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Giving Voice to People with Upper Airway Disorders

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Giving Voice to People with Upper Airway Disorders ➦ Giving Voice to people with upper airway disorders TM Giving Voice to people with upper airway disorders pper airway disorders can significantly affect quality breathlessness); and triggers (e.g. exertion, cold air, irritants) of life and place an unnecessary financial burden which can mimic lower respiratory disease making it difficult to on health services if unidentified or misdiagnosed. differentiate between the two. Lack of understanding from patients Speech and language therapists have an important role and professionals regarding upper airway disorders further risks in supporting people with upper airway disorders by misdiagnosis. contributing to differential diagnosis and the management of these Udisorders. What is the role of SLT? Speech and language therapists (SLTs) have a key role to play in the What is the upper airway? assessment, differential diagnosis and treatment of upper airway Vocal cords enable us to speak, breathe, cough and swallow safely. disorders. Timely and appropriate input from SLTs can reduce the They are located in the throat (larynx), behind the voice box. They frequency and severity of symptoms and reduce health costs. sit in a V-shape at rest; shut gently to prevent unwanted material ● SLTs work within a multidisciplinary team of respiratory experts, entering the lungs during swallowing; and shut forcefully to cough including doctors, nurses, physiotherapists, lung physiologists unwanted material out of the lungs. and clinical psychologists. ● SLTs perform videolaryngeal examinations, to observe laryngeal What are upper airway disorders? pathology and assess function and sensation, which is essential Upper airway disorders affect the co-ordination of muscles in for the differential diagnosis of upper airway disorders. the throat (larynx). They can occur independently, or co-exist ● SLTs support people with respiratory conditions through with lower respiratory disease – for example, asthma, COPD or teaching them rescue breathing strategies, throat and upper body bronchiectasis (a long-term condition where the airways of the relaxation exercises, giving advice on how to maintain a healthy lungs become abnormally widened, leading to a build-up of excess larynx including throat care advice, behaviour change techniques mucus that can make the lungs more vulnerable to infection). and offering psychological support. Upper airway disorders are thought to result from heightened The case for SLT input sensitivity in the throat and hyperactivity of throat muscles, which ● The World Health Organization identifies a need ‘to minimise can result in the vocal cords shutting unnecessarily. They include: symptom burden of incurable chronic respiratory diseases’.1 ● Inducible laryngeal obstruction (ILO, previously known as vocal ● The British Thoracic Society’s guidelines for asthma management cord dysfunction): A choking sensation/wheeze (typically when recommend controlling asthma using ‘the lowest possible doses breathing in) caused by throat muscles squeezing together and of medication’.2 obstructing airflow in the throat. ● The NHS England Severe Specification for Asthma identifies a ● Chronic cough: Dry coughing bouts which persist for longer than ‘need for a speech and language therapists within the severe eight weeks and do not respond to medication. asthma multi-disciplinary team’.3 ● Throat clearing: Often in response to an irritation in the throat ● The RCSLT Respiratory Position Paper recommends that ‘patients that will not clear. with ILO should have access to an effective and timely respiratory ● Globus pharyngeous: Lump sensation in the throat in the absence speech and language therapy service’.4 of a physical lump. ● The James Lind Alliance Priority Setting Partnerships promotes a ● Voice difficulties (dysphonia): Typically due to muscle tightness, need to ‘explore the role of complementary therapies for asthma inflammation, structural lesions or neurological disorders. management, including breathing exercises’.5 ● Swallowing difficulties (dysphagia): Dysphagia or ● Research has shown that laryngeal retraining by SLTs significantly pseudodysphagia, often associated with altered laryngeal reduced A & E attendances and hospital admissions. It also sensitivity. reduced GP visits by almost 50%.6 ● A recent Cochrane review identified two randomised controlled trials for management of chronic cough. The one with only SLT Why is management complicated? intervention revealed significantly reduced laryngeal symptom Upper airway disorders and lower respiratory disease can burden post-intervention. The one with combined SLT and co-occur or present independently. Misdiagnosis of upper airway physiotherapy intervention revealed a significant reduction of disorders is common due to several symptoms (e.g. cough, wheeze, cough counts and scores.7 WHAT SYMPTOMS MIGHT PEOPLE WITH UPPER AIRWAY DISORDERS EXPERIENCE AND WHICH MANAGEMENT STRATEGIES CAN HELP? PHYSIOLOGY PATIENT EXPERIENCE Throat sensitivity and A sensation of being over-reaction unable to breathe and/or (laryngeal hyper a need to clear unwanted sensitivity and muscle material from the throat and panic hyper reactivity) POSSIBLE SYMPTOMS NOSE AND/OR PURSED LIPS - Itch BREATHING - Dryness Filters out irritants - Lump sensation Alters air temperature - Throat clearing Reduces speed of airflow in the larynx - Dry cough - Voice problems THROAT CARE ADVICE - Choking sensation Increasing fluid intake - Sensation of Inhaling steam regularly swallow Swallowing instead of throat difficulties clearing ILO EMERGENCY STRATEGIES - Sudden onset Quick sniff or quick pursed lips inhale - Wheeze on breath in + - Wheeze during 2 x cheek puffs exhale exertion Focus on exhale, not inhale - Easier to breathe out - Inhalers not effective -Tightness in throat Inducible laryngeal obstruction (ILO) and speech and Triggers ● Panic.25 language therapy ILO is considered to be of equal importance to asthma in the ● Anxiety (41.8%) and Depression (23.3%).26 ILO, previously known as vocal cord dysfunction, is a debilitating management of exercise related wheeze.19 It can also be triggered upper airway disorder that imposes a great burden upon patients by chemicals, odours, anxiety, vocal tasks and psychological stress. What is the impact of misdiagnosed ILO on health services? and health services. Speech and language therapists (SLTs) working within a respiratory multidisciplinary team are identified Misdiagnosis of ILO risks increasing costs to the wider health What are the links between ILO and chronic respiratory disease? as the cornerstone treatment option for ILO.8 They play a system, including through: crucial role in the assessment and management of ILO, including ILO symptoms can mimic those of asthma, COPD and ● Over-prescription of medication, some of which is inappropriate. triggering an attack while looking at the vocal cords (provocation bronchiectasis. Severe ILO symptoms closely resemble an asthma 20 21 ● Inappropriate hospital admissions. laryngoscopy), which is identified as the only definitive diagnostic attack, often resulting in misdiagnosis and mismanagement. ● Excessive medical assessments. test.9 Accordingly, speech and language therapy supports diagnostic Identifying triggers and specific characteristics of breathlessness accuracy, clinical outcomes and offers cost-saving incentives. can help to differentiate between ILO and lower respiratory ● Inappropriate hospital reviews. 22 disease. Laryngoscopy is essential for differential diagnosis. ● Prolonged hospital stays. What is ILO? ● Avoidable patient and family distress. The true prevalence of ILO is thought to be underestimated but ILO is the abnormal closure of the vocal cords during respiration, the official joint European Respiratory Society and European most commonly when breathing in.10 It can result in a choking What impact can SLT management of ILO have on the wider 11 Laryngological Society statement reports that between 24% and sensation, wheezing and breathlessness and has also been 23 health economy? 12,13 53% of patients with severe asthma have ILO. Thus, with an linked with voice disorders (dysphonia), swallowing disorders The RCSLT Respiratory Care Position Paper highlights how 14 15 estimated 8 million asthma sufferers in the UK, between two and (dysphagia) and chronic refractory cough. SLTs have expertise for 27 four million people in the UK may have ILO. SLT management has been shown to produce economic benefits the management of all such symptoms. due to the following: ● Providing correct diagnosis, and preventing misdiagnosis and What is the impact of ILO on individuals? Co-occurring conditions incorrect management. Over-treatment of primary airways disease, in the absence of ILO can occur independently but commonly co-occurs with ● Reducing the frequency of ILO attacks. accurate ILO diagnosis, can drive many symptoms. People with ILO respiratory disease, heartburn (acid reflux and/or silent reflux), are at risk of: ● Reducing dependency on medication. nasal disease, neurological disorders, psychological disorders and/ ● Reducing hospital admissions and appointments. or thyroid surgery.16,17,18 ● Significantly reduced quality of life, as it can cause frustration, embarrassment, avoidance of social situations or absence from ● Reducing length of hospital stay. 24 work. ● Reducing use of tracheostomy/ventilation. Diane’s story Diane presented to hospital with her second presumed asthma attack in six months. She had attended hospital previously and, on that occasion, had been prescribed
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