Approach
Effective treatment for paradoxical vocal fold motion (intermittent laryngeal obstruction) (PVFM/ILO) begins with and relies upon a comprehensive team approach from an experienced and knowledgeable multidisciplinary team. This team may include the primary care physician, allergy/asthma specialist, cardiologist, pulmonologist, otolaryngologist, speech language pathologist, sports medicine physician, psychologist, psychiatrist, and/or gastroenterologist.
A combination of behavioral treatment, medical management of reflux and asthma, and counseling (if indicated) is highly successful in eliminating paradoxical breathing attacks, but treatment needs to be tailored to the individual, as a blanket treatment plan for all is not helpful.[31]
Emergency management
Individuals with undiagnosed PVFM/ILO frequently present to the emergency department with sudden-onset breathing attacks and are often misdiagnosed with an acute exacerbation of asthma. These patients commonly present with the following characteristics:[75][79][81][87]
Prescription of large doses of asthma medication
Multiple emergency department visits
History of previous intubation or tracheotomy
Low IgE and normal eosinophil counts
Nasal complaints with negative sinus CT
Normal or truncated inspiratory flow volume loops
Presentation of the acute breathing attack in PVFM/ILO is variable and poorly defined by the patient. It may include inspiratory stridor, wheeze (inspiratory or biphasic), shortness of breath, panic, inability to breathe in deeply, and/or throat tightness.
To allow differentiation between PVFM/ILO and an acute exacerbation of asthma, the following may be used:[27]
Ask the patient to pant or hold his or her breath: patients having an acute asthma attack will not be able to do either task, and breathing difficulty may intensify, while those with PVFM/ILO are likely to show improvement with panting.
The immediate management of a patient presenting to the emergency department with inspiratory stridor is as follows:[27][64][88][89][90]
The stability of the patient should be determined with assessment and support of the airway, breathing (monitoring of respiratory rate and oxygen saturation, high-concentration oxygen >60%), and circulation (monitoring of pulse and BP). PVFM/ILO does not typically lead to instability and, if present, other conditions should be considered.
Patients with progressive airway obstruction should be treated with appropriate emergency management per facility.
Stable patients, without signs of progressive airway obstruction, cardiac, or other pulmonary failure, should be given oxygen for comfort, calmed with continuous reassurance and positive encouragement, and instructed to undertake breathing exercises (breathing in through the nose and out through the mouth and repeated sniffs); these measures should be continued throughout until the breathing attack ceases.
Stable patients should then be investigated with flexible laryngoscopy for the presence of PVFM/ILO to be confirmed and documented.[Figure caption and citation for the preceding image starts]: Normal larynx: normal color of vocal folds and surrounding structures, smooth vocal fold edgesFrom the collection of the University of Wisconsin School of Medicine and Public Health [Citation ends].
[Figure caption and citation for the preceding image starts]: Reproduction of breathing attack: adduction of arytenoid complex during inhalationFrom the collection of the University of Wisconsin School of Medicine and Public Health [Citation ends].
If the above measures are unsuccessful at resolving the breathing attack, heliox may be administered via a mask. Heliox is a mixture of oxygen and helium (in the ratios of 20:80, 30:70, or 40:60) and leads to reduced airflow turbulence through laryngeal relaxation, allowing prompt resolution of symptoms and anxiety.
If the patient loses consciousness, airway, breathing, and circulation should be closely monitored and airway support should be readily available. If vital signs worsen or oxygen saturation decreases, he or she should be treated with appropriate emergency medical management per facility. This should prompt investigation of a cause other than PVFM/ILO.
Intubation should be avoided, as breathing attacks are self-limited in PVFM/ILO.
Behavioral therapy
The speech pathologist is considered the primary provider of behavioral management related to PVFM/ILO. Speech pathologists possess unique knowledge and training related to the laryngeal airway.[73][91][92]
Laryngeal control therapy is directed toward eliminating adductory breathing behavior in order to open the airway.[93][94] The aim of the treatment plan is not only to promote relaxation but also to cultivate awareness of the subtle physiologic feedback provided by the body. In order to be successful with the behavioral management of breathing attacks, patients need to be provided with a clear understanding of the breathing attack and its causes and triggers, as, without confidence in their ability to stop or prevent the attack, its severity can escalate.
The goals of behavioral management include:[67][95]
Increasing self-awareness of physical muscle tension: the patient is taught how to recognize increased muscle tension in the body and begin an abduction breathing exercise before the breathing attack escalates into a fearful situation
Increasing awareness of breathing attack onset and physiologic responses to known triggers
Resumption of diaphragmatic breathing following successful management of an acute attack
Management of laryngopharyngeal reflux (LPR), breathing attacks, chronic throat clearing, and cough
Prevention of future attacks
Focusing attention away from medical management
Implementation of a behavior maintenance program
Patients with irritant-specific PVFM/ILO, where odor sensitivity triggers the laryngeal response typical of PVFM/ILO, may blame their symptoms on the odor itself. In such cases behavioral therapy may be necessary to reduce the conditioned response to specific odors, and the patient should be advised to avoid or minimize exposure to chemical odors.[96]
Behavioral therapy can also be used to reduce the conditioned response to other PVFM/ILO triggers such as exercise, sitting, eating, sleeping, airborne irritants (smoke, perfume), extreme temperatures, and stress.[3] Patients with PVFM/ILO associated with a specific irritant should also receive allergy testing to identify possible allergens. Keeping a daily journal may be helpful for individuals with poor awareness of breathing attacks, triggers, diet, and physical/psychological stress, to help identify possible triggers.[1]
Behavioral treatment with the speech language pathologist should comprise an initial visit followed by 3-4 visits in order to achieve the best outcome.[55] If the patient is not responsive after behavioral management, additional behavioral treatment with the speech language pathologist may be required.
As stress can be associated with PVFM/ILO, patients should be encouraged to find appropriate avenues for stress relief and management. These may include psychological counseling, exercise, and modification of a stressful lifestyle.[67]
As athletes often experience PVFM/ILO attacks at very high levels of physical exercise or during competition, additional breathing retraining can take place on the site of the athletic event.
Evaluation of breathing patterns during exercise in the particular athletic event will often reveal areas of upper-body muscle tension that contribute to intrinsic and extrinsic laryngeal muscle tension.
Activity-based breathing exercises are introduced at a slow pace and increased until effective at the competitive level.
Involvement and education of the coach or trainer and behavioral management of the condition will support a successful outcome.
Children may require more intensive therapy involving:[67]
Frequent behavioral management
Parental education and involvement in the treatment plan
Education of support staff in the child's school on the signs and symptoms of a breathing attack and making appropriate referrals for diagnosis and treatment
A school contact such as the nurse or classroom aide who can help support and guide recovery exercises as required
Ineffective treatment and decreased patient adherence, if evident, will most likely occur during behavioral management.
Patients without a good understanding of PVFM/ILO and the effectiveness of breathing exercises may not follow the recommended treatment plan and will therefore gain little benefit during a breathing attack.
Some patients will need several treatment sessions with the speech language pathologist to create an individualized program that achieves success.
Patients need to invest time and effort into developing personal awareness and be actively involved in behavioral plans designed to improve laryngeal function and decrease or eliminate laryngeal irritations and detrimental behaviors.
An individual with poor self-awareness may require extra guidance for identifying triggers and physical muscle tension.
Visual biofeedback
One of the most important steps in helping patients understand the problem of PVFM/ILO, and how they will be able to manage the attack, is to provide visual biofeedback during diagnostic laryngeal visualization.[67] This should be undertaken in all patients with PVFM/ILO.
An abduction breathing exercise, which consists of a deep sniff in through the nose followed by a 3- to 10-second exhalation, should be introduced during visualization. [Figure caption and citation for the preceding image starts]: Abduction breathing exercise: abduction of the arytenoid complex bilaterally with nasal inhalationFrom the collection of the University of Wisconsin School of Medicine and Public Health [Citation ends].
This method of biofeedback increases the patient's knowledge and understanding of PVFM/ILO and airway control as well as establishing a state of mind for independent behavioral management.
Once patients understand that they have a means of controlling the breathing attack, they express both relief and confidence.
Medical treatment of comorbid conditions
All patients with suspected or confirmed PVFM/ILO must be thoroughly assessed and given appropriate treatment for any underlying medical condition.
The main goal of medical treatment is to encourage recovery of laryngeal tissue and reprogram central nervous system input to regulate the larynx, thus restoring normal respiratory reflexes and airway protection.
Medical treatment may be required for asthma, upper respiratory symptoms, GERD, LPR, chronic cough, or cardiac and pulmonary conditions. It must be directed by the appropriate specialist and tailored to the individual patient. For example, ipratropium may be used to create an open and relaxed airway where asthma coexists with PVFM/ILO.[97]
Patients with high levels of stress and anxiety should be assessed for the presence of clinical anxiety and treated appropriately.
Psychotherapy
Adolescents with vocal cord dysfunction and coexisting asthma have been found to experience more anxiety symptoms than those with isolated moderate to severe chronic asthma.[28] Individuals with PVFM/ILO also score highly for separation anxiety, a condition associated with panic attacks.[28]
Many studies have associated stressful environments and anxiety with occurrences of PVFM/ILO, and there is support for the presence of anxiety and, possibly, conversion disorder in the condition.[18][28][59][60][61]
Referral for psychotherapy may be beneficial for:
Individuals in whom there is a suspicion that psychological factors are associated with the breathing attacks
Athletes referred to a sports psychology specialist, with whose help the athlete's attention is focused on issues related to competition, winning, and coping with defeat and expectations.
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