratory irritants. The patient underwent inhalation challenges consisting of water, ammonia, pine oil, and a combination of eucalyptus (dried leaves) and ammonia. Two independent observers before patient challenge could not identify eucalyptus. RESULTS Vocal cord dysfunction occurred within minutes of exposure to eucalyptus. This is the first report to prospectively document that a specific irritant, eucalyptus, can precipitate VCD. Negative skin prick test results, total IgE level, and negative IgE eucalyptus-specific antibodies support a nonimmunologic mechanism. CONCLUSIONS A new pathogenic mechanism for this clinical entity is supported by our observations. Furthermore, a nonimmunologic mechanism in which respiratory irritants may induce VCD is suspected. Future studies to elucidate this mechanism need to be performed in individuals with irritant-specific VCD.
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Affiliation(s)
- John T Huggins
- Division of Pulmonary and Critical Care Medicine, Allergy and Clinical Immunology, Medical University of South Carolina, Charleston, South Carolina 29425, USA. hugginjtmusc.edu
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Abstract
The diagnosis of a functional respiratory disorder is sometimes difficult and time-consuming, because the symptoms often resemble those of organic diseases. The most common entities are hyperventilation syndrome, psychogenic cough, sighing dyspnea, and vocal cord dysfunction. Typical signs are heavy breathing or dyspnea, cough or sneezing, various breathing sounds, tightness of the throat or chest, pain, and fear. Criteria for differentiation include the lack of nocturnal symptoms, the sudden occurrence, no typical trigger factors, the variable duration, a quick regression, and that symptoms do not respond to adequate pharmacotherapy and finally normal results of diagnostic work-up. Therapeutic options comprise psychological intervention (by reassurance, relaxation techniques, and behaviour therapy) and physiotherapy (e.g. breathing therapy, voice training). Intensive efforts should be made to diagnose functional symptoms at an early stage because this will prevent stigmatization and fixation of symptoms and disease, and also prevent children from undergoing unnecessary and potentially harmful therapies.
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Affiliation(s)
- Bodo Niggemann
- Department of Pneumology and Immunology, University Children's Hospital Charité of Humboldt University, Berlin, Germany.
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