Exercise Induced Vocal Cord Dysfunction

Just last week I was asked to speak to the Respirology Division at the Alberta Children's Hospital here in Calgary about some of the work I have been doing with treating vocal cord dysfunction.  And it became quite clear that they are seeing many patients that have some sort of excerise induced vocal cord dysfunction (EIVCD).  EIVCD is described as an inappropriate closure of the vocal cords on inhalation during strenuous activity.   Usually, when we breathe in, the vocal cords widen, to allow for air to enter the airways and lungs.  When we exhale they may close slightly, and when we talk they narrow more, and then they completely close when we cough and swallow.  But sometimes, the reflexive opening and closing becomes dysfunctional and we see the vocal cords coming together on the in breath.  As you can imagine, this makes breathing very difficult: symptoms of EIVCD are shortness of breath, inspiratory stridor (a hoarse wheezing on inhale), and tightness of the throat.  Sometimes this can be quite alarming and may lead to hyperventilation and panic.

Often EIVCD is misdiagnosed as asthma, although it does tend to occur in conjunction with asthma.  A few clues that the vocal cords may be involved is the report of throat tightness - usually in asthma it is chest tightness; inspiratory sounds - with asthma it is generally a wheeze on breathing out; and if symptoms do not resolve with taking a bronchodilator (like Ventolin) EIVCD should be suspected.  Of note, it is three times more likely to occur in females than males.  

So all that being said, where does breathing fit into this?  Well, there is some evidence to indicate that the muscles that help open the vocal folds are linked to the movement of the diaphragm.  That is, the downward motion of the diaphragm that occurs during inhale assists in the activation of these "throat opening" muscles.  In all of the patients I have seen with complaints of EIVCD, they have demonstrated a breathing pattern that relies heavily on the accessory muscles of breathing located in the neck and chest, with very little activation of the diaphragm.  We also know there is a link between tight muscles in the neck and tight muscles around the larynx (where the vocal cords are located).

Management of EIVCD generally includes education and breathing retraining. Patients who have an understanding about what is going are less likely to panic when experiencing symptoms.  Learning new breathing patterns that help to relax tense neck muscles and activate the diaphragm assist in decreasing the frequency and severity of events.  "Rescue breathing" exercises are also taught to help gain control in an acute episode.   I also include postural retraining and manual therapy to address neck muscle tension.  There is also some evidence showing that low load inspiratory muscle training assists in restoring reflexive opening of the vocal folds.  I have certainly noticed clinically an improvement in breathing patterns when adding this modality to my treatment programs.

If you or someone you know has asthma, and struggles during strenuous exercise, take note of your symptoms and compare them to the ones mentioned here.  If you are finding it has been hard to manage your symptoms to this point, perhaps you may want to consider if exercise induced vocal cord dysfunction is involved.

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