Transcript PVFM

Paradoxical Vocal Fold Motion
a.k.a….
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Munchausen’s Stridor
Psychogenic Stridor
Functional Inspiratory
Stridor
Functional upper airway
obstruction
Atypical asthma
Factitious asthma
Emotional laryngeal
wheezing
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vocal cord dysfunction
Adult spasmodic croup
Functional abduction
paresis
Emotional
laryngospasm
Episodic laryngeal
dyskinesia
pseudoasthma
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Paradoxical Vocal Fold Motion (PVFM):
What is it?
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Primarily a breathing impairment
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upper airway (extrathoracic) obstruction
vocal folds adducting (closing) when they should be
abducting (opening)
Inspiration, expiration or both
occurs in isolation, or with asthma
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Paradoxical Vocal Fold Motion
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Etiology
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Unknown
psychological factors are implicated but well
controlled studies are lacking
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Paradoxical Vocal Fold Motion
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Commonly induced by
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Stress
Exercise
gastroesophageal reflux (nocturnal)
Post-nasal drip
Respiratory irritants
cold air
panic associated with asthma
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PVFM: Patient Characteristics
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More common in girls/women
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3-4/1 female/male ratio
Children, adolescents, adults 20-40 years
Diagnosis of uncontrolled asthma
Anomalous findings for severe asthma
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Brugman & Newman, (1993)
Kuppersmith et al. (1993)
PVFM: Some Characteristics
May see
 Hx of asthma treatment
 Previous emergency intubation (rare)
 Hx of tracheotomy (rare)
 Chronic steroid use
 Hoarseness and other voice changes
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Assessment of PVFM
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Team approach including
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Speech pathology
Otolaryngology
Pulmonary function
Gastroenterology (GERD/LPR)
Allergy
Psychiatry
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PVFM: Signs
Clinical
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Stridor
rapid breathing
accelerated pulse rate
anxiety/panic
Auscultation identifies the larynx as site of
obstruction
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PVFM: Signs
Laryngoscopy
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Adduction of anterior 2/3’s of TVFs during
inspiration
small posterior diamond shaped glottic
chink
Mediolateral compression of ventricular
folds
Exam normal when asymptomatic
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PVFM: Signs
Laryngoscopic Assessment (SLP & ENT)
 Tidal breathing (rest)
 Forced inspiration, forced expiration
 Panting
 Sniffing
 Repeated rapid deep inspirations
 Exercise challenge
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PVFM: Signs
Pulmonary Function (Spirometry)
When symptomatic…
PVFM
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Forced vital capacity: normal
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Forced expiratory volume in 1 sec: normal
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Inspiratory flow: reduced
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Expiratory flow/inspiratory flow ratio: elevated
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Bronchodilator treatment: limited improvement
Asthma
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Forced vital capacity: normal
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Forced expiratory volume in 1 sec: reduced
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Expiratory flow/inspiratory flow: normal or reduced
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Bronchodilator treatment: marked improvement
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Tilles (2003)
PVFM: Bronchoprovocation
Methacholine challenge
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Induces small airway narrowing
A negative response will help exclude asthma
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PVFM: Provocation
Exercise challenge
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Helpful for eliciting symptoms in certain clients
Does not differentiate asthma and PVCD
Allows signs/symptoms to be observed so that a Dx
may be made
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PVFM: Psychosocial Characteristics
Reports of
 Perfectionism
 Obsessive-compulsive features
 Anxiety disorders (panic)
 Somatization disorder
 Difficulty expressing anger, sadness and fear
 Conversion reaction (??)
Rate of psychopathology no different from severe
asthmatics
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Mathers-Schmidt (2001)
Mathers-Schmidt (2001)
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PVFM: Management
Education
 Review normal airway function
 Review test results
 Discuss possible precipitants
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stress, exercise, GERD, panic etc
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PVFM: Management
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Quick controls (+/- endoscopic feedback)
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Sniffing, 3 quick sniff in, slow controlled
exhalation on /s/ or /sh/, lips pursed
Manual lowering of larynx
Panting: shallow and limited number of times (but
not with asthma)
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PVFD: Management
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Teach relaxed throat breath, awareness of laryngeal
muscle tension
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Flatten tongue, drop jaw, inhale through nose and exhale on /s/
Abdominal breathing pattern
Controlled exhalation
General relaxation exercises (audiotapes)
Stress management, counseling
Antireflux protocol
Biofeedback using endoscope
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