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Semin Respir Crit Care Med 2012; 33(06): 595-605
DOI: 10.1055/s-0032-1326959
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Asthma: Vocal Cord Dysfunction (VCD) and other Dysfunctional Breathing Disorders

Ron Balkissoon
1   Pulmonary Division, National Jewish Health, Denver, Colorado
,
Klaus Kenn
2   Department of Pulmonology, Klinikum Berchtesgadener Land, Koenigssee, Germany
› Author Affiliations
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Publication History

Publication Date:
09 October 2012 (online)

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Abstract

Vocal cord dysfunction (VCD) and dysfunctional breathing (DB) disorders may mimic or coexist with asthma, leading to overtreatment with corticosteroids with consequent morbidity. Iatrogenic complications can be averted by early and correct diagnosis. VCD, also termed paradoxical vocal fold motion disorder (PVFMD), is characterized by intermittent paradoxical adduction of the vocal cords, mainly during inspiration, leading to airflow obstruction and dyspnea. Patients with VCD may have repetitive emergency room visits due to acute dyspnea (mimicking exacerbations of asthma). In the seminal descriptions of VCD, young women (often with psychiatric issues) predominated; however, other groups at increased risk for developing VCD include elite athletes, military recruits, and individuals exposed to irritants (inhaled or aspirated). Chronic postnasal drip, laryngopharyngeal reflux (LPR), and gastroesophageal reflux (GER) may lead to laryngeal hyperresponsiveness. The diagnosis of VCD may be difficult because physical exam and spirometry may be normal between episodes. During symptomatic episodes, spirometry typically reveals variable extrathoracic airway obstruction (truncated inspiratory flow volume loop). The gold standard for identifying VCD is flexible fiberoptic rhinolaryngoscopy. Management of VCD includes identification and treatment of underlying disorders (eg, chronic postnasal drip, LPR, GER, anxiety, depression) and a multidisciplinary approach (including highly trained speech therapists). Speech therapy and biofeedback play a critical role in teaching techniques to override various dysfunctional breathing habits. When postnasal drip, LPR, or GER coexist, these disorders should be aggressively treated. With successful therapy, corticosteroids can often be discontinued. During severe, acute episodes of VCD, therapeutic strategies include heliox (80% helium/20% oxygen), topical lidocaine, anxiolytics, and superior laryngeal blocks with Clostridium botulinum toxin.

DB is a poorly understood disorder with features that overlap with VCD and asthma. The dysfunctional pattern may reflect abnormalities in the rate or depth of breathing or in breathing mechanics that may involve the nasal passages, oropharynx, larynx, or chest wall muscles. Not unlike VCD, patients with DB are often diagnosed with asthma, and their symptoms do not improve on asthma medicines. There is no consensus regarding diagnostic criteria or appropriate testing for DB. The pathophysiology of DB is poorly understood, but psychological or physiological stress may precipitate episodes in some patients. Treatment requires a multidisciplinary approach (including speech therapy and psychological support). Prognosis is usually good.

Keywords

vocal cord dysfunction - dysfunctional breathing - asthma - upper airway obstruction
 

  • References

  • 1 Bahadori K, Doyle-Waters MM, Marra C , et al. Economic burden of asthma: a systematic review. BMC Pulm Med 2009; 9: 24
    CrossrefPubMedGoogle Scholar
  • 2 Wenzel S. Severe asthma in adults. Am J Respir Crit Care Med 2005; 172 (2) 149-160
    CrossrefPubMedGoogle Scholar
  • 3 Newman KB, Dubester SN. Vocal cord dysfunction: masquerader of asthma. Semin Respir Crit Care Med 1994; 15: 161-167
    Article in Thieme ConnectPubMedGoogle Scholar
  • 4 Dunglison R. The Practice of Medicine. Philadelphia, PA: Lea and Blanchard; 1842: 247-258
    Google Scholar
  • 5 Patterson R, Schatz M, Horton M. Munchausen's stridor: non-organic laryngeal obstruction. Clin Allergy 1974; 4 (3) 307-310
    PubMedGoogle Scholar
  • 6 Kenn K, Schmitz M. Prevalence of vocal cord dysfunction in patients with dyspnea. First prospective clinical study [abstract]. Am J Respir Crit Care Med 1997; 155: A965
    PubMedGoogle Scholar
  • 7 Christopher KL, Wood II RP, Eckert RC, Blager FB, Raney RA, Souhrada JF. Vocal-cord dysfunction presenting as asthma. N Engl J Med 1983; 308 (26) 1566-1570
    CrossrefPubMedGoogle Scholar
  • 8 Newman KB, Mason III UG, Schmaling KB. Clinical features of vocal cord dysfunction. Am J Respir Crit Care Med 1995; 152 (4 Pt 1) 1382-1386
    CrossrefPubMedGoogle Scholar
  • 9 Ciccolella DE, Brennan KJ, Borbely B. Identification of vocal cord dysfunction (VCD) and other diagnoses in patients admitted to an inner city university hospital asthma centre [abstract]. Am J Respir Crit Care Med 1997; 155: A82
    PubMedGoogle Scholar
  • 10 Jain S, Bandi V, Officer T, Wolley M, Guntupalli KK. Role of vocal cord function and dysfunction in patients presenting with symptoms of acute asthma exacerbation. J Asthma 2006; 43 (3) 207-212
    CrossrefPubMedGoogle Scholar
  • 11 Brugman S. The many faces of vocal cord dysfunction. What 36 years of literature tells us [abstract]. Am J Respir Crit Care Med 2003; 167: A588
    PubMedGoogle Scholar
  • 12 Morris MJ, Allan PF, Perkins PJ. Vocal cord dysfunction: aetiologies and treatment. Clin Pulm Med 2006; 13: 73-86
    CrossrefPubMedGoogle Scholar
  • 13 Carlsen KH. The breathless adolescent asthmatic athlete. Eur Respir J 2011; 38 (3) 713-720
    CrossrefPubMedGoogle Scholar
  • 14 Morris MJ, Grbach VX, Deal LE, Boyd SY, Morgan JA, Johnson JE. Evaluation of exertional dyspnea in the active duty patient: the diagnostic approach and the utility of clinical testing. Mil Med 2002; 167 (4) 281-288
    PubMedGoogle Scholar
  • 15 Rundell KW, Spiering BA. Inspiratory stridor in elite athletes. Chest 2003; 123 (2) 468-474
    CrossrefPubMedGoogle Scholar
  • 16 Perkner JJ, Fennelly KP, Balkissoon R , et al. Irritant-associated vocal cord dysfunction. J Occup Environ Med 1998; 40 (2) 136-143
    PubMedGoogle Scholar
  • 17 Kenn K, Hess MM. [Vocal cord dysfunction—a “solely pneumatologic” illness?]. HNO 2004; 52 (2) 103-109
    CrossrefPubMedGoogle Scholar
  • 18 Bucca C, Rolla G, Scappaticci E , et al. Extrathoracic and intrathoracic airway responsiveness in sinusitis. J Allergy Clin Immunol 1995; 95 (1 Pt 1) 52-59
    CrossrefPubMedGoogle Scholar
  • 19 Shusterman D. Critical review: the health significance of environmental odor pollution. Arch Environ Health 1992; 47 (1) 76-87
    CrossrefPubMedGoogle Scholar
  • 20 Merati AL, Lim HJ, Ulualp SO, Toohill RJ. Meta-analysis of upper probe measurements in normal subjects and patients with laryngopharyngeal reflux. Ann Otol Rhinol Laryngol 2005; 114 (3) 177-182
    PubMedGoogle Scholar
  • 21 Field SK, Underwood M, Brant R, Cowie RL. Prevalence of gastroesophageal reflux symptoms in asthma. Chest 1996; 109 (2) 316-322
    CrossrefPubMedGoogle Scholar
  • 22 Vincent D, Cohen-Jonathan AM, Leport J , et al. Gastro-oesophageal reflux prevalence and relationship with bronchial reactivity in asthma. Eur Respir J 1997; 10 (10) 2255-2259
    CrossrefPubMedGoogle Scholar
  • 23 Sontag SJ, O'Connell S, Khandelwal S , et al. Most asthmatics have gastroesophageal reflux with or without bronchodilator therapy. Gastroenterology 1990; 99 (3) 613-620
    PubMedGoogle Scholar
  • 24 Harding SM, Guzzo MR, Richter JE. The prevalence of gastroesophageal reflux in asthma patients without reflux symptoms. Am J Respir Crit Care Med 2000; 162 (1) 34-39
    CrossrefPubMedGoogle Scholar
  • 25 Harding SM. Gastroesophageal reflux: a potential asthma trigger. Immunol Allergy Clin North Am 2005; 25 (1) 131-148
    CrossrefPubMedGoogle Scholar
  • 26 Harding SM. Recent clinical investigations examining the association of asthma and gastroesophageal reflux. Am J Med 2003; 115 (Suppl 3A) 39S-44S
    CrossrefPubMedGoogle Scholar
  • 27 Koufman JA, Aviv JE, Casiano RR, Shaw GY. Laryngopharyngeal reflux: position statement of the committee on speech, voice, and swallowing disorders of the American Academy of Otolaryngology-Head and Neck Surgery. Otolaryngol Head Neck Surg 2002; 127 (1) 32-35
    CrossrefPubMedGoogle Scholar
  • 28 Hicks DM, Ours TM, Abelson TI, Vaezi MF, Richter JE. The prevalence of hypopharynx findings associated with gastroesophageal reflux in normal volunteers. J Voice 2002; 16 (4) 564-579
    CrossrefPubMedGoogle Scholar
  • 29 Johnston N, Bulmer D, Gill GA , et al. Cell biology of laryngeal epithelial defenses in health and disease: further studies. Ann Otol Rhinol Laryngol 2003; 112 (6) 481-491
    PubMedGoogle Scholar
  • 30 Morrison M, Rammage L, Emami AJ. The irritable larynx syndrome. J Voice 1999; 13 (3) 447-455
    CrossrefPubMedGoogle Scholar
  • 31 Tilles SA. Vocal cord dysfunction in children and adolescents. Curr Allergy Asthma Rep 2003; 3 (6) 467-472
    CrossrefPubMedGoogle Scholar
  • 32 Goldberg BJ, Kaplan MS. Non-asthmatic respiratory symptomatology. Curr Opin Pulm Med 2000; 6 (1) 26-30
    CrossrefPubMedGoogle Scholar
  • 33 Balkissoon R, Shusterman D. Occupational upper airway disorders. Semin Respir Crit Care Med 1999; 20 (6) 569-580
    Article in Thieme ConnectPubMedGoogle Scholar
  • 34 Balkissoon R. Occupational upper airway disease. Clin Chest Med 2002; 23 (4) 717-725
    CrossrefPubMedGoogle Scholar
  • 35 Ayres JG, Gabbott PL. Vocal cord dysfunction and laryngeal hyperresponsiveness: a function of altered autonomic balance?. Thorax 2002; 57 (4) 284-285
    CrossrefPubMedGoogle Scholar
  • 36 Gavin LA, Wamboldt M, Brugman S, Roesler TA, Wamboldt F. Psychological and family characteristics of adolescents with vocal cord dysfunction. J Asthma 1998; 35 (5) 409-417
    CrossrefPubMedGoogle Scholar
  • 37 Kendrick AH, Higgs CM, Whitfield MJ, Laszlo G. Accuracy of perception of severity of asthma: patients treated in general practice. BMJ 1993; 307 (6901) 422-424
    CrossrefPubMedGoogle Scholar
  • 38 Kikuchi Y, Okabe S, Tamura G , et al. Chemosensitivity and perception of dyspnea in patients with a history of near-fatal asthma. N Engl J Med 1994; 330 (19) 1329-1334
    CrossrefPubMedGoogle Scholar
  • 39 Watson MA, King CS, Holley AB, Greenburg DL, Mikita JA. Clinical and lung-function variables associated with vocal cord dysfunction. Respir Care 2009; 54 (4) 467-473
    PubMedGoogle Scholar
  • 40 Sifrim D, Dupont L, Blondeau K, Zhang X, Tack J, Janssens J. Weakly acidic reflux in patients with chronic unexplained cough during 24 hour pressure, pH, and impedance monitoring. Gut 2005; 54 (4) 449-454
    CrossrefPubMedGoogle Scholar
  • 41 Kenn K, Freitag L. Endospirometry - development of a device to objectify vocal cord dysfunction and proposal for a classification system. Eur Respir J 2006; 28 (Suppl. 50) 793S
    PubMedGoogle Scholar
  • 42 Low K, Lau KK, Holmes P , et al. Abnormal vocal cord function in difficult-to-treat asthma. Am J Respir Crit Care Med 2011; 184 (1) 50-56
    CrossrefPubMedGoogle Scholar
  • 43 Clerf LH. Unilateral vocal cord paralysis. J Am Med Assoc 1953; 151 (11) 900-903
    PubMedGoogle Scholar
  • 44 Parnell FW, Brandenburg JH. Vocal cord paralysis. A review of 100 cases. Laryngoscope 1970; 80 (7) 1036-1045
    CrossrefPubMedGoogle Scholar
  • 45 Leo RJ, Konakanchi R. Psychogenic respiratory distress: a case of paradoxical vocal cord dysfunction and literature review. Prim Care Companion J Clin Psychiatry 1999; 1 (2) 39-46
    CrossrefPubMedGoogle Scholar
  • 46 Tarlo SM, Poonai N, Binkley K, Antony MM, Swinson RP. Responses to panic induction procedures in subjects with multiple chemical sensitivity/idiopathic environmental intolerance: understanding the relationship with panic disorder. Environ Health Perspect 2002; 110 (Suppl. 04) 669-671
    CrossrefPubMedGoogle Scholar
  • 47 Poonai NP, Antony MM, Binkley KE , et al. Psychological features of subjects with idiopathic environmental intolerance. J Psychosom Res 2001; 51 (3) 537-541
    CrossrefPubMedGoogle Scholar
  • 48 Poonai N, Antony MM, Binkley KE , et al. Carbon dioxide inhalation challenges in idiopathic environmental intolerance. J Allergy Clin Immunol 2000; 105 (2 Pt 1) 358-363
    CrossrefPubMedGoogle Scholar
  • 49 Bailer J, Witthöft M, Paul C, Bayerl C, Rist F. Evidence for overlap between idiopathic environmental intolerance and somatoform disorders. Psychosom Med 2005; 67 (6) 921-929
    CrossrefPubMedGoogle Scholar
  • 50 Murry T, Tabaee A, Owczarzak V, Aviv JE. Respiratory retraining therapy and management of laryngopharyngeal reflux in the treatment of patients with cough and paradoxical vocal fold movement disorder. Ann Otol Rhinol Laryngol 2006; 115 (10) 754-758
    PubMedGoogle Scholar
  • 51 Gibson PG, Vertigan AE. Speech pathology for chronic cough: a new approach. Pulm Pharmacol Ther 2009; 22 (2) 159-162
    CrossrefPubMedGoogle Scholar
  • 52 Andrianopoulos MV, Gallivan GJ, Gallivan KH. PVCM, PVCD, EPL, and irritable larynx syndrome: what are we talking about and how do we treat it?. J Voice 2000; 14 (4) 607-618
    CrossrefPubMedGoogle Scholar
  • 53 Reisner C, Borish L. Heliox therapy for acute vocal cord dysfunction. Chest 1995; 108 (5) 1477
    PubMedGoogle Scholar
  • 54 Maillard I, Schweizer V, Broccard A, Duscher A, Liaudet L, Schaller MD. Use of botulinum toxin type A to avoid tracheal intubation or tracheostomy in severe paradoxical vocal cord movement. Chest 2000; 118 (3) 874-877
    CrossrefPubMedGoogle Scholar
  • 55 van Dixhoorn J. Cardiorespiratory effects of breathing and relaxation instruction in myocardial infarction patients. Biol Psychol 1998; 49 (1,2) 123-135
    CrossrefPubMedGoogle Scholar
  • 56 Morgan MD. Dysfunctional breathing in asthma: is it common, identifiable and correctable?. Thorax 2002; 57 (Suppl. 02) II31-II35
    PubMedGoogle Scholar
  • 57 Thomas M, McKinley RK, Freeman E, Foy C, Prodger P, Price D. Breathing retraining for dysfunctional breathing in asthma: a randomised controlled trial. Thorax 2003; 58 (2) 110-115
    CrossrefPubMedGoogle Scholar
  • 58 Gardner WN. The pathophysiology of hyperventilation disorders. Chest 1996; 109 (2) 516-534
    CrossrefPubMedGoogle Scholar
  • 59 Lum IC. Symptoms and signs of hyperventilation. In: Timmons B, Ley R, , eds. Behavioural and Psychological Approaches in Breathing Disorders. London: Plenum Press; 1994: 113-123
    CrossrefGoogle Scholar
  • 60 Folgering H. The pathophysiology of hyperventilation syndrome. Monaldi Arch Chest Dis 1999; 54 (4) 365-372
    PubMedGoogle Scholar
  • 61 Hormbrey J, Jacobi MS, Patil CP, Saunders KB. CO2 response and pattern of breathing in patients with symptomatic hyperventilation, compared to asthmatic and normal subjects. Eur Respir J 1988; 1 (9) 846-851
    PubMedGoogle Scholar
  • 62 Han JN, Stegen K, Simkens K , et al. Unsteadiness of breathing in patients with hyperventilation syndrome and anxiety disorders. Eur Respir J 1997; 10 (1) 167-176
    CrossrefPubMedGoogle Scholar
  • 63 Han JN, Stegen K, Schepers R, Van den Bergh O, Van de Woestijne KP. Subjective symptoms and breathing pattern at rest and following hyperventilation in anxiety and somatoform disorders. J Psychosom Res 1998; 45 (6) 519-532
    CrossrefPubMedGoogle Scholar
  • 64 Thomas M, McKinley RK, Freeman E, Foy C. Prevalence of dysfunctional breathing in patients treated for asthma in primary care: cross sectional survey. BMJ 2001; 322 (7294) 1098-1100
    CrossrefPubMedGoogle Scholar
  • 65 Lum LC. Hyperventilation: the tip and the iceberg. J Psychosom Res 1975; 19 (5-6) 375-383
    CrossrefPubMedGoogle Scholar
  • 66 Rice RL. Symptom patterns of the hyperventilation syndrome. Am J Med 1950; 8 (6) 691-700
    CrossrefPubMedGoogle Scholar
  • 67 Thomas M, McKinley RK, Freeman E, Foy C, Price D. The prevalence of dysfunctional breathing in adults in the community with and without asthma. Prim Care Respir J 2005; 14 (2) 78-82
    CrossrefPubMedGoogle Scholar
  • 68 Enzer NB, Walker PA. Hyperventilation syndrome in childhood. A review of 44 cases. J Pediatr 1967; 70 (4) 521-532
    PubMedGoogle Scholar
  • 69 Herman SP, Stickler GB, Lucas AR. Hyperventilation syndrome in children and adolescents: long-term follow-up. Pediatrics 1981; 67 (2) 183-187
    PubMedGoogle Scholar
  • 70 Seear M, Wensley D, West N. How accurate is the diagnosis of exercise induced asthma among Vancouver schoolchildren?. Arch Dis Child 2005; 90 (9) 898-902
    CrossrefPubMedGoogle Scholar
  • 71 Hammo AH, Weinberger MM. Exercise-induced hyperventilation: a pseudoasthma syndrome. Ann Allergy Asthma Immunol 1999; 82 (6) 574-578
    CrossrefPubMedGoogle Scholar
  • 72 Löwhagen O. Asthma—a disease difficult to define. Patients can receive correct treatment by means of differential diagnosis criteria [in Swedish]. Lakartidningen 2005; 102 (50) 3872-3873 , 3875–3878
    PubMedGoogle Scholar
  • 73 van Dixhoorn J, Duivenvoorden HJ. Efficacy of Nijmegen Questionnaire in recognition of the hyperventilation syndrome. J Psychosom Res 1985; 29 (2) 199-206
    CrossrefPubMedGoogle Scholar
  • 74 Baranes T, Rossignol B, Stheneur C, Bidat E. [Hyperventilation syndrome in children]. Arch Pediatr 2005; 12 (12) 1742-1747
    CrossrefPubMedGoogle Scholar
  • 75 Hagman C, Janson C, Emtner M. A comparison between patients with dysfunctional breathing and patients with asthma. Clin Respir J 2008; 2 (2) 86-91
    CrossrefPubMedGoogle Scholar
  • 76 Hornsveld HK, Garssen B, Dop MJ, van Spiegel PI, de Haes JC. Double-blind placebo-controlled study of the hyperventilation provocation test and the validity of the hyperventilation syndrome. Lancet 1996; 348 (9021) 154-158
    CrossrefPubMedGoogle Scholar
  • 77 Kinnula VL, Sovijärvi AR. Elevated ventilatory equivalents during exercise in patients with hyperventilation syndrome. Respiration 1993; 60 (5) 273-278
    CrossrefPubMedGoogle Scholar
  • 78 White KM, Quinn JM, Hagan LL, Johnson II TL. Exercise-induced hyperventilation. Ann Allergy Asthma Immunol 2008; 100 (2) 171-172
    CrossrefPubMedGoogle Scholar
  • 79 Lear SA, Brozic A, Myers JN, Ignaszewski A. Exercise stress testing: an overview of current guidelines. Sports Med 1999; 27 (5) 285-312
    CrossrefPubMedGoogle Scholar
  • 80 van der Cammen-van Zijp MH, Ijsselstijn H, Takken T , et al. Exercise testing of pre-school children using the Bruce treadmill protocol: new reference values. Eur J Appl Physiol 2010; 108 (2) 393-399
    CrossrefPubMedGoogle Scholar
  • 81 DeGuire S, Gevirtz R, Hawkinson D, Dixon K. Breathing retraining: a three-year follow-up study of treatment for hyperventilation syndrome and associated functional cardiac symptoms. Biofeedback Self Regul 1996; 21 (2) 191-198
    CrossrefPubMedGoogle Scholar
  • 82 Han JN, Stegen K, De Valck C, Clément J, Van de Woestijne KP. Influence of breathing therapy on complaints, anxiety and breathing pattern in patients with hyperventilation syndrome and anxiety disorders. J Psychosom Res 1996; 41 (5) 481-493
    CrossrefPubMedGoogle Scholar
  • 83 Grossman P, de Swart JC, Defares PB. A controlled study of a breathing therapy for treatment of hyperventilation syndrome. J Psychosom Res 1985; 29 (1) 49-58
    CrossrefPubMedGoogle Scholar
  • 84 Stanton AE, Vaughn P, Carter R, Bucknall CE. An observational investigation of dysfunctional breathing and breathing control therapy in a problem asthma clinic. J Asthma 2008; 45 (9) 758-765
    CrossrefPubMedGoogle Scholar
  • 85 Lewis BI. Hyperventilation syndrome: a clinical and physiological evaluation. Calif Med 1959; 91: 121-126
    PubMedGoogle Scholar
  • 86 Holloway EA, West RJ. Integrated breathing and relaxation training (the Papworth method) for adults with asthma in primary care: a randomised controlled trial. Thorax 2007; 62 (12) 1039-1042
    CrossrefPubMedGoogle Scholar
  • 87 Kenn K, Balkissoon R. Vocal cord dysfunction: what do we know?. Eur Respir J 2011; 37 (1) 194-200
    CrossrefPubMedGoogle Scholar
  • 88 Wamboldt FS, Wamboldt MZ. Psychiatric aspects of respiratory symptoms. In: Taussig LM, Landau LI, , eds. Textbook of Pediatric Respiratory Medicine. 2nd edition. St. Louis, MO: Mosby; 2008: 1039-1051
    CrossrefGoogle Scholar