Vocal Fold-Induced Dyspnea

Educational Objectives

The goal of this program is to improve management of inducible laryngeal obstruction. After hearing and assimilating this program, the clinician will be better able to:

1. Identify symptoms and triggers commonly associated with inducible laryngeal obstruction.

2. Optimize training in breathing techniques to manage inducible laryngeal obstruction.

3. Guide patients in avoiding triggers and addressing cofactors that worsen dyspnea associated with inducible laryngeal obstruction.

Summary

Case of 9-yr-old girl: history — large tonsils, obesity, and snoring; symptoms — dyspnea that occurs after 4 to 5 min of exertion during basketball and improves after 5 min of rest; patient tolerates increasingly longer periods of exertion after each period of rest; trigger — exercise; length of time between sensation and event — 4 to 5 min; development over several seconds or breaths; location — primarily throat; secondarily upper chest; location in respiratory cycle — primarily inhalation

Case of 14-yr-old boy: symptoms — onset after compression fracture of nasal septum; uncontrollable yawning and burping; inability to breathe deeply; triggers — exercise and exposure to cold air; symptoms (continued) — sensation of tight throat; location — throat; location in respiratory cycle — inhalation

Glottic closure reflex: reflex arc between sensation in and closure of larynx originates from superior laryngeal nerve (obtains sensation from internal mucosal surfaces of supraglottis and sends signal to close larynx when area stimulated); stimulation can occur 1) through direct anastomoses from superior to recurrent laryngeal nerve or 2) from superior laryngeal nerve to brain and to recurrent laryngeal nerve

Implications for treatment: nerve anastomoses contribute to involuntary glottic closure; condition may be involuntary; brain plays role; goal of therapy to interpose central control on reflex process

Inducible laryngeal obstruction (ILO)

Triggers: cause obstruction, which induces symptoms; include exertion, odors, textures of food, and acid reflux

Site: identify location of obstruction in larynx and point in respiratory cycle

Symptoms: should be documented to assess improvement and evaluate condition; may include dyspnea or other laryngeal symptoms (eg, globus); ask patient whether speaking possible during episode

Typical history: dyspnea of sudden onset (particularly in inspiratory phase) that often resolves quickly; intermittent stridor and other laryngeal symptoms; trigger identifiable; dyspnea does not improve with correct administration of albuterol

Differentiation between asthma and ILO: conditions may coexist, or ILO may be misdiagnosed as asthma; consider anatomic location and point in respiratory cycle of symptoms; in asthma, symptoms often present in expiratory phase; in ILO, symptoms typically occur at peak of exercise (rather than after its resolution); consider degree of responsiveness to bronchodilators

Pulmonary function tests: recommended for all patients; analyze curves and notes from respiratory technician (eg, assessment of validity of test); patients with asthma often have low forced expiratory volume in first second of expiration (FEV1) and blunted flow-volume loops; jagged flow-volume loops characteristic of ILO or vocal cord dysfunction; partial glottal closure often found in chronic obstructive pulmonary disease (COPD) and can appear as obstruction during testing

Other tests: perform bronchoscopy to distinguish ILO from tracheomalacia or tracheal stenosis; laryngoscopy to rule out paralysis of vocal cords

First-Line Therapy

Education of patient: includes function of larynx, opening of vocal folds during breathing and exercise, vibration of vocal folds to produce voice, and location of larynx (enables control)

Rescue breathing: standard treatment; ask patient to exhale small amount of air through pursed lips or by making sound (eg, “shhh,” “ssss,” “ffff”) to relax vocal folds; then to inhale to open vocal folds; ensure that breath originates from ribs and abdomen by instructing patient to bend over in chair while provider places hands on patient’s waist (patient can feel breathing more effectively than when lying on back); then gradually bring patient upright (bring head up last)

Increasing level of difficulty: after patients successful at rescue breathing in sitting position, integrate breathing pattern into increasingly challenging settings (eg, walking down hall, then walking upstairs); after patients proficient, instruct them to perform rescue breathing when they feel onset of ILO and throughout incident until breathing quiet; level of difficulty can be increased by performing rescue breaths while walking upstairs quickly, jumping rope, riding bicycle, running, or jumping in place

Medical management: reassure patient that ILO not life-threatening and management effective; introduce concept of rescue breathing; identify triggers and address cofactors that may worsen dyspnea (eg, allergies, reflux, asthma); anxiety typically not sole reason for onset of symptoms; refer patient to allergist for testing if signs of allergies present; work on techniques for avoidance of environmental triggers; if patient has heartburn, takes antacid agents, or reports sour taste in mouth, consider acid reflux as trigger, and counsel patient to begin dietary avoidance (not medication)

Refractory Cases

Medical management: look for alternative diagnoses (eg, early sign of neurologic or autonomic dysfunction); consider asthma as cofactor necessitating treatment

Injection of botulinum toxin (eg, Botox): large dose required to weaken laryngeal adductors; dysphonia likely result; recommended only for patients refractory to speech therapy with severe issues (eg, frequent hospitalization, intubation, inability to work); may prevent hospitalization in patients with severe symptoms who live in remote areas without access to speech therapy (patients often treated aggressively in emergency department if physician not familiar with ILO)

Exercise-induced laryngeal obstruction (EILO) biphasic inspiratory breathing technique: starts at high inspiratory resistance and followed rapidly by low resistance during inhalation; tongue variant — placing tongue on alveolar ridge and inhaling through nose, followed by inhalation through wide-open mouth; tooth variant — placing upper teeth on lower lip and inhaling through mouth; lip variant — inhaling through pursed lips, followed by open-mouth inhalation; expectations — ≈6 lessons required to achieve competence

Step 1 (planning): plan to use specific rescue breath on every fourth breath (may be increased to every other breath later); patient may hyperventilate if rescue breath performed during every breath

Step 2 (emptying): deliberately exhale before inhaling

Step 3 (splitting): use lip, tongue, or tooth variant to go from high to low resistance

Step 4 (timing): high resistance must be brief, but long enough to hear and feel constriction of air

Step 5 (forcefulness): inhalation should be audible; patients likely to be successful if they can also feel inhalation

Step 6 (fullness): develop feeling of fullness with each inhalation

Step 7 (ribs): breath should originate from lateral rib cage and abdomen

Study in patients who did not respond to rescue breathing: understanding instructions reported by 62%; ability to apply techniques, by 79%; and perception of clinical effectiveness, by ≈66%

Case of 9-yr-old girl (continued): patient’s condition does not improve with rescue breathing; she prefers tooth variant of EILO biphasic inspiratory breathing technique and able to apply it while running until exhausted; breathing improved; patient cognitively unable to apply technique while playing soccer or basketball after 3 of 6 sessions

Case of 14-yr-old boy (continued): patient cannot perform regular rescue breathing because nose crushed; EILO biphasic inspiratory breathing techniques successful after 2 sessions; at end of treatment, patient reveals that he had been punched in abdomen (possible cause of burping and yawning)

Readings

Haines J et al: Clinical presentation, assessment, and management of inducible laryngeal obstruction. Curr Opin Otolaryngol Head Neck Surg. 2018 Jun;26(3):174-179; Johnston KL et al: The Olin EILOBI breathing techniques: description and initial case series of novel respiratory retraining strategies for athletes with exercise-induced laryngeal obstruction. J Voice. 2018 Nov;32(6):698-704; Lee JW et al: Diagnosis of concomitant inducible laryngeal obstruction and asthma. Clin Exp Allergy. 2018 Dec;48(12):1622-1630; Olin JT et al: Inducible laryngeal obstruction during exercise: moving beyond vocal cords with new insights. Phys Sportsmed. 2015 Feb;43(1):13-21; Røksund OD et al: Exercise inducible laryngeal obstruction: diagnostics and management. Paediatr Respir Rev. 2017 Jan;21:86-94

Disclosures

For this program, members of the faculty and planning committee reported nothing to disclose.

Acknowledgements

Dr. Long and Ms. Bolden were recorded at the UCLA Laryngology Update 2019, held April 5, 2019, in Los Angeles, CA, and presented by the Office of Continuing Medical Education at the David Geffen School of Medicine at UCLA. For information on future CME activities from this sponsor, please visit cme.ucla.edu. The Audio Digest Foundation thanks the speakers and the Office of Continuing Medical Education at the David Geffen School of Medicine at UCLA for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

OT521501

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.