What is the best treatment for vocal cord dysfunction and swallowing issues in a patient with CAD, hypertension, hyperlipidemia, and T2DM experiencing worsening shortness of breath?

Treatment for Vocal Cord Dysfunction and Swallowing Issues in a Patient with Multiple Comorbidities

Speech therapy is the primary recommended treatment for vocal cord dysfunction (VCD) and associated swallowing issues, combined with management of potential underlying causes such as gastroesophageal reflux disease (GERD). 1

Diagnosis Confirmation

The patient's clinical presentation strongly suggests vocal cord dysfunction:

• Pittsburgh VCD Index score of 8 points (indicating VCD more likely than asthma)
• Normal PFTs (6/2025)
• Negative CXR and normal BNP
• No acute findings on CT chest
• History of multiple cardiovascular comorbidities

Treatment Algorithm for Vocal Cord Dysfunction

1. Speech Therapy Interventions (First-line)

• Reduction of excessive musculoskeletal tension in speech and non-speech muscles of the head, neck, shoulders, face, and mouth 1
• Teaching specific breathing techniques focusing on relaxed-throat breathing patterns 2
• Symptomatic strategies:
  • Elimination of secondary or accessory movements
  • Dual tasking while speaking as a form of distraction
  • Slowing speech down or elongating sounds rather than building tension
  • Introduction of mindfulness during oromotor tasks 1

2. Management of Contributing Factors

• GERD management (common trigger for VCD):

  • Provide information and advice to reduce acid reflux
  • Consider medical management of acid reflux if present 1
  • Note: Laryngopharyngeal reflux is commonly associated with VCD 1

• Swallowing issues management:

  • Adapting bolus characteristics - modify food texture and liquid thickness to facilitate swallowing and avoid aspiration 1
  • Postural maneuvers - particularly chin-tuck posture to protect the airway during swallowing 1
  • Fractionate meals if experiencing muscular fatigue during eating 1

3. Psychological Support

• Address cognitive features related to locus of control, abnormal illness beliefs, and hypervigilance to bodily functions 1
• Education about anxiety physiology if relevant
• Consider cognitive behavioral therapy strategies to challenge beliefs and cognitions about swallowing difficulties 1

Special Considerations for This Patient

Cardiovascular Comorbidities Management

• Continue current management for CAD, hypertension, hyperlipidemia, and T2DM
• Ensure coordination with cardiology (especially with upcoming stress test in August)
• Monitor for potential interactions between VCD symptoms and cardiac symptoms

Monitoring and Follow-up

• Schedule follow-up after initial speech therapy sessions to assess improvement
• Consider laryngoscopy during symptoms to confirm diagnosis if not already performed 1
• Coordinate care with pulmonology and cardiology given the patient's complex medical history

Important Caveats and Pitfalls

1. Avoid misdiagnosis as asthma - VCD is frequently misdiagnosed as asthma, leading to inappropriate treatment 3

2. Recognize potential phenotypes - Two distinct phenotypes exist: exercise-induced VCD and spontaneously occurring VCD, which may require different management approaches 3

3. Consider coexisting conditions - VCD often coexists with other conditions; ensure comprehensive management of all comorbidities 1

4. Rule out other causes - Ensure other causes of shortness of breath have been excluded, particularly given the patient's cardiac history 4

5. Assess for aspiration risk - Patients with impaired laryngeal sensation and history of aspiration pneumonia are at higher risk for aspiration even with thickened liquids 1

Speech therapy has demonstrated effectiveness for VCD that is functional in nature, with many patients achieving complete resolution of symptoms over time 3. Early intervention with appropriate speech therapy techniques offers the best chance for symptom control and improved quality of life.