Vocal Cord Dysfunction: An Often-misdiagnosed Condition

Sarah M. Jabusch, MS Clinical Research; Timothy M. Hinson, PharmD, AE-C

Disclosures

US Pharmacist. 2017;42(9):34-39. 

In This Article

Evaluation and Management

Before pharmacotherapy is initiated, objective testing for EIB or asthma should be done.[11] Because of the common misdiagnosis of VCD as asthma or EIB, patients should not be treated for asthma based on symptoms alone; objective tests must be conducted.[3,10] To differentiate the diseases, a thorough patient history with physical examination should be conducted to determine which factors precipitate an attack, and spirometry should be performed by a trained professional.[6] Spirometry should be conducted to determine the presence of asthma or EIB.[6] Once asthma has been ruled out, the diagnosis of VCD should be considered and confirmed by laryngoscopy. As explained previously, laryngoscopy is used to observe the abnormal adduction of vocal cords during inspiration and to rule out other laryngeal anomalies.[16] Because VCD is multifaceted, a multidisciplinary approach to management is necessary.[6] Pulmonologists, otolaryngologists, physiatrists, clinical psychologists, allergists, and speech therapists work together in the diagnosis and management of VCD. Therefore, it is important for the pharmacist to monitor the patient's medications for drug interactions or duplication of pharmacologic classes prescribed by multiple healthcare providers.

The management of VCD is multifactorial, with speech therapy universally considered the cornerstone of treatment.[11] The purpose of speech therapy is to teach the patient to maintain an open airway during respiration, and success rates are as high as 95% in female athletes.[1] Other nonpharmacologic management techniques are to approach the patient in a calm, reassuring manner to help terminate an attack and to use chronic therapies such as biofeedback, psychotherapy, and/or hypnosis.[11,16] Pharmacologic therapies that have shown limited benefit in acute attacks include benzodiazepines, inhaled heliox, and nebulized lidocaine.[11] The benzodiazepine selection and dosage depend on the patient's individual needs. It should be emphasized that benzodiazepines have the potential to be habit-forming and can result in abuse or misuse.[26] Heliox is a gas mixture of 70% to 80% helium and 20% to 30% oxygen.[27] Nebulized lidocaine has been administered at concentrations of 1%, 2%, and 4%, but levels exceeding 5 mcg/mL are associated with serious toxicity; therefore, the pharmacist should be careful not to exceed these investigational doses.[28] Limited data have also demonstrated that inhaled ipratropium bromide (two inhalations prior to exercise) is advantageous in preventing exercise-induced symptoms.[29] None of these agents are FDA-approved for this use.

Pharmacists usually see patients more often than the prescribing physician does, and they can monitor whether a patient is refilling medications too frequently. When a problem is perceived, the pharmacist can further question the patient and recommend additional medical consultation. For a summary of the differences between VCD, asthma, and EIB, see Table 1.

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