Page 17 - Škrgat, Sabina, ed. 2023. Severe Asthma Forum - Monitoring and Treatable Traits in Severe Asthma. Koper: University of Primorska Press. Severe Asthma Forum, 2
P. 17
18. We should be suspicious in a patient tion, and exercise7,21. Patients with VCD of- 17
with exercise-induced asthma-like symptoms, ten show inappropriate vocal fold movement
or an athlete with choking sensation during during inspiration or expiration when laryn- dysfunctional breathing – view of otorhinolaryngologist
exercise and irritant-induced asthma-like goscopy is performed immediately following
symptoms. But we must be aware that VCD a bronchoprovocation challenge with metha-
with asthma is possible, and we should be also choline. Therefore, laryngoscopy should be
aware of exercise-induced bronchospasm32. ideally performed after a bronchoprovoca-
tion challenge with methacholine. We should
Assessment of symptoms avoid benzodiazepines and lidocaine before
the examination. Negative laryngoscopy in
Relevant issues should be discussed with pa- an asymptomatic patient does not rule out
tients. We can use standardized question- VCD5,18.
naires, for example, 12-item VCDQ (vocal
cord dysfunction questionnaire), which is a Continuous laryngoscopy during
valid tool for symptom monitoring and track- exercise – CLE test
ing improvement in scores after speech thera- Video recorded trans nasal flexible laryngos-
py. It also gives insight into which symptoms copy and larynx examination are performed
are important to patients and could guide fu- during exercise from the rest to the peak ex-
ture therapy refinements11. Another one is the ercise – continuous laryngoscopy exercise test
Pittsburgh VCD index, which helps distin- (CLE test). Any form of physical exercise can
guish VCD from asthma. This scoring sys- be used, running, or cycling on stationary bi-
tem correctly diagnosed VCD in 77.8% of pa- cycles, which provoke symptoms15. A flexible
tients. Since many patients have coexistent laryngoscope is attached to the head via a hel-
VCD and asthma, further diagnostic tests met. The tip of the scope is introduced through
should be performed, if a strong suspicion of the nose into the larynx, allowing visualiza-
asthma exists33. tion of the supraglottic and glottic structures in
real time throughout the exercise. During test-
Physical examination ing cardiopulmonary data is collected, as the
patient exercise to peak in an attempt to repro-
The physical examination in patients with duce EILO symptoms. EILO-related findings
VCD is normal when they are not experienc- on laryngoscopy include vocal fold narrow-
ing an acute attack. During symptoms, we ing, supraglottis narrowing, obstruction, and/
can identify high-pitched wheezing, stridor, or collapse of supraglottic structures. CLE is
tachypnea, hoarseness, dysphonia, cough, the test of choice for EILO32.
and respiratory distress. Arterial hypoxemia
is usually lacking. The patient has a normal Other tests
oxygen saturation. Only in a few patients with Pulmonary function tests, methacholine chal-
VCD, we can identify the presence of hypox- lenge testing, spirometry, and flow volume
emia. Laryngoscopy is the gold standard for loops are also done in VCD and EILO pa-
the diagnosis of VCD. Direct visualization tients1.
of the vocal folds via flexible, trans-nasal fi-
ber-optic laryngoscopy should be done while Treatment
a patient has symptoms. Complete adduc- Correct diagnosis is essential for proper treat-
tion of the vocal folds during inspiration and ment. The patient should be reassured that
a formation of a small posterior glottal chink the condition is benign and self-limited. The
during exhalation is seen18. In asymptomat- treatment approach is multidisciplinary. Pri-
ic patients, we can provoke symptoms by deep
breathing, cold air, phonation, forced expira-
with exercise-induced asthma-like symptoms, ten show inappropriate vocal fold movement
or an athlete with choking sensation during during inspiration or expiration when laryn- dysfunctional breathing – view of otorhinolaryngologist
exercise and irritant-induced asthma-like goscopy is performed immediately following
symptoms. But we must be aware that VCD a bronchoprovocation challenge with metha-
with asthma is possible, and we should be also choline. Therefore, laryngoscopy should be
aware of exercise-induced bronchospasm32. ideally performed after a bronchoprovoca-
tion challenge with methacholine. We should
Assessment of symptoms avoid benzodiazepines and lidocaine before
the examination. Negative laryngoscopy in
Relevant issues should be discussed with pa- an asymptomatic patient does not rule out
tients. We can use standardized question- VCD5,18.
naires, for example, 12-item VCDQ (vocal
cord dysfunction questionnaire), which is a Continuous laryngoscopy during
valid tool for symptom monitoring and track- exercise – CLE test
ing improvement in scores after speech thera- Video recorded trans nasal flexible laryngos-
py. It also gives insight into which symptoms copy and larynx examination are performed
are important to patients and could guide fu- during exercise from the rest to the peak ex-
ture therapy refinements11. Another one is the ercise – continuous laryngoscopy exercise test
Pittsburgh VCD index, which helps distin- (CLE test). Any form of physical exercise can
guish VCD from asthma. This scoring sys- be used, running, or cycling on stationary bi-
tem correctly diagnosed VCD in 77.8% of pa- cycles, which provoke symptoms15. A flexible
tients. Since many patients have coexistent laryngoscope is attached to the head via a hel-
VCD and asthma, further diagnostic tests met. The tip of the scope is introduced through
should be performed, if a strong suspicion of the nose into the larynx, allowing visualiza-
asthma exists33. tion of the supraglottic and glottic structures in
real time throughout the exercise. During test-
Physical examination ing cardiopulmonary data is collected, as the
patient exercise to peak in an attempt to repro-
The physical examination in patients with duce EILO symptoms. EILO-related findings
VCD is normal when they are not experienc- on laryngoscopy include vocal fold narrow-
ing an acute attack. During symptoms, we ing, supraglottis narrowing, obstruction, and/
can identify high-pitched wheezing, stridor, or collapse of supraglottic structures. CLE is
tachypnea, hoarseness, dysphonia, cough, the test of choice for EILO32.
and respiratory distress. Arterial hypoxemia
is usually lacking. The patient has a normal Other tests
oxygen saturation. Only in a few patients with Pulmonary function tests, methacholine chal-
VCD, we can identify the presence of hypox- lenge testing, spirometry, and flow volume
emia. Laryngoscopy is the gold standard for loops are also done in VCD and EILO pa-
the diagnosis of VCD. Direct visualization tients1.
of the vocal folds via flexible, trans-nasal fi-
ber-optic laryngoscopy should be done while Treatment
a patient has symptoms. Complete adduc- Correct diagnosis is essential for proper treat-
tion of the vocal folds during inspiration and ment. The patient should be reassured that
a formation of a small posterior glottal chink the condition is benign and self-limited. The
during exhalation is seen18. In asymptomat- treatment approach is multidisciplinary. Pri-
ic patients, we can provoke symptoms by deep
breathing, cold air, phonation, forced expira-
