vcd in athletes handout - · pdf file•frequent episodic attacks causing dyspnea...
TRANSCRIPT
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Assessment and Treatment of VCD:
Helping Athletes Work it Out!
Joy Gaziano MA, CCC-SLP, BCS-S
Joy McCann Culverhouse Center for
Swallowing Disorders
University of South Florida
Disclosures
• No financial relationships exist between me and any companies with products which are described in this presentation.
What’s in a Name?• 1983-Vocal cord dysfunction-VCD
• 1999-Irritable larynx syndrome-ILS
• 2004-Paradoxical vocal fold motion-PVFM
• 2010-Periodic occurrence of laryngeal obstruction -POLO
A respiratory condition characterized by episodic laryngeal closure with chief complaints of noisy breathing and SOB and variable secondary symptoms including cough, throat and chest tightness, and voice changes among others.
VCD Demographics
• Documented in patients from infancy to geriatrics
• Female: Male -2:1 to 3:1
• Early reports of young white female with psych disorders as typical
• 14% severely asthmatic children have VCD
• 15% military personnel with exertional dyspnea
• 3% intercollegiate athletes with EIA
• 5% elite athletes with inspiratory stridor with exertion
Athletes with VCDpresent unique challenges
• Documented in athletes of all skill levels.
• In 370 elite athletes, 5% had inspiratory stridor suggestive of VCD. (Rundell, 2003)
• Often co-occurs with exercise-induced bronchospasm (EIB).
• Vocal fold narrowing seen in EIB episodes.
Athletes with asthma
• Airway hyper-responsiveness (asthma) is the most common chronic medical condition experienced by both Summer and Winter Olympic athletes.
• High ventilation during exercise and/or environmentally unfavorable conditions may cause injury to the airway epithelium during high-level exercise.
• Repeated injury and repair process of the epithelium could lead to structural and functional changes within the airways and be the underlying cause for the development of asthma. (Kippelen, et.al, 2012)
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Etiological issues in Athletes
• Laryngeal irritants:
– GERD
– PND
– Chemical inhalants
– Environmental irritants
Etiological Issues in Athletes
• Behavioral /Phonatory
– Voice use profiles
– Employment
– Extra-curricular activity
Etiological Issues in Athletes
• Psychogenic contribution
– Conversion reaction
– Coexisting psychological/psychiatric conditions
– Continued symptoms increase emotional stress during performance
– Labored breathing is concerning to teammates and coaches
Differential DiagnosisMust Rule These Out First!
• Structural abnormalities
• Inflammatory process/lesions
• Neurologic impairment
• Deconditioning/poor fitness
• Asthma
Rule Out Asthma• Pulmonary function test-PFT
– Negative methacholine challenge in VCD
– Flattened inspiratory loop in VCD
– Increased ratio between forced expiratory flow and forced inspiratory flow (FEF>FIF) in VCD
• Laryngoscopy –normal in asthma
• CT scan – hyperinflation and peribronchial thickening in asthma; NL in VCD
• Arterial Blood Gas (ABG)- hypoxemia and hypercapnia in asthma; NL in VCD
• O2 saturation: reduced in asthma; NL in VCD
Flow-Volume Loop
“Truncated” or “saw toothed” inspiratory loop can be indicative of VCD
Advance for Nurse Practitioners, Detecting Vocal Cord Dysfunction With Coexisting Asthma Labored Breathing in a 12-Year-Old Girl, 2010 By Melinda F. Miller, NP
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Rule Out Asthma
• Misdiagnosis of VCD as asthma leads to:
– Intubation
– Multiple unnecessary asthma medications
– Increased utilization of subspecialty care and comparable use of prescriptions, hospitalizations, and urgent care visits for VCD compared to moderate persistent asthma.
– Increase/prolong athlete’s anxiety
– Delay or exclude athletic participation
Mikita, J. and J. Parker (2006). "High levels of medical utilization by ambulatory
patients with vocal cord dysfunction as compared to age- and gender-matched asthmatics.
Chest 129(4): 905-908.
Structural & Inflammatory Lesions:Papilloma & Reinke’s Edema
Subglottic Stenosis/Laryngomalacia Rule in VCD
Tracheal stenosis or VCD?
Neurological-Bilateral Vocal Fold Paralysis
Exercise induced anaphalaxis
• Rare potentially life threatening syndrome
• Sensitivity reaction involving skin, respiratory tract, cardiovascular and GI systems.
• +/- associated with food
Barg, et al 2011
• Clinical history and physical exam
• Acute tx with epinephrine, antihistamines, and systemic corticosteroids.
• Pathophysiology: histamine release
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Case History: Patient Reports
Trouble with inhalation > exhalation
Tightness or closing down in throat +/- chest
Specific triggers
Specific contexts
Recent exposure to specific chemicals or URI
Refractory period for exercise
Quick onset, quick resolution
Poor response to inhalers
Typical Case Histories
• Post URI/ intubation• Chronic refractory cough for months• Frequent episodic attacks causing dyspnea• Asthma-like symptoms refractory to steroid or
bronchodilator• Worsened with perfume, smoke, strong odor• Diagnosis of GERD/ LPR and on PPI • Allergy/ PND/Sinus issues• Exercise induced • Stress/Anxiety/Tension
Endoscopic Evidence of VCD
Approximation of true vocal folds with posterior glottic
chink
Approximation of TVF
Endoscopic Evidence of VCD
Approximation of Ventricular Folds
Right arytenoid and left ventricular fold
Contact of tissue overlying the left arytenoid and
epiglottis
Acute Therapy
• Reassurance
• Panting
• Heliox
• IPPV and CPAP
• Benzodiazepines
• General anesthetic injection
• Intralaryngeal injection of botulinum toxin type A
• Bronchodilators / oxygen / corticosteroids are ineffective for relief in patients with PVCM
Goals of Treatment: Education
• Review normal/abnormal laryngeal physiology using visual feedback to change aberrant movement patterns.
• Name the disease-claim the disease!
• Reassures that it’s not all in their head!
• Educate all key players.
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Goals of Treatment:Education
• Reassure that condition is treatable.
• Develop their “bag of tricks”.
• Identify triggers that exacerbate the problem.
• Teach avoidance of panic.
• Motivate patient to follow recs. with quick success.
Relaxation Techniques
• Relaxation exercises
– Relax oropharyngeal muscle groups as well as neck, shoulders, and chest.
– Teach awareness of tension vs relaxation.
– Train release of specific tension (ie breath holding, jaw clenching, shoulder raising).
– Sport specific patterns
Retraining Breathing
• Relaxed Throat Breathing Techniques
– Reduce tension in extrinsic laryngeal musculature and allow intrinsic laryngeal musculature to release from the constricted pattern
– Concentrate on active exhalation utilizing abdominal muscles and minimize chest/neck tension.
– Begin in supine/semi-reclined in quiet environment.
– Use tactile, verbal and visual biofeedback (mirror)
– Teach distraction
Then Incorporate…Open Throat Posturing
• Relaxed Throat Breathing Techniques:
– Tongue on FOM behind the lower front teeth and inhales with gently closed lips as the abdomen expands. Exhale with a gentle “s” or “th” sound as the abdomen returns to resting state.
– Make “lots of space” in the back of the throat
– “Picture the vocal folds being wide open”
– “Don’t hold your breath”
Breathing easier during exercise
• Pursed lip breathing-oral inhale for max. flow
• Positioning- bending forward
• Paced breathing-walking; stair-climbing
• Desensitization-music to distract
• Maneuvers- quick sniff, drop jaw/tongue
• Rescue breathing
Patient Monitoring of Breathing
• Increase their awareness of breathing
– Keep a daily journal of breathing and activities
– Note any breath holding
– Generalize to other situations
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Respiratory Pattern is Sport Specific
• Swimmers
– Reactivity to chlorine, carry over in to pool with supervision, pace inhalation with stroke
• Runners
– Easy due to rhythm of sport, consider nasal allergies, watch breath holding
• Basketball
– Cognitively demanding, involves bending from waist, start carryover in least demanding situation and advance.
Adapt breathing to specific needs
Exhale on the ActionCross train in activity with rhythmic
breathing patterns
Inspiratory Muscle Strength Training (IMST)
Athletic Trainers address sport specific technique
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Sport Psychologist
–Arousal regulation
–Goal setting
– Imagery
–Self talk
–Pre-performance routine
Physical Therapist
• Comprehensive assessment of physical functioning .– UE or LE weakness or reduced ROM
– Pain issues
– Associated arm, shoulder, and rib cage movements
– Elevate shoulders (at rest, and/or during running activities)
– Limited rib cage mobility (“locks rib cage” for stability)
– Cervical spine issues
– Cardiovascular conditioning
– Breathing retraining
Case Examples
• 34 year old female tri-athlete
• 16 year old male cross country runner
• 6 year old female hates PE
• 15 year old female Jr. Olympic tennis player
• 20 year old female collegiate cheerleader
• 17 year old male HS football player
• 48 year old female exercises for fitness/rec.
Case 1: Three Cheers for Cheerleaders
History
• 20 year old female with life long SOB with cheerleading or running.
• Frequent fainting at end of routine
• DX with VCD at 14 with 1 yr of tx without benefit.
Assessment
• ENT:
• Allergy/Asthma:
• Speech Pathology:
• Physical Therapy:
Pre-Post Exercise Borg Perceived Exertion Scale• 6 - 20% effort
• 7 - 30% effort - Very, very light
• 8 - 40% effort
• 9 - 50% effort - Very light
• 10 - 55% effort
• 11 - 60% effort - Fairly light
• 12 - 65% effort
• 13 - 70% effort - Somewhat hard
• 14 - 75% effort
• 15 - 80% effort - Hard
• 16 - 85% effort
• 17 - 90% effort - Very hard
• 18 - 95% effort
• 19 - 100% effort - Very, very hard
• 20 - Exhaustion
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Treadmill walking Treadmill walking
Case 2: Running on Empty
• Source of referral: Allergist
• 15 year old; Male; “A” student
• Sophomore member of cross country team
• Desires college scholarship in track
• Severe SOB at 2.5 miles with stridor; becomes faint and dizzy
• Pulmonologist: “Exercise Induced Asthma” rx meds: prednisone, flovent, singulair, albuterol, theophylline
• Cardiologist: No abnormality
• Psychologist: Stress issues
• Allergist: Allergies to many FL aeroallergens. PFT VCD
Evaluation
• Laryngeal Exam: WNL
– No reduplication of symptoms during SLP exam.
• PT eval with SLP present
– Stridor on treadmill at 2.5 miles.
– Excessive use of accessory muscles.
– Responded to rescue breathing.
Treatment
• Behavioral Techniques
– Laryngeal relaxation
– Drop jaw/tongue
• IMST
• Physical Therapy
• School coach and Athletic trainer
• Parents
MIP: Pre- and Post- IMST
0
20
40
60
80
100
120
140
160
180
Baseline/wk1 wk 2 wk 3 wk 4 wk 5
Maximum Inspiratory Pressure
MIP
cmH20
Case 3: Lean on Me
History
• 34 year old female PE teacher and Tri-athlete
• Intense competitor
• Trains only with males
• MVA with chest injury
Assessment
• ENT:
• Asthma/Allergy:
• Pulmonology:
• Cardiology:
• Speech Pathology:
• Physical Therapy:
Evaluation
• Laryngeal Exam: WNL
– Could not generate sufficient effort in clinic
• PT eval with SLP present
– Symptoms on UE cycle at 10 minutes
– Asymmetric UE/shoulder strength
– Equipment analysis
Treatment
• Behavioral Techniques
– Laryngeal relaxation
– Listening
• IMST
• Physical Therapy
• Psychologist– Abuse counseling
– Sports psychology
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Case 4: Back to School Blues
History:
• 6 year old female with sudden onset SOB/sighing 1 week after school begins.
• Usually occurs at PE/recess.
• Younger sister excels at gymnastics/dance.
Assessment:
• Pediatrician:
• Allergy/Asthma:
• Speech Pathology:
• School counselor:
ReferencesAl-Alwan, A., & Kaminsky, D. (2012). Vocal cord dysfunction in athletes: Clinical presentation and
review of the literature. The Physician and Sportsmedicine, 40(2), 22-27.
Borg, G. (1998). Borg's Perceived Exertion and Pain Scales. Champagne, IL: Human Kinetics.
Boulet, L. P. (2012). Cough and upper airway disorders in elite athletes: A critical review. British Journal of Sports Medicine, 46(6), 417-421.
Hanks, C. D., Parsons, J., Benninger, C., Kaeding, C., Best, T. M., Phillips, G., & Mastronarde, J. G. (2012). Etiology of dyspnea in elite and recreational athletes. The Physician and Sportsmedicine, 40(2), 28-33.
Ibrahim, W. H., H. A. Gheriani, et al. (2007). Paradoxical vocal cord motion disorder: past, present and future. Postgraduate Medical Journal 83(977): 164-172.
Kippelen, P., Fitch, K., Anderson, S., Bourgault, V., Boulet, LP, Rundel, K., Sue-Chu, M., McKenzie, D. Respiratory health of elite athletes-preventing airway injury: a critical review. (2012). Br J Sports Med. 46:471-476.
Mathers-Schmidt, BA, Brilla, LR.(2005). Inspiratory muscle training in exercise induced paradoxical vocal fold motion. J Voice. 19(4):635-44.
McFadden, E. R.,Jr, & Zawadski, D. K. (1996). Vocal cord dysfunction masquerading as exercise-induced asthma. a physiologic cause for "choking" during athletic activities. American Journal of Respiratory and Critical Care Medicine, 153(3), 942-947
Mikita, J. and J. Parker (2006). High levels of medical utilization by ambulatory patients with vocal cord dysfunction as compared to age- and gender-matched asthmatics. Chest. 129(4): 905-908.
ReferencesMorris, M. J., L. E. Deal, et al. (1999). Vocal cord dysfunction in patients with exertional dyspnea.
Chest. 116(6): 1676-1682.
Newsham, K. R., Klaben, B. K., Miller, V. J., & Saunders, J. E. (2002). Paradoxical vocal-cord dysfunction: Management in athletes. Journal of Athletic Training, 37(3), 325-328.
Pope, J. S., & Koenig, S. M. (2005). Pulmonary disorders in the training room. Clinics in Sports Medicine, 24(3), 541-64,
Powell, SA, Nguyen, CT, Gaziano, J, Lewis, V, Lockey, RF, Padhya, TA. (2007). Mass psychogenic illness presenting as acute stridor in an adolescent female cohort. Ann Otol Rhinol Laryngol. Jul;116(7):525-31.
Rhodes, R. K. (2008). Diagnosing vocal cord dysfunction in young athletes. Journal of the American Academy of Nurse Practitioners, 20(12), 608-613.
Rundell, K. W. and B. A. Spiering (2003). Inspiratory stridor in elite athletes. Chest. 123(2): 468-474.
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