1996 OPEN FORUM Abstracts
DOCUMENTATION OF VOCAL CORD DYSFUNCTION (VCD) IN CHILDREN.
Daniel Laskowski RPFT, Vanessa Jensen Psy. D, Kay Stelmach RN, RRT, Kevin MCCarthy RCPT, Paul Stillwell MD. THE CLEVELAND CLINIC FOUNDATION, CLEVELAND, OHIO.
Paradoxical vocal cord dysfunction is characterized by involuntary adduction of the vocal cords that produces dyspnea, stridor and wheezing, usually in an episodic fashion. Vocal Cord dysfunction is often confused with asthma, including exercise induced asthma. Endoscopic examination is normal between episodes. The purpose of this study is to report our experience with 24 patients age 8 to 19 (55% male), referred to our institution over the last 36 months predominately for exercise induced asthma. Sixteen of 24 patients were positive for vocal cord adduction of greater than 30%. The majority of the positive patients were well trained athletes whose attacks frequently occurred during exercise. This was preventing them from exercising or advancing to the next level of competition.
After a comprehensive history and physical examination each patient had an upper airway endoscopy to rule out any fixed airway obstruction. Patients were then asked to hyperventilate while an Olympus video assisted infant bronchoscope was in place above the patients vocal cords. Seven patients were positive for vocal cord adduction from hyperventilation alone. Those patients who did not exhibit vocal cord dysfunction with hyperventilation were then exercised to their maximum exercise tolerance or until symptoms limited further testing. Patients exercised on a bicycle ergometer with the video-assisted infant bronchoscope in place. Flow and volume were measured simultaneously using a CODAS system (Data Instruments AKRON, OH). A modified Vital Signs (Totowa, NJ) exercise mask which accommodated both the scope and a heated pneumotach was used; this allowed us to measure flow and volume during testing.
Vocal cord dysfunction does not respond to routine medical treatment for asthma. It has been shown to significantly interfere with daily functioning in young patients including absence from school, and frequent medical intervention. Treatment includes clinical interviews with the patient and parents. A cognitive behavioral treatment program is instituted including education regarding vocal cord adduction, diaphragmatic breathing exercises, muscle relaxation and stress management techniques. All patients reported a significant decrease in symptoms.
In conclusion, comprehensive challenge with direct visualization allows separation of VCD, asthma, and deconditioning. Recognition of VCD directs therapy away from asthma and allows the patient to begin psychotherapy which in our patients population has been met with a great deal of success. We are becoming more confident in predicting vocal cord adduction from viewing flow and volume alone during exercise, however comprehensive challenge with direct visualization during exercise continues to be the definitive diagnostic tool.