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Exercise Induced Paradoxical Vocal Cord Dysfunction (EI-PVCD). Dale R. Gregore M.S., CCC-SLP Speech Language Pathologist Clinical Rehabilitation Specialist - Voice. NORMAL Respiration 101.

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exercise induced paradoxical vocal cord dysfunction ei pvcd

Exercise Induced Paradoxical Vocal Cord Dysfunction(EI-PVCD)

Dale R. Gregore


Speech Language Pathologist

Clinical Rehabilitation Specialist - Voice

normal respiration 101
NORMAL Respiration 101
  • On inhalation, the vocal cords (folds) ABduct allowing air to flow into the trachea, bronchial tubes, lungs
  • On exhalation, the vocal folds may close slightly, however should and do remain ABducted

Vocal fold ADDUCTION

Occurs during

swallowing, coughing, etc…

paradoxical vocal fold movement pvfm
Paradoxical Vocal Fold Movement (PVFM)
  • The cord function is reversed in that the vocal folds ADDuct on inspiration versus ABduct
  • Leads to tightness or spasm in the larynx
  • Inspiratory wheeze evident
definition of ei vcd
Definition of EI-VCD
  • “Inappropriate closure of the vocal folds upon inspiration resulting in stridor, dyspnea and shortness of breath (SOB) during strenuous activity”
    • Matthers-Schmidt, 2001; Sandage et al, 2004
  • Vocal Cord Dysfunction (VCD)
    • Most common term
  • Munchausen’s Stridor
  • Emotional Laryngeal Wheezing
  • Pseudo-asthma
  • Fictitious Asthma
  • Episodic Laryngeal Dyskinesia
patient description of vcd episodes
Patient description of VCD episodes
  • “in the top of my throat I see a McDonalds straw surrounded by darkness. The straw ends in a pool of thick, sticky liquid that is encased by a wall of rubber bands and outside of the rubber bands is air that I can’t access”.
  • “The top part of my throat is complete darkness, at the back part of the darkness there are cotton balls. These are holding my fear”.
pvfm visualized
PVFM Visualized
  • Anterior portion of the vocal folds are ADDucted
  • Only a small area of opening at the
  • Posterior aspect of the vocal folds
  • Diamond shaped ‘CHINK’
  • May be evident on both inhalation and exhalation
essential features
Essential Features
  • Vocal fold adduct (close) during respiration instead of abducting (opening)
  • Laryngeal instability while patient is asymptomatic
        • Treole,K. et. al. 1999
  • Episodic respiratory distress
  • Stridor
  • Difficulty with inspiratory phase
  • Throat tightening > bronchial/ chest
  • Dysphonia during/following an attack
  • Abrupt onset and resolution
  • Little or NO response to medical treatment (inhalers, bronchodilators)
various etiologies
Various Etiologies
  • Laryngo-Pharyngeal Reflux (LPR)
    • Food/ liquid/ acid refluxes from the stomach up the esophagus into the pharynx (throat)
    • Can spill over and into the larynx
    • causes coughing, choking, breathing and voice changes, swelling, irritation,
    • Can be SILENT or sensed when it happens
lpr continued
LPR, continued
  • Clinical characteristics can be observed using videolaryngoscopic or stroboscopic visualization of the larynx
  • Ideally, diagnosed by a 24-hour pH. Probe or EGD
lpr and athletes
LPR and Athletes
  • Well documented occurrence in weight lifting
  • Can be aggravated by bending, pushing/ resisting (tackling, etc…), tight clothing, even drinking water during a game/ meet/ match
  • Timing of meals before exercise is important
  • Type of foods/ liquids should be monitored
laryngopharyngeal reflux clinical signs
Laryngopharyngeal Reflux: Clinical Signs

Interarytenoid Edema

Lx Erythema

Vocal Fold Edema

other potential causes of paradoxical vocal cord dysfunction
Other potential causes of Paradoxical Vocal Cord Dysfunction
  • Allergic rhinitis or reaction
  • Conversion disorder
  • Anxiety
  • Respiratory-type or drug-induced laryngeal dystonia
etiologies cont
Etiologies (cont.)
  • Asthma-associated laryngeal dysfunction
  • Brainstem dysfunction
      • CVA or injury
  • Chronic laryngeal instability, sensitivity & tension
athlete profile for ei vcd
Athlete Profile for EI-VCD
  • Onset between 11-18
  • Females have a greater incidence (generally 3:1)
  • High achieving
  • “Type A” personalities
  • High personal standards and/or social pressures
  • Intolerant to personal failure
athlete profile cont
Athlete Profile, cont…
  • Competitive
  • Self demanding
  • Perceives family pressure to achieve a high level of success
  • “Choke” under pressure
  • May have recently graduated to higher level of competition within their sport (JV to Varsity: Rep to Travel team; college level sports, etc)
ei vcd versus asthma
EI-VCD versus Asthma
  • Recalcitrant to asthma medications i.e. does not respond to
  • Individuals with “asthma” after long term steroid use might not truly have asthma, but VCD
  • Individuals with significant anxiety: is it LIVE OR MEMOREX? Which causes which?
differential diagnosis of ei vcd
Differential Diagnosis of EI-VCD
  • Includes a detailed Case History
  • Pulmonary function Studies
  • Lab Test
  • ENT/ Pulmonary/ Allergy evaluations
  • Flexible Laryngoscopy/ videostroboscopy
  • Speech-language pathology evaluation
  • Supplemental as needed: Psychological evaluation
differential diagnosis of vcd
Differential Diagnosis of VCD
  • Team Must Rule Out:
    • Mass Obstruction
    • Bilateral vocal fold paralysis
    • Anaphylactic laryngeal edema
    • Extrinsic airway compression
    • Foreign body aspiration
    • Infectious croup
    • Laryngomalacia
    • Exercise Induced Asthma/ Asthma
diagnosis of ei vcd
Diagnosis of EI-VCD
  • Often mistaken for asthma
  • Diagnosis of EI-PVCD is by exclusion = when patient fails to respond to asthma or allergy medication, then VCD is finally considered
ei vcd and asthma
EI-VCD and Asthma
  • Can exist independently
  • Can also coexist
    • Patient may experience LPR which causes Asthma flare-up and then laryngospasm (VCD) from coughing
    • May experience chest (asthma) and/or laryngeal (VCD) tightness
typical spirometry findings for pvcd
Typical Spirometry Findings for PVCD
  • Asymptomatic
    • Flow-volume loops are normal
  • Symptomatic:
    • Blunted inspiratory curve
    • Inspiratory curves highly varied
    • Expiratory portion may be blunted
    • Ratio of forced expiratory to inspiratory flow at 50% VC can be greater than 1.0
case history questions
Case History Questions
  • Do you have more trouble breathing in than out?
  • Do you experience throat tightness?
  • Do you have a sensation of choking or suffocation?
  • Do you have hoarseness?
  • Do you make a breathing-in noise (stridor) when you are having symptoms?
questions cont
Questions (cont.)
  • How soon after exercise starts do your symptoms begin?
  • How quickly do symptoms subside?
  • Do symptoms recur to the same degree when you resume exercise?
  • Do inhaled bronchodilators prevent or abort attacks?
  • Do you experience numbness and/or tingling in your hands or feet or around your mouth with attacks
questions cont1
Questions (cont.)
  • Do symptoms ever occur during sleep?
  • Do you routinely experience nasal symptoms (postnasal drip, nasal congestion, runny nose, sneezing)?
  • Do you experience reflux symptoms?
videostroboscopic examination
Videostroboscopic Examination
  • Instrumentation
    • Flexible fiberoptic laryngeal endoscope with stroboscopic capability
  • Observations
    • Movement of arytenoids during respiration at rest: Complete closure; Posterior diamond
    • Signs of laryngopharyngeal reflux disorder (LPR)
    • Degree of laryngeal instability
laryngeal supraglottic hyperfunction
Laryngeal Supraglottic Hyperfunction
  • arytenoid compression
  • ventricular compression
  • Limited airway for phonation
vcd appearance on direct examination
VCD appearance on direct examination
  • Laryngeal Supraglottic Hyperfunction
  • Abnormal ventricular compression during speech
laryngeal supraglottic hyperfunction1
Laryngeal Supraglottic Hyperfunction
  • Sphincteric contraction of the supraglottis during speech production
pvcm visualized
PVCM Visualized

Posterior ‘chink’

Rounded arytenoids, but normal abduction

diagnostic features pvfm asthma
Diagnostic Features PVFM Asthma
  • Flow-volume loop Inspiratory cut-off,Reduced expiratory
  • perhaps some expiratorylimb only
  • limb reduction *
  • Bronchial provocationNegativePositive
  • test
  • Laryngoscopic Inspiratory adduction Vocal folds may observations adduct during
  • of anterior 2/3 of vocal exhalation
  • folds; posterior diamond-
  • shaped chink; perhaps
  • medialization of ventricular
  • folds; inspiratory adduction
  • may carry over to expiration
diagnostic features pvfm asthma1
Diagnostic Features PVFM Asthma
  • Precipitators (triggers) Exercise, extreme Exercise, extreme temperatures, airway temperatures, irritants, emotional airway irritants, stressors emotional stressors, allergens
  • Number of triggers Usually one Usually multiple
  • Breathing obstruction Laryngealarea Chestarea
  • location
  • Timing of breathing Stridor on Wheezing on
  • noises inspiration exhalation
Pattern of dyspneic Sudden onset and More gradual onset event relatively rapidlonger recoverycessation period
  • Nocturnal awakening Rarely Almost always
  • with symptoms
  • Response to broncho- No responseGood response
  • dilators and/or systemic
  • corticosteroids
acute management of ei vcd in the field
Acute Management of EI-VCD in the field
  • Approach to the patient is important
  • It is generally agreed that patients do not consciously manipulate or control their upper airway obstruction
acute management of ei vcd
Acute Management of EI-VCD
  • During an episode, they usually feel helpless and terrified
  • Implying that it is “in their head” is incorrect and counterproductive to their recovery
  • Coach them through, help them out
  • Be positive
acute management of attacks
Acute Management of Attacks
  • Offer reassurance and empathy
  • Eliminate activity and people from environment
  • Prompt for EASY BREATHING
  • Elicit controlled ‘Panting’
    • Relaxed jaw
    • Tongue on floor of mouth behind bottom teeth
acute management in the game
Acute Management in the Game
  • Visualize WIDE OPEN AIRWAY
  • 6 lane highway with no roadblocks
  • Air goes in and circles around, goes out
  • Shoulders relaxed
  • Standing w/ open chest, hands on hips, or bent over/ hands on knees….which position works best?
quick sniff technique
Quick Sniff Technique
  • Sniff then Blow….talk the athlete through this
  • Sniff in with focal emphasis at the tip of the nose
    • Sniff = ABduction
  • Then exhale with pursed lips on
    • “ssssss”
    • “shhhhhh”
    • “ffffffff”
    • “whhhhhhhh”
    • = Back pressure respiration
acute treatment cont
ACUTE treatment, cont…
  • Breathing against pressure (hand on abdomen)
    • Resistance and focus on pressure against / in another body part
  • Heliox
    • Administered by Paramedics or ER MDs
  • Sedatives and psychotropic medications
    • Last resort
    • Calming effect
    • Eliminates tension/ constriction
treatment speech therapy
Treatment: Speech Therapy
  • Patient counseling, education
  • Respiratory retraining
  • Focal and whole body relaxation
  • Phonatory retraining
  • Monitor reflux Sx or anxiety
  • Develop / outline a ‘Game Plan’ = practice when asymptomatic; implement at the onset of sx
therapeutic goals and methods

Ability to overcome fear and helplessness

Reduced tension in- extrinsic laryngeal muscles

Diversion of attention from larynx


Mastery of breathing techniques

Open throat breathing; resonant voice technique

Diaphragmatic breathing and active exhalation

Therapeutic goals and methods
therapeutic goals and methods1

Reduced tension in neck, shoulders and chest

Ability to use techniques to reduce severity and frequency of attacks


Movement, stretching, progressive relaxation

Increase awareness of early warning symptoms; Rehearse action plan

Therapeutic goals and methods
speech therapy
Speech Therapy
  • Patient Counseling & Education
    • Description of laryngeal events
    • Viewing of laryngoscopy tape
    • Relate parallels to other stress induced disorders: migraine, irritable colon, muscle tension dysphonia, GEReflux
    • Flexible endoscopic biofeedback
    • Sensory biofeedback (sEMG)
speech therapy1
Speech Therapy
  • Respiratory training
    • Low “diaphragmatic” breathing versus “high” clavicular thoracic
    • Rhythmic respiratory cycles
    • Use resistance exhale (draw attention away from larynx and extend exhale)
    • Prevention and coping strategies during episodes = Action Plan
back pressure breathing
Back Pressure Breathing
  • Nasal Sniff = OPEN cords
  • Prolonged exhalation /w/, /f/, /sh/, /s/
  • Shoulders relaxed
  • Throat open
  • Implement when laying, sitting, standing, walking, jogging, running, playing sports, etc
relaxation training
Relaxation Training
  • Goal
    • Teach the patient to relax focal areas then the entire body during an episode of respiratory distress
  • Methods
    • Use progressive relaxation with guided imagery
    • Explore the patient’s visual concept of their disorder and alter
st duration the cchs approach
ST Duration: The CCHS Approach
  • 2-8 sessions
  • Average 4 sessions
  • Followed by clinical observation during sport/ game
  • Followup phone / email contact: tell me how it is going?
  • Re-evaluation as necessary, if symptoms reoccur (rarely)
case discussion
  • 14 year old female
  • Sports: field hockey, soccer
  • Travel soccer U-17 team/ midfiled
  • Initial symptoms: ‘throat closes’ ~5 minutes in to game; hand on throat; signals coach; pulled from game; 20 minute recovery: lying on sideline
therapy focus and outcome
Therapy Focus and Outcome
  • 5 sessions
  • Breathing 101
  • Training from static to active movement/ running
  • Full coaching then observation of strategy implemetation in therapy and during game
  • Outcome: (-) sx during mile run; cool down routine implemented; 20-30 minute game play/ no EI-VCD w/ ‘game plan’
case discussion 2
Case Discussion #2
  • 14 year old female
  • Sports: cross country; basketball
  • Initial Symptoms: ‘throat closed’ during CC trials; had to ‘drop out’
  • Secondary Symptoms: inspiratory stridor when wearing mouth guard/ basketball; felt ‘faint’
therapy focus and outcome1
Therapy Focus and Outcome
  • 5 sessions
  • Goals: establish ‘low’ AD breathing/ eliminate shoulder elevation and CT respiration pattern; train in back pressure breathing w/ and w/out mouthguard during activities of progressive effort including walk; jog; stairs, treadmill; suicide drills; BB drills; sprints, etc
  • Successful resolution of PVFM during 20 minute runs and when playing BB
  • Increased awareness of AD versus CT respiration
  • Habituated alternate use of sniff/ pant – blow, etc.
  • Increased perceived ‘control’ over breathing and performance
  • Spring Sport pending: soccer
  • Brugman, S. M., & Newman, K. (1993). Vocal cord dysfunction. Medical/Scientific Update. 11. 5. 1-5.
  • Christopher, K. L., WoodII, R. P., Eckert, R. C., Blager, F. B., Raney, R. A., & Souhrada, J. F. (1983). Vocal-cord dysfunction presenting as asthma. The New England Journal of Medicine. 308. 1556-1570.
  • Gavin, L. A., Wamboldt, M., Brugman, S., Roesler, T. A., & Wamboldt, F. (1998). Psychological and family characteristics of adolescents with vocal cord dysfunction. Journal of Asthma. 35. 409-417.
  • Martin, R. J., Blager, F. B., Gay, M. L., & WoodII, R. P. (1987). Paradoxic vocal cord motion in presumed asthmatics. Seminars in Respiratory Medicine. 8. 332-337.
Matthers-Schmidt B.A Paradoxical Vocal Fold Motion: A Tutorial on a Complex Disorder and the Speech Language Pathologist’s Role. American Journal of Speech-Language Pathology 2001; 10:111-25.
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  • Vlahakis NE, Patel AM, Maragos NE, Beck KC. Diagnosis of Vocal Cord Dysfunction: The Utility of Spirometry and Plethysmography. Chest 2002; 122: 2246-2249.
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Powell DM, Karanfilov BI, Beechler KB, Treole K, Trudeau MD, Forrest L. Paradoxical vocal cord dysfunction in Juveniles.Arch. Otolaryngol Head Neck Surg. 2000 Jan; 126 (1): 29-34
  • Morris MJ, Deal LE, Bean DR, Grbach VX, Morgan JA. Vocal Cord Dysfunction in Patients with Exertional Dyspnea. Chest 1999; 116: 1676-1682.