The Ins and Outs of Recognizing and Treating Vocal Cord Dysfunction & Exercise Induced 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 :

Lower Respiratory Tract: 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

Flexible Laryngoscope Rigid Laryngoscope Vocal Cords: Normal and Abnormal Function

 Vocal Pathology III: Blue Tree Publishing VCD Symptoms  Dyspnea/  Stridor on Inhalation  Cough/Throat clearing  Panic/  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)

• (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 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 ( inhalers, steroids)*  RX Nasal disease (meds or surgery)*  * 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

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□□□□□ □□□□□ □□□□□ □□□□□ □□□□□ 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

 Airway obstruction that worsens with expiration

 Common obstructive disorders: Asthma COPD Emphysema Chronic 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

 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 a nebulized, high-dose, short-acting bronchodilator to relieve airflow obstruction  Transport to Health Care Facility per protocol Medication Administration via Nebulizer

Aerosolized delivery of medication to the lung Established treatment plan: EIA

 Structured warm-up  Education of student athlete and AT staff  Use of medications prophylactically  devices  Asthma triggers  Recognition of signs and symptoms  Compliance with monitoring condition and taking medication  Monitor lung function  Should be at least 80% of baseline values to be allowed to participate

(National Athletic Trainers’ Association Position Statement: Preventing Sudden Death in Sports. JAT 2012:47(1);96-118) Separating the Symptoms Allergy & Asthma Today, Volume 6, Issue 1, Updated 2/09 Vocal cord dysfunction (VCD) is often mistaken for asthma, especially exercise-induced asthma (EIA). Management of Acute Episodes of VCD or EIA

Vocal Cord Dysfunction Exercise Induced Asthma

 Recognition!  Recognition!  Breathing Exercises  Administration of a nebulized,  Frequent Reassurance high-dose, short-acting bronchodilator to relieve airflow obstruction – OR – rescue inhaler  Supplemental oxygen if blood oxygen saturation is < 92%.  Transport to Health Care Facility per protocol Treatment Team

 Both  Team Physician, Athletic Trainer, Sports Dietitian, Sports Psychologist

 EIA  Pulmonologist, Allergist

 VCD  Otolaryngologist, Speech Language Pathologist, Allergist Respiratory Pathology Toolkit

Tools Specialized Equipment  Knowledge base  Nebulizer  Peak flow meter  Supplemental Oxygen  Pulse oximeter  Spare rescue inhaler prescribed to  Stethoscope athlete(s) you are responsible for Resources/References

 Casa DJ, Guskiewicz KM, Anderson SA, et al. National Athletic Trainers’ Association Position Statement: Preventing Sudden Death in Sports. J Athl Train. 2012;47(1):96-118.  Chiang, Marcinow, deSilva, Ence, Lindsey, and Forrest. Exercise-induced paradoxical vocal fold motion: diagnosis and management. The Laryngoscope 2013; (3) 727-731.  Denipah N, Dominquez DM, Kraai EP, Kraai TL, Leos P, and Braude D. Acute Management of Paradoxical Vocal Fold Motion (Vocal Cord Dysfunction). Ann Emerg Med. 2017; 69:18-23.  Fretzayas A, Moustaki M, Loukou I, and Douros K. Differentiating Vocal Cord Dysfunction From Asthma. Journal of Asthma and Allergy 2017:10 277-283.  Koester MC and Amundson CL. Seeing the Forest Through the Wheeze: A Case-Study Approach to Diagnosing Paradoxical Vocal-Cord Dysfunction. J Athl Train. 2002; Sep; 37 (3): 320-324. Resources/References

 Marcinow, Thompson, Chiang, Forest, and deSilva. Paradoxical Vocal Fold Motion Disorder in the Elite Athlete: Experience at a Large Division I University. The Laryngoscope 2013.  Newsham KR, Klaben BK, Miller VJ, and Saunders JE. Paradoxical vocal-cord dysfunction: management in athletes. J. Athl. Train. 2002; Sep; 37 (3): 325-328.  Newman KB, Mason UG, and Schmaling KB. Clinical Features of Vocal Cord Dysfunction. Am J Respir Crit Care Med. 1995; 152: 1382-6.  Rundell KW, Spiering BA. Inspiratory Stridor in elite athletes. Chest 2003; Feb; 123 (2): 468-74.  Weir M, Vocal cord dysfunction mimics asthma and may respond to . Clin Pediatr (Phila). 2002 Jan-Feb; 41 (1): 37-41.  Wilson, Cooke, and Edwards. Predicted normal values for maximal respiratory pressures in Caucasian adults and children. Thorax 1984; (39) 535- 538.  Wilson JJ, and Wilson. Practical management: Vocal cord dysfunction in athletes. Clin J Sport Med. 2006; Jul;16 (4): 357-60 DISCUSSION