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

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

Normal Larynx

Vocal fold
ABDUCTION occurs
during respiration

Vocal fold ADDUCTION

Occurs during
swallowing, coughing, etc

Strobe exam

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
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

Pseudonyms
Vocal Cord Dysfunction (VCD)
Most common term

Munchausens Stridor
Emotional Laryngeal Wheezing
Pseudo-asthma
Fictitious Asthma
Episodic Laryngeal Dyskinesia

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 cant
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
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
Vocal fold adduct (close) during
respiration instead of abducting
(opening)
Laryngeal instability while patient is
asymptomatic
Treole,K. et. al. 1999

Episodic respiratory distress

Symptoms
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
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
WATERBRASH

LPR, continued
Clinical characteristics can be
observed using
videolaryngoscopic or
stroboscopic visualization of
the larynx
Ideally, diagnosed by a 24hour pH. Probe or EGD

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
Interarytenoid Edema
Lx Erythema
Vocal Fold Edema

Other potential causes of

Paradoxical Vocal Cord
Dysfunction
Allergic rhinitis or reaction
Conversion disorder
Anxiety
Respiratory-type or druginduced laryngeal dystonia

Etiologies (cont.)
Asthma-associated
laryngeal dysfunction
Brainstem dysfunction
CVA or injury

Chronic laryngeal
instability, sensitivity &
tension

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

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

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

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

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
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

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

EI-PVCD versus
Exercise Induced Asthma
Feature
Female Preponderance
Chest Tightness
Throat Tightness
Stridor
Usual onset of symptoms after beginning exercise (min)
Recovery period (min)
Refractory period
Late-phase response
Response to beta-agonist

PVCM
+
+/+
+
<5
5-10
-

EIA
>5-10
15-60
+
+
+

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

Inspiratory cut-off, flattening of the

inspiratory limb (curve)

NORMAL

VCD

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.)
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 (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
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
arytenoid
compression
ventricular
compression
Limited airway for
phonation

VCD appearance on direct

examination
Laryngeal
Supraglottic
Hyperfunction
Abnormal
ventricular
compression during
speech

Laryngeal Supraglottic
Hyperfunction
Sphincteric
contraction of the
supraglottis during
speech production

PVCM Visualized

Posterior chink

Rounded arytenoids, but normal

abduction

Diagnostic Features PVFM

Asthma

Flow-volume loop

Inspiratory cut-off,
Reduced expiratory
perhaps some expiratory limb only
limb reduction *

Bronchial provocation
test

Negative

Laryngoscopic
observations

Inspiratory adduction
of anterior 2/3 of vocal
folds; posterior diamondshaped chink; perhaps
medialization of ventricular
folds; inspiratory adduction
may carry over to expiration

Positive

Vocal folds may

adduct during
exhalation

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
location

Laryngeal area

Chest area

Timing of breathing
Stridor on
Wheezing on
noises
inspiration
exhalation

Pattern of dyspneic
event

Sudden onset and

relatively rapid
cessation

Nocturnal awakening
with symptoms

Rarely

Response to bronchodilators and/or systemic

corticosteroids

No response

More gradual onset

longer recovery
period
Almost always

Good response

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

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

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

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

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

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

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

Goal
Ability to
overcome fear
and helplessness
Reduced tension
in- extrinsic
laryngeal muscles
Diversion of
attention from
larynx

Method
Mastery of
breathing
techniques
Open throat
breathing; resonant
voice technique
Diaphragmatic
breathing and
active exhalation

Therapeutic goals and methods

Goal
Reduced tension
in neck,
shoulders and
chest
Ability to use
techniques to
reduce severity
and frequency of
attacks

Method
Movement,
stretching,
progressive
relaxation
Increase
awareness of early
warning
symptoms;
Rehearse action
plan

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 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

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
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 patients visual concept of
their disorder and alter

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

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
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 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

Outcome
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

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