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Vocal cord dysfunction
diagnosis and management
Douglas S Robinson
University College London
Hospital, UK
DISCLAIMER: The views and opinions expressed in this presentation are those of the authors and do not necessarily represent the views and policy of PLAN(Pan London
Airways Network).
Vocal cord dysfunction
2
Definition: abnormal adduction of the vocal cords during
breathing
Symptoms: breathlessness, wheeze (inspiratory), blockage in
throat, voice change
Frequently misdiagnosed as asthma, 33% also have asthma
May lead to frequent A&E visits/admissions
Prevalence: 3-15% depending on who is studied
Diagnosis
3
Think about it!
Symptom patterns
Inspiratory noise/wheeze
Throat/upper chest
Frequently admissions
Lack of response to asthma
treatment
Flow volume loop
Laryngoscopy (with provocation)
?imaging
?VCDQ
Exclude asthma:
full lung function
PC20
FeNO
4
https://www.youtube.com/watch?v=j67yey-gYC4
5
6
7
8
9
10
Management
MDT
Respiratory physician: often diagnosis,
treating/assessing co-existing asthma,
or preventing treatment for asthma
Laryngologist (specialist ENT): assessment at rest
and with exercise/provocation
Speech therapy: throat relaxation and cough suppression
Physiotherapy: breathing control
Where: London: Royal Brompton ? Any others
11
12
13
Asthma since childhood
Multiple hospital admissions
Atopy nut anaphylaxis
Paramedic
Blood eos not raised, FeNO 16ppb, IgE 22, spIgE all negative, PC20 negative
14
Management
Wean off oral steroids
Physiotherapy and CNS for breathing control
Psychology input
Still intermittent admissions
ACQ 3.0
15
VCD Summary
• Probably much commoner than is appreciated
• May co-exist with asthma
• Diagnosis difficult
• Symptoms: inspiratory wheeze, upper airway
• Lung function (FLC)
• Laryngoscopy (with challenge)
• ?VCDQ
• MDT management: speech therapy, physiotherapy
• psychology
What is severe asthma?
• The term severe asthma should be reserved for patients
with asthma in whom alternative diagnoses have been
excluded; co morbidities have been treated; trigger
factors have been removed (if possible); and adherence
with treatment, including inhaler technique has been
checked, but still have poor symptom control (Asthma
Control Questionnaire > 1.5 or Asthma Control Test <
20), or frequent severe exacerbations (2 or more bursts
of systemic corticosteroids in the previous year), or
serious exacerbations (at least one hospitalisation, ICU
stay or mechanical ventilation in the previous year)
despite the prescription of high- intensity treatment (step
IV/V of the asthma guidelines), or those patients with
controlled asthma that worsens on tapering of high
doses of inhaled or systemic corticosteroids.
Chung KF, et al. Eur Respir J 2014; 43: 343-73.
CONSIDER
patients at step 3 or 4 not responding to therapy
recent A&E visits or hospitalisation (2 or more)
recent exacerbations requiring oral prednisolone (2 or more)
diagnostic doubt
questions about biologics
Who to refer
(NHSE)
• Symptoms of asthma are not responding to high dose inhaled corticosteroids
together with additional controller (LABA, theophylline or LTRA), or require long
term oral corticosteroids for control
•AND
–Hospital admission for asthma (especially ITU), or two A and E attendances in
the last year
–Frequent oral corticosteroids use within a year or daily oral corticosteroid
dependence
–Asthma with persistent airflow obstruction (FEV1<70% predicted)
 Is it asthma ?
 Lung function/reversibility/PC20/CT scan
 Adherence
 Prescription records, FeNO suppression
 Physiotherapy: breathing pattern, sputum clearance,
exercise
 Psychology
 Objective measures of severity
 ACQ
 mAQLQ
 FeNO
 Blood eos
 Spirometry/PEF
 Access to biologics
 Research
19
Severe Asthma Service UCLH
Staff:
Consultants: Douglas Robinson
Harsha Kariyawasam
Nurse Specialist: Therese Bidder
Dietician: Flora Wilcox
Physiotherapist: Rebecca Livingston/Helene Bellas
Psychologist: Florian Vogt
Pharmacist: Ravijyot Saggu
Admin: Badar Alavi
Referrals: uclh.severeasthmaservice@nhs.net
tel: 0203 447 9005 | Fax: 020 3447 9476

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Vocal cord dysfunction

  • 1. Vocal cord dysfunction diagnosis and management Douglas S Robinson University College London Hospital, UK DISCLAIMER: The views and opinions expressed in this presentation are those of the authors and do not necessarily represent the views and policy of PLAN(Pan London Airways Network).
  • 2. Vocal cord dysfunction 2 Definition: abnormal adduction of the vocal cords during breathing Symptoms: breathlessness, wheeze (inspiratory), blockage in throat, voice change Frequently misdiagnosed as asthma, 33% also have asthma May lead to frequent A&E visits/admissions Prevalence: 3-15% depending on who is studied
  • 3. Diagnosis 3 Think about it! Symptom patterns Inspiratory noise/wheeze Throat/upper chest Frequently admissions Lack of response to asthma treatment Flow volume loop Laryngoscopy (with provocation) ?imaging ?VCDQ Exclude asthma: full lung function PC20 FeNO
  • 5. 5
  • 6. 6
  • 7. 7
  • 8. 8
  • 9. 9
  • 10. 10 Management MDT Respiratory physician: often diagnosis, treating/assessing co-existing asthma, or preventing treatment for asthma Laryngologist (specialist ENT): assessment at rest and with exercise/provocation Speech therapy: throat relaxation and cough suppression Physiotherapy: breathing control Where: London: Royal Brompton ? Any others
  • 11. 11
  • 12. 12
  • 13. 13 Asthma since childhood Multiple hospital admissions Atopy nut anaphylaxis Paramedic Blood eos not raised, FeNO 16ppb, IgE 22, spIgE all negative, PC20 negative
  • 14. 14 Management Wean off oral steroids Physiotherapy and CNS for breathing control Psychology input Still intermittent admissions ACQ 3.0
  • 15. 15 VCD Summary • Probably much commoner than is appreciated • May co-exist with asthma • Diagnosis difficult • Symptoms: inspiratory wheeze, upper airway • Lung function (FLC) • Laryngoscopy (with challenge) • ?VCDQ • MDT management: speech therapy, physiotherapy • psychology
  • 16. What is severe asthma? • The term severe asthma should be reserved for patients with asthma in whom alternative diagnoses have been excluded; co morbidities have been treated; trigger factors have been removed (if possible); and adherence with treatment, including inhaler technique has been checked, but still have poor symptom control (Asthma Control Questionnaire > 1.5 or Asthma Control Test < 20), or frequent severe exacerbations (2 or more bursts of systemic corticosteroids in the previous year), or serious exacerbations (at least one hospitalisation, ICU stay or mechanical ventilation in the previous year) despite the prescription of high- intensity treatment (step IV/V of the asthma guidelines), or those patients with controlled asthma that worsens on tapering of high doses of inhaled or systemic corticosteroids. Chung KF, et al. Eur Respir J 2014; 43: 343-73.
  • 17. CONSIDER patients at step 3 or 4 not responding to therapy recent A&E visits or hospitalisation (2 or more) recent exacerbations requiring oral prednisolone (2 or more) diagnostic doubt questions about biologics Who to refer (NHSE) • Symptoms of asthma are not responding to high dose inhaled corticosteroids together with additional controller (LABA, theophylline or LTRA), or require long term oral corticosteroids for control •AND –Hospital admission for asthma (especially ITU), or two A and E attendances in the last year –Frequent oral corticosteroids use within a year or daily oral corticosteroid dependence –Asthma with persistent airflow obstruction (FEV1<70% predicted)
  • 18.  Is it asthma ?  Lung function/reversibility/PC20/CT scan  Adherence  Prescription records, FeNO suppression  Physiotherapy: breathing pattern, sputum clearance, exercise  Psychology  Objective measures of severity  ACQ  mAQLQ  FeNO  Blood eos  Spirometry/PEF  Access to biologics  Research
  • 19. 19 Severe Asthma Service UCLH Staff: Consultants: Douglas Robinson Harsha Kariyawasam Nurse Specialist: Therese Bidder Dietician: Flora Wilcox Physiotherapist: Rebecca Livingston/Helene Bellas Psychologist: Florian Vogt Pharmacist: Ravijyot Saggu Admin: Badar Alavi Referrals: uclh.severeasthmaservice@nhs.net tel: 0203 447 9005 | Fax: 020 3447 9476