What to do if a patient with Vocal Cord Dysfunction (VCD) is not making progress with breathing exercises?

Management of Patients with Vocal Cord Dysfunction Not Responding to Breathing Exercises

For patients with Vocal Cord Dysfunction (VCD) who are not responding to initial breathing exercises, a multidisciplinary approach focusing on identifying and treating underlying causes is essential for improving outcomes.

Diagnostic Reassessment

When breathing exercises alone fail to improve VCD symptoms, consider:

1. Confirm diagnosis with laryngoscopy during symptoms

   • Direct visualization of vocal cord adduction during inspiration is the gold standard for diagnosis 1
   • Consider continuous laryngoscopy during exercise challenge if symptoms are exercise-induced 1
   • Look for flattening or truncation of the inspiratory portion of the flow-volume loop during symptomatic periods 1

2. Identify potential triggers and comorbidities

   • Gastroesophageal reflux disease (GERD) or laryngopharyngeal reflux (LPR) 1, 2
   • Chronic postnasal drip 2
   • Psychological factors (anxiety, stress, depression) 2, 3
   • Environmental irritants 3
   • Exercise-induced factors in athletes 4

Treatment Escalation Algorithm

Step 1: Address Underlying Conditions

• Treat GERD/LPR aggressively if laryngoscopy shows posterior laryngeal changes 1, 2

  • Empiric pharmacologic treatment is recommended in juveniles with VCD 1

• Manage postnasal drip with appropriate therapies 2, 3

• Address psychological factors

  • Consider psychological evaluation and support 2
  • Anxiety management techniques may benefit patients with stress-triggered VCD 3

Step 2: Specialized Speech Therapy

• Refer to speech-language pathologists with VCD expertise 2, 3
  • Speech therapy is critical for teaching techniques to override dysfunctional breathing patterns 2
  • Focus on vocal cord relaxation techniques beyond basic breathing exercises 3

Step 3: Consider Additional Therapies

• For acute severe episodes:

  • Heliox (80% helium/20% oxygen) may provide relief 2, 5
  • Topical lidocaine can help break severe episodes 2
  • Anxiolytics may be beneficial in anxiety-triggered episodes 2

• For refractory cases:

  • Superior laryngeal blocks with Clostridium botulinum toxin may be considered 2
  • OnabotulinumtoxinA injections for certain cases with severe dyspnea, though evidence is limited 3

Special Considerations for Athletes

• Athletes with VCD often require specialized approaches:
  • Free running exercise challenge may be needed to reproduce symptoms 6
  • Sport-specific breathing techniques during competition 4
  • Certified athletic trainers may need to be involved in management 4

Monitoring and Follow-up

• Regular reassessment of symptoms and treatment response
• Adjust therapy based on identified triggers and comorbidities
• For patients with both VCD and asthma, ensure proper management of both conditions 6

Common Pitfalls to Avoid

• Misdiagnosing as refractory asthma - VCD is often mistaken for asthma leading to unnecessary corticosteroid treatment 2
• Focusing only on breathing techniques without addressing underlying causes 2
• Overlooking psychological factors that may contribute to symptom persistence 2
• Failing to recognize coexisting conditions - VCD often coexists with asthma and other respiratory disorders 6

Remember that VCD management typically requires a coordinated approach involving multiple specialties including pulmonology, otolaryngology, speech-language pathology, gastroenterology, and psychology as appropriate 4.