Multi-Institutional Study of Patient-Reported Outcomes of Paradoxical Vocal Fold Motion.

OBJECTIVE: To explore patient-reported outcome measures of pediatric paradoxical vocal fold motion through a multi-institutional study of geographically diverse United States medical facilities to assess long-term management and outcomes. METHODS: Eligible participants >8 years of age diagnosed with PVFM over a 10-year period from 7 tertiary pediatric hospitals were invited to complete a survey addressing study objectives. RESULTS: 65 participants completed the survey, of whom 80% were female, 75% reported a 3.5 grade point average or better, and 75% identified as competitive athletes or extremely athletic individuals. Participants rated their perceived efficacy of 13 specific treatments. Only five treatments were considered effective by a majority of the participants who tried them. The treatments that participants tried most often were breathing exercises (89.2%), bronchodilator treatments (45%), and allergy medications (35.4%). 78.8% of participants reported receiving more than one treatment and 25% reported receiving a combination of bronchodilators, anticholinergics, and steroids. At the time of PVFM diagnosis, 38% of participants had no idea when their symptoms would completely resolve. 23.3% of participants did not experience symptom resolution until greater than 1 year after diagnosis. CONCLUSIONS: Traditional management tools such as breathing exercises and biofeedback treatments may not provide the long-term benefit that providers anticipate. In addition to these commonly used management strategies, highly efficacious techniques such as counseling and lifestyle management should be incorporated into the long-term management of patients whose symptoms are refractory to traditional care. LEVEL OF EVIDENCE: 4 Laryngoscope, 133:970-976, 2023.

Buteyko Breathing Technique for Exertion-Induced Paradoxical Vocal Fold Motion (EI-PVFM).

PURPOSE: The primary purpose of the current study was to determine the usefulness of Buteyko breathing technique (BBT) in reducing dyspnea in patients with one form of Paradoxical Vocal Fold Motion (PVFM), exertion-induced PVFM (EI-PVFM), concomitant with hyperventilation. The secondary purpose was to determine whether BBT had an effect on physiological markers of hyperventilation, as speculated by BBT theory: respiratory tidal minute volume (RTMV), end-tidal carbon dioxide (ETCO2), and resting heart rate (HR). METHODS: Using a within-subjects, repeated measures group design, 12 participants with EI-PVFM and hyperventilation underwent 12 weeks of BBT, following an initial no-treatment control condition. Outcome measures of PVFM-dyspnea frequency and severity-and of hyperventilation-HR, RTMV, and ETCO2-were acquired pre- and post-treatment. RESULTS: Results showed post-treatment decreases in dyspnea severity, HR, and RTMV, as well as increases in ETCO2. Decreases in dyspnea and RTMV measures remained after correction for alpha inflation. CONCLUSIONS: Findings suggest BBT may be useful for some individuals with EI-PVFM and hyperventilation. The high prevalence of hyperventilation in EI-PVFM found in the current study warrants further investigation.

Reduced Asthma Medication Use after Treatment of Pediatric Paradoxical Vocal Fold Motion Disorder.

OBJECTIVES/HYPOTHESES: The primary objective of this study was to determine whether the diagnosis and treatment of pediatric Paradoxical Vocal Fold Motion Disorder (PVFMD) leads to decreased asthma medication use. Our secondary objective was to determine dyspnea outcomes following diagnosis and treatment for PVFMD. STUDY DESIGN: Prospective observational study. METHODS: Patients with newly diagnosed PVFMD between the ages of 11 and 17 were recruited at a single pediatric institution. A medication questionnaire and Dyspnea Index (DI) were completed at the initial visit, at the first return visit, and at greater than 6 months post-diagnosis and therapy. Laryngeal Control Therapy (LCT) consisted of teaching breathing techniques and identifying emotional, physical, and environmental contributing factors and strategies to reduce them. RESULTS: Twenty-six patients were recruited to the study. There were 19/26 (73%) patients diagnosed with asthma prior to a diagnosis of PVFMD, and 26/26 (100%) patients were using an inhaler prior to the enrollment visit. Twenty-two (85%) patients completed follow-up questionnaires. Five patients participated in no therapy, seven patients in partial therapy, and 14 patients in full therapy. Significant reduction in asthma medication use was seen in the full therapy group (P < .05) and in those with exercise as their only trigger (P < .05). Furthermore, symptoms as scored by the DI decreased overall from 25.5 to 18.8 (P < .001). CONCLUSIONS: Diagnosis and treatment of pediatric PVFMD leads to a decline in asthma medication use in those patients who participate in at least two LCT sessions and in those with exercise-induced PVFMD. LCT for pediatric PVFMD leads to a significant decrease in symptoms as measured by the DI. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:1639-1646, 2021.

Outcomes of Paradoxical Vocal Cord Motion Diagnosed in Childhood.

OBJECTIVES: To explore long-term patient reported outcome (PRO) measures of pediatric paradoxical vocal cord motion (PVCM) including ease of diagnosis, management, symptom duration and effect on quality of life. METHODS: All children >8 years of age diagnosed with PVCM at a tertiary pediatric hospital between 2006 and 2017 were invited to complete a survey addressing study objectives. RESULTS: 21/47 eligible participants could be contacted and 18/21 (86%) participated. 78% were female with a mean age at diagnosis of 11.6 and 15.0 years at survey completion. Common PVCM symptoms reported were dyspnea (89%), globus sensation (56%), and stridor (50%). The median time to diagnosis was 3 months (IQR 2-5 months). Nearly all reported being misdiagnosed with another condition, usually asthma, until being correctly diagnosed usually by an otolaryngologist. Participants reported undergoing 3.7 diagnostic studies (range 0-8); pulmonary function testing was most common. Of numerous treatments acknowledged, breathing exercises were common (89%) but only reported helpful by 56%. Use of biofeedback was recalled in 1/3 of subjects but reported helpful in only 14% of them. Anti-reflux, allergy, anticholinergics, inhalers and steroids were each used in >50%, but rarely reported effective. PVCM was reportedly a significant stressor when initially diagnosed but despite 2/3 of participants still reporting ongoing PVCM symptoms, the perceived stress significantly decreased over time (Z = 3.26, P = 0.001). CONCLUSIONS: This first PVCM PRO study endorses that diagnosis is often delayed and prescribed treatments often viewed as ineffective. While biofeedback and breathing exercises may be critical for short-term control of PVCM episodes, lifestyle changes and stress reduction are likely necessary for long-term management. Increased awareness and improvements in management are needed for this condition.

Gasping for a Diagnosis: Pediatric Vocal Cord Dysfunction.

Vocal cord dysfunction is an obstruction of the upper airway, primarily on inspiration, due to the paradoxical adduction of the vocal cords. Vocal cord dysfunction continues to be underdiagnosed as its own entity. The lack of diagnosis can be attributed to the overlap of symptoms between asthma and exercise-induced bronchospasm. It is possible for patients diagnosed with asthma and/or exercise-induced bronchospasm to have underlying vocal cord dysfunction, which needs to be considered when prescribing asthma medications. This article will review the history of vocal cord dysfunction, the differential diagnosis, diagnostic testing, and the role of the nurse practitioner in caring for these patients.

Short-Term Intensive Therapy and Outcomes for Athletes With Paradoxical Vocal Fold Motion Disorder.

Purpose The aim of the study was to develop a treatment for athletes with paradoxical vocal fold motion disorder (PVFMD) based on exercise physiology and learning theory principles and administer it over a preestablished time frame. Method A prospective, repeated-measures, within-subject group design was used. Eleven adolescent/teen athletes diagnosed with PVFMD via laryngoscopy received short-term intensive (STI) therapy. Eight of the athletes returned for extended follow-up. Changes in postexercise inspiratory ( R i) and expiratory ( R e) resistances and Modified Borg Dyspnea Scale (MBDS) ratings collected at baseline were compared immediately posttreatment and at extended follow-up. Dyspnea Index scores were collected at baseline and at extended follow-up. Two no-treatment control athletes with PVFMD participated in two exercise challenges-baseline and 6 weeks later. Results Immediately after STI therapy, athletes attained significant improvement in R i, R e, and MBDS ratings. These changes were maintained at extended follow-up as well as a significant change in Dyspnea Index scores. The 2 control athletes who were reassessed 6 weeks after baseline experienced negative changes in postexercise R i and MBDS ratings. Conclusion STI therapy that incorporated individuality, specificity, and variable practice effectively changed outcome measures posttreatment with further improvement observed at extended follow-up. These results provide preliminary evidence for STI therapy for PVFMD.

Speech-Language Pathology as a Primary Treatment for Exercise-Induced Laryngeal Obstruction.

Exercise-induced laryngeal obstruction is a condition that restricts respiration during exercise via inappropriate glottic or supraglottic obstruction. The literature supports behavioral treatment provided by a speech-language pathologist as an effective means of treating exercise-induced laryngeal obstruction. Treatment includes educating the patient, training on relaxation, instruction on paced exercise, and use of various breathing techniques to optimize laryngeal aperture. Intervention for patients with exercise-induced laryngeal obstruction may be delivered by a speech-language pathologist, given their clinical skill of facilitating long-term behavioral change and expertise in the laryngeal mechanism.

The Fortuitous Discovery of the Olin EILOBI Breathing Techniques: A Case Study.

Exercise-induced laryngeal obstruction (EILO) is the term for the condition previously named vocal cord dysfunction and paradoxical vocal fold motion. It is defined by glottic or supraglottic obstruction during periods of intense exercise. Not all patients respond to conventional therapy with speech-language pathology, behavioral health interventions, and treatment of contributing conditions. In this edition of Journal of Voice, the authors describe a novel series of respiratory retraining techniques, now called Olin EILOBI (EILO biphasic inspiratory) breathing techniques, specifically designed for athletes with EILO. This case presentation describes the discovery of one of these techniques during a session of therapeutic laryngoscopy during exercise. The patient was an adolescent with EILO who demonstrated a positive response to therapy with a variant of these techniques over a few days, having previously struggled with symptoms despite multiple sessions of conventional respiratory retraining over the course of months.

The Olin EILOBI Breathing Techniques: Description and Initial Case Series of Novel Respiratory Retraining Strategies for Athletes with Exercise-Induced Laryngeal Obstruction.

INTRODUCTION: Exercise-induced laryngeal obstruction (EILO), the condition previously known as paradoxical vocal fold motion and vocal cord dysfunction, is characterized by inappropriate glottic or supraglottic obstruction during high-intensity exercise, causing exertional dyspnea, frequently with stridor. EILO is definitively diagnosed through upper-airway visualization during a characteristic episode. Although respiratory retraining is a primary therapy for EILO, many patients report symptom persistence despite adequate performance of traditional techniques. This report describes three novel breathing techniques for EILO, the Olin EILOBI (EILO biphasic inspiratory) breathing techniques. We include a teaching process and case series with patient-reported assessments. MATERIALS AND METHODS: Following descriptions of the techniques and teaching process, we present data from a questionnaire offered to all patients who learned at least one of the techniques between September 2015 and March 2017. Subjects evaluated (1) expectation setting, (2) teaching processes, (3) their ability to implement the techniques during high-intensity exercise, and (4) perceived clinical effectiveness. RESULTS: Ninety-five percent of eligible patients participated, a primarily young, female, and Caucasian sample. Over 50% of subjects competed at the high school varsity level. Sixty-two percent of subjects perceived reasonable expectations, and 82% positively evaluated the teaching process. Seventy-nine percent were able to employ their technique in the high-intensity activity of choice, and 66% perceived clinical effectiveness with the techniques. CONCLUSIONS: The Olin EILOBI breathing techniques are novel respiratory retraining techniques for use in high-intensity exercise. Case series subjects reported reasonable expectations, a helpful teaching process, the ability to use these techniques during high-intensity exercise, and perceived clinical effectiveness.

Hypnosis for Asthma and Vocal Cord Dysfunction in a Patient With Autism.

Wheezing in children often is the result of asthma, but vocal cord dysfunction (VCD) may cause stridor or sounds that sometimes are misattributed to the wheezing of asthma. The frequent comorbidity of asthma and VCD also adds to the difficulty in making a clear diagnosis. The challenges of evaluating and treating wheezing are complicated further in children with developmental disorders, such as autism, because of the difficulties of obtaining an adequate history and assessing the clinical response to treatment. This article presents a patient with multiple psychiatric problems, including autism, with severe recurrent wheezing as a result of vocal cord dysfunction and asthma. Hypnosis has previously proven efficacious for treating vocal cord dysfunction, and in this case, hypnotic techniques were major factors in successful symptom control.

Breathing exercises for dysfunctional breathing/hyperventilation syndrome in children.

BACKGROUND: Dysfunctional breathing is described as chronic or recurrent changes in breathing pattern causing respiratory and non-respiratory symptoms. It is an umbrella term that encompasses hyperventilation syndrome and vocal cord dysfunction. Dysfunctional breathing affects 10% of the general population. Symptoms include dyspnoea, chest tightness, sighing and chest pain which arise secondary to alterations in respiratory pattern and rate. Little is known about dysfunctional breathing in children. Preliminary data suggest 5.3% or more of children with asthma have dysfunctional breathing and that, unlike in adults, it is associated with poorer asthma control. It is not known what proportion of the general paediatric population is affected. Breathing training is recommended as a first-line treatment for adults with dysfunctional breathing (with or without asthma) but no similar recommendations are available for the management of children. As such, breathing retraining is adapted from adult regimens based on the age and ability of the child. OBJECTIVES: To determine whether breathing retraining in children with dysfunctional breathing has beneficial effects as measured by quality of life indices.To determine whether there are any adverse effects of breathing retraining in young people with dysfunctional breathing. SEARCH METHODS: We identified trials for consideration using both electronic and manual search strategies. We searched CENTRAL, MEDLINE and EMBASE. We searched the National Research Register (NRR) Archive, Health Services Research Projects in Progress (HSRProj), Current Controlled Trials register (incorporating the metaRegister of Controlled Trials and the International Standard Randomised Controlled Trial Number (ISRCTN) to identify research in progress and unpublished research. The latest search was undertaken in October 2013. SELECTION CRITERIA: We planned to include randomised, quasi-randomised or cluster-randomised controlled trials. We excluded observational studies, case studies and studies utilising a cross-over design. The cross-over design was considered inappropriate due to the purported long-lasting effects of breathing retraining. Children up to the age of 18 years with a clinical diagnosis of dysfunctional breathing were eligible for inclusion. We planned to include children with a primary diagnosis of asthma with the intention of undertaking a subgroup analysis. Children with symptoms secondary to cardiac or metabolic disease were excluded.We considered any type of breathing retraining exercise for inclusion in this review, such as breathing control, diaphragmatic breathing, yoga breathing, Buteyko breathing, biofeedback-guided breathing modification and yawn/sigh suppression. We considered programmes where exercises were either supervised (by parents or a health professional, or both) or unsupervised. We also considered relaxation techniques and acute episode management as long as it was clear that breathing exercises were a component of the intervention.Any intervention without breathing exercises or where breathing exercises were not key to the intervention were excluded. DATA COLLECTION AND ANALYSIS: We planned that two authors (NJB and MJ) would extract data independently using a standardised form. Any discrepancies would be resolved by consensus. Where agreement could not be reached a third review author (MLE) would have considered the paper. MAIN RESULTS: We identified 264 potential trials and reviews from the search. Following removal of duplicates, we screened 224 papers based on title and abstract. We retrieved six full-text papers and further evaluated them but they did not meet the inclusion criteria. There were, therefore, no studies suitable for inclusion in this review. AUTHORS' CONCLUSIONS: The results of this systematic review cannot inform clinical practice as no suitable trials were identified for inclusion. Therefore, it is currently unknown whether these interventions offer any added value in this patient group or whether specific types of breathing exercise demonstrate superiority over others. Given that breathing exercises are frequently used to treat dysfunctional breathing/hyperventilation syndrome, there is an urgent need for well-designed clinical trials in this area. Future trials should conform to the CONSORT statement for standards of reporting and use validated outcome measures. Trial reports should also ensure full disclosure of data for all important clinical outcomes.