Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

unstable, undiagnosed patient with stridor

1st line – advanced life support as required

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ACUTE
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unstable, undiagnosed patient with stridor
1st line – 

advanced life support as required

Individuals with undiagnosed paradoxical vocal fold motion (intermittent laryngeal obstruction) (PVFM/ILO) frequently present to the emergency department with sudden-onset breathing attacks. 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.[98]​

Patients with progressive airway obstruction should be treated with appropriate emergency management per facility.[64][88]

stable patient with stridor suspected to be secondary to PVFM/ILO

1st line – oxygen, breathing exercises, and reassurance

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ACUTE
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stable patient with stridor suspected to be secondary to PVFM/ILO
1st line – 

oxygen, breathing exercises, and reassurance

Stable patients, without signs of progressive airway obstruction, cardiac, or other pulmonary failure, should be given high-concentration oxygen (>60%) for comfort.

Patient instructed to undertake breathing exercises (breathing in through the nose and out through the mouth and repeated sniffs).

Patient calmed with continuous reassurance and positive encouragement.

These measures should be continued throughout until the breathing attack ceases.

A flexible laryngoscopy should be undertaken at this point in order to confirm and document the presence of paradoxical vocal fold motion (intermittent laryngeal obstruction) (PVFM/ILO).

Consider – heliox

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ACUTE
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stable patient with stridor suspected to be secondary to PVFM/ILO
Consider – 

heliox

Treatment recommended for SOME patients in selected patient group

Mixture of oxygen and helium (in ratios of 20:80, 30:70, or 40:60).

Leads to reduced airflow turbulence through laryngeal relaxation, allowing prompt resolution of symptoms and anxiety.[27][90]

Plus – monitoring

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ACUTE
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stable patient with stridor suspected to be secondary to PVFM/ILO
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with loss of consciousness
Plus – 

monitoring

Treatment recommended for ALL patients in selected patient group

Airway, breathing, and circulation should be closely monitored.

Airway support should be readily available.

Intubation should be avoided if possible as breathing attacks are generally self-limited.

If the patient destabilizes, he or she should be treated with appropriate emergency management per facility.[64][88]​​​ This should prompt investigation of a cause other than paradoxical vocal fold motion (intermittent laryngeal obstruction) (PVFM/ILO).

ONGOING

without acute stridor

1st line – behavioral therapy and visual biofeedback

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ONGOING
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without acute stridor
1st line – 

behavioral therapy and visual biofeedback

To eliminate adductory breathing behavior and open the airway.

Recognition of increased muscle tension and initiation of abduction breathing exercise before breathing attack escalates.

Abduction breathing exercise: deep sniff in through the nose followed by a 3- to 10-second exhalation.

Resumption of diaphragmatic breathing following resolution of acute attack.[67]

In visual biofeedback, abduction breathing exercise is introduced during diagnostic laryngeal visualization.

Daily journal to document breathing attacks, triggers, diet, and physical/psychological stress.

Children require more intensive behavioral therapy, with parental and school involvement in management.

Lack of response will require several treatment sessions with the speech language pathologist to create an individualized behavioral therapy program in order to increase understanding of paradoxical vocal fold motion (intermittent laryngeal obstruction) (PVFM/ILO) and the effectiveness of breathing exercises, promote self-awareness of muscle tension, and provide guidance on trigger identification.

Plus – management of comorbid medical condition

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ONGOING
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without acute stridor
Plus – 

management of comorbid medical condition

Treatment recommended for ALL patients in selected patient group

Main goal of medical treatment is to encourage recovery of laryngeal tissue and to reprogram central nervous system input to regulate the larynx, thus restoring normal respiratory reflexes and airway protection.

Must be directed by the appropriate specialist and tailored to the individual patient.

Medical treatment of coexisting asthma, upper respiratory infection, GERD, laryngopharyngeal reflux, and allergies should be initiated where appropriate.

Plus – psychotherapy

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ONGOING
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without acute stridor
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with high anxiety and/or stress levels
Plus – 

psychotherapy

Treatment recommended for ALL patients in selected patient group

Psychotherapy, behavioral therapy, lifestyle modification, and exercise for management of anxiety and stress.[99]

Consider – medical management of anxiety

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ONGOING
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without acute stridor
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with high anxiety and/or stress levels
Consider – 

medical management of anxiety

Treatment recommended for SOME patients in selected patient group

Medical treatment for anxiety should be initiated in addition to psychotherapy if patient is diagnosed with an anxiety disorder.

Plus – trigger avoidance

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ONGOING
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without acute stridor
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with specific trigger(s)
Plus – 

trigger avoidance

Treatment recommended for ALL patients in selected patient group

Allergy testing and avoidance or minimization of exposure to chemical odors and other allergens.[3]

Plus – specialized behavioral therapy

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ONGOING
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without acute stridor
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with specific trigger(s)
Plus – 

specialized behavioral therapy

Treatment recommended for ALL patients in selected patient group

Behavioral therapy to reduce conditioned response to specific triggers (e.g., exercise, sitting, eating, sleeping, airborne irritants [smoke, perfume], extreme temperatures, and stress).[3]

Plus – psychotherapy

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ONGOING
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without acute stridor
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athletes
Plus – 

psychotherapy

Treatment recommended for ALL patients in selected patient group

Sports psychology specialist addresses issues related to competition, winning, and coping with defeat and expectations.

Plus – activity-based breathing exercises

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ONGOING
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without acute stridor
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athletes
Plus – 

activity-based breathing exercises

Treatment recommended for ALL patients in selected patient group

Evaluation of breathing patterns during exercise reveals upper-body muscle tension contributing to intrinsic and extrinsic laryngeal muscle tension.

Activity-based breathing exercises introduced gradually until effective at competitive level.

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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