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Vocal Cord Dysfunction & Exercise Induced Asthma The Ins and Outs of Recognizing and Treating Vocal Cord Dysfunction & Exercise Induced Asthma in Athletes GLATA – District 4 - NATA 50th Annual Meeting and Symposium March 13 – 17, 2018 The Westin Chicago North Shore Alice Wilcoxson PhD, PT, ATC Acknowledgement: Barbara S.W. Solomon, SLP Elaine Hannigan MSN, RN Purdue University West Lafayette, IN Provider Disclaimer No conflicts to report. No financial or other associations with the manufacturers of commercial products, suppliers of commercial services, or commercial supporters. The views expressed in these slides and the today’s discussion are mine My views may not be the same as the views of my company’s clients or my colleagues Participants must use discretion when using the information contained in this presentation Mount Fuji at Sunrise Objectives: Define VCD (aka: PVCM) and EIA Understand the mechanisms through which VCD and EIA impact respiration Identify testing equipment and procedures commonly utilized to diagnose VCD and EIA. Identify the level of respiratory function of athletes with VCD and/or EIA Understand the importance of developing a plan of treatment for established levels of respiratory function / distress. Normal respiratory function Upper Respiratory Tract: Nasal Cavity Pharynx Larynx Lower Respiratory Tract: Trachea Primary Bronchi Lungs Function: Move air into the body Gas Exchange between air & bloodstream Move air out of the body Vocal Cord Dysfunction A laryngeal disorder that affects breathing. There is an inappropriate closure of the true vocal folds during inhalation and respiratory obstruction occurs. Diagnostic Equipment to Visualize Vocal Cords Flexible Laryngoscope Rigid Laryngoscope Vocal Cords: Normal and Abnormal Function Vocal Pathology III: Blue Tree Publishing VCD Symptoms Shortness of breath Dyspnea/airway obstruction Stridor on Inhalation Cough/Throat clearing Panic/Anxiety disorder Uses INHALER AND DOES NOT HELP Original Diagnosis typically EIA Throat tightness Chest tightness Refluxing – LPR-GERD Asthma can co-exist Hoarseness can co-exist COMMON characteristics of athletes with VCD Young women (female 18:1) High achiever/ perfectionist Anxiety / stress perception Intense physical activity Outdoor sports Incidence 3-5% of ALL athletes LESS COMMON characteristics of athletes with VCD • Allergy/asthma coexisting • Sinonasal pathology (polyps, septal deviation) • Laryngopharyngeal Reflux (LPR) VCD Triggers URI Stress Exercise - Children and Adults who are high achievers and usually participate in competitive sports Extreme temperatures Irritants: environmental pollutants, dust, smoke, chemicals, paints, perfume-cologne, mist, mold, and fumes VCD Triggers DIAGNOSIS History MOST IMPORTANT, therefore need to educate coaches, athletic trainers, etc. Physical Examination / Flexible laryngoscopy to rule in and rule out other dx - GOLD STANDARD Ideally when symptoms are present with or without exercise Greater than 50% ADDuction – inhalation Count to ten and/or count until end volume and watch for incomplete ABDuction Ask to mimic episode VCD TREATMENT Reassure / Educate SLP – Laryngeal Control Therapy (LCT) RX LPR- PPI and GERD instructions* RX ASTHMA (bronchodilator inhalers, steroids)* RX Nasal disease (meds or surgery)* Psychotherapy* SLP Treatment for VCD Body Awareness–Physiological Awareness Reassurance (not life-threatening) VCD Fact Sheet Training of Breathing Exercises Relaxed Breathing Three Step Breathing PowerBreathe Consultation and Follow-up with AT Collaborative Team Approach with other Health Professionals: Pulmonologist, Allergist, Psychology, etc. IMST/EMST Breathing Techniques POWERbreathe IM Treatment (Respiratory PREs) - Inspiratory Muscle Strength Training Set to 70% of the patient’s maximum inspiratory pressure or the highest level the patient can tolerate Patient completes: 5 breaths through the device, 5 times per day 5 days per week For 4-5 weeks Device setting is increased as the patient improves ATHLETIC TRAINER COLLABORATION Weekly Home Practice Log Day Set 1 Set 2 Set 3 Set 4 Set 5 □□□□□ □□□□□ □□□□□ □□□□□ □□□□□ □□□□□ □□□□□ □□□□□ □□□□□ □□□□□ □□□□□ □□□□□ □□□□□ □□□□□ □□□□□ □□□□□ □□□□□ □□□□□ □□□□□ □□□□□ □□□□□ □□□□□ □□□□□ □□□□□ □□□□□ MANAGING LARYNGEAL REFLUX - (LPR) Drink Water Avoid eating for at least 2-3 hours before going to bed or Eat Friendly Refluxing foods Reduce/Eliminate stress/tension Elevate the head of the bed 6-10 inches. Place cinder blocks, bricks, wood under the legs at the head of the bed. REFLUX FRIENDLY /UNFRIENDLY FOODS Medication We recommend that you consult with your physician regarding the above suggestions. Established treatment plan: VCD Breathing Exercises Inspiratory Muscle Strength Training Program Addressing any contributing / co-existing pathology: Stress Management Reflux Asthma / EIA Nasal Disease Obstructive Lung Disease Airway obstruction that worsens with expiration Common obstructive disorders: Asthma COPD Emphysema Chronic bronchitis Common Signs and Symptoms of Obstructive Lung Disease Dyspnea (difficulty breathing) Wheezing Increased Work of Breathing Decreased forced expiratory volume Asthma Chronic inflammatory disorder of the airways Airways become Hyper-responsive Bronchial smooth muscle spasm with vascular congestion Widespread variable airflow obstruction Asthma Occurs at all ages Half of all cases occur in children Genetic Predisposition More than 100 Genes associated with Asthma Airway Inflammation Airways become sensitive to allergens and irritants Body’s immune system overreacts and produces persistent inflammation of the airways Airways can remain inflamed even without overt symptoms of wheezing, chest tightness, coughing or shortness of breath Asthma Triggers Exposure to Allergens in Childhood Parental Smoking Wood Stoves Recurrent Viral Respiratory Infections Respiratory Syncytial Virus (RSV) Urban Pollution Cockroaches, dust mites, mold Strong odors: perfume, spray, paints Pets Pollen Increased Obesity Gastroesophageal Reflux Disease (GERD) Asthma Triggers Weather Inhaling cold air triggers bronchospasm Covering the nose and mouth with a scarf often decreases symptoms Exercise Symptoms occur during exercise or 5-20 min after exercise Symptoms often take 20-30 minutes to resolve Stress Identification of main causes of stress can help to minimize symptoms Food Sensitivity Beer, wine, shrimp, dried fruit, processed potatoes Clinical Manifestations of Asthma Between attacks athlete is asymptomatic and pulmonary function studies are normal Beginning of an attack Chest Congestion/Constriction Wheeze on Expiration Nonproductive Cough Tachycardia (rapid heart rate) Tachypnea (rapid respiratory rate) Severe Attack Use of accessory muscles Wheezing on inspiration and expiration Diagnosis of EIA History Pulmonary Function Testing Before Exercise After 15 minutes of high-intensity aerobic activity After inhalation of albuterol Primary Drug Therapy for Asthma Anti-inflammatory agents Glucocorticoids Administered by inhalation Fixed (routine) schedule Bronchodilators Beta2 agonists Administered by inhalation Fixed Schedule for long-term control PRN to manage acute attacks Advantages of Inhalation Drug Therapy Therapeutic effects are enhanced by delivering medication directly to their site of action Systemic effects are minimized Relief of acute attacks is rapid Commonly Used Anti-inflammatory Medications Budesonide (Pulmacort) and fluticasone (Flovent) Considered the most effective anti-asthma drugs available Anti-inflammatory Medication: cromolyn (Intal) Can be administered 15-60 minutes prior to exposure to known precipitating situation • Exposure to allergens on golf course or while running cross country • Exercise-induced asthma Bronchodilators Provide symptomatic relief but do not alter the underlying disease process (inflammation) In almost all cases, patient taking a bronchodilator should also be taking a glucocorticoid for long-term suppression of inflammation Most effective drugs for relief of acute bronchospasm and prevention of exercise-induced bronchospasm Adverse effects: tachycardia (fast heart rate) angina (chest pain) tremor Bronchodilators: Beta2-Adrenergic Agonists Mechanism of action Activate beta2 receptors in smooth muscle of lung, Promote bronchodilation Relieve bronchospasm Suppress histamine release in lung Increase ciliary motility Short- Acting (Rescue Inhaler) albuterol (Proventil) levabuterol (Xopenex) Long-Acting salmeterol (Serevent) Not used during an acute episode Glucocorticoid/Long Acting Beta 2 Agonist (LABA) Combinations Available combinations Fluticasone/salmeterol (Advair) Budesonide/formoterol (Symbicort) Method of Administration Metered Dose Inhaler (MDI) Dosing is usually accomplished in one or two puffs Using the MDI Correctly Technique requires good hand-lung coordination Must must exhale prior to depressing MDI chamber If more than one puff is administered, should wait one minute between puffs Only 10% of MDI dose reaches the lungs 80% is lost in the oropharynx and swallowed Use of spacer is recommended to deliver more drug to the lungs Metered Dose Inhaler with Spacer Advantages of Spacer Use 1. Less need for hand-lung coordination 2. Increased delivery of drug to the lungs Treatment for Acute Severe Exacerbations Requires immediate attention Goal is to relieve airway obstruction and hypoxemia Normalize lung function as quickly as possible Treatment: Administration of
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