Vocal Advocates

November 26, 2015

Frequently misdiagnosed as asthma, vocal cord dysfunction-exercise-induced laryngeal obstruction may be present in as high as five percent of athletes. These authors are working hard to educate their peers about the condition.

The following article appears in the December 2015 issue of Training & Conditioning.

By Mike Matheny and Mary Pitti

Mike Matheny, MS, ATC, has been Head Athletic Trainer at Ithaca College for 26 years. He is also a Clinical Associate Professor in the Department of Exercise and Sport Sciences. Matheny can be reached at: matheny@ithaca.edu.

Mary Pitti, MS, CCC-SLP, is a Clinical Assistant Professor in the Speech-Language Pathology and Audiology Department at Ithaca College, as well as the Program Director of the Ewing Speech and Hearing Clinic. Since fall 2014, she has also served as Assistant Chair of the Speech-Language Pathology Department.

 

An athlete collapsing on the field complaining of shortness of breath is an immediate call to action for an athletic trainer. Many different diagnoses—cardiac event, asthma attack, or sickle cell trait collapse—will come to mind when rushing to the struggling player. However, athletic trainers should be aware of an additional condition that presents with breathing difficulty as a primary symptom—vocal cord dysfunction-exercise-
induced laryngeal obstruction (VCD-EILO).

Often mistaken for asthma and triggered by intense exercise, VCD-EILO occurs when an athlete’s vocal cords block their airway. A team of health care professionals is usually needed to provide care for an athlete following diagnosis, including athletic trainers, physicians, and speech-language pathologists (SLPs).

Our first encounter with VCD-EILO came when an Ithaca College men’s soccer player collapsed during the team’s opening fitness test in 2013 and had shortness of breath. Fortunately, Mike had recently attended a lecture on breathing disorders in athletes and was familiar with VCD-EILO. His suspicion that the soccer player was suffering from this condition was later confirmed by the team physician, who referred the athlete to Mary for treatment.

While working with the soccer player, Mike and Mary met often to discuss VCD-EILO. We quickly realized few colleagues in our respective professions were fully informed and felt that educating both groups would help streamline diagnosis and treatment.

Since then, we’ve made it our mission to address this lack of knowledge. We recently published two articles in the International Journal of Athletic Therapy and Training to spread the word about VCD-EILO, and we also presented a poster about athletic trainers and SLPs teaming up to treat it at the 2015 New York State Speech-Language Hearing Association’s annual conference. We plan to continue educating others about the symptoms, diagnosis, and treatment of VCD-EILO, as well as the role athletic trainers and SLPs can play in helping athletes who have it.

DEFINING THE DISORDER

VCD-EILO is a condition in which the vocal cords or other supraglottic tissue inhibit an athlete’s inhalation by narrowing his or her airway. It is typically caused by the vocal cords acting paradoxically—that is, they close during inhalation rather than opening as they should.

Although the exact cause for VCD-EILO is unknown, episodes can be brought on by several factors. They occur most often during periods of intense exercise, but other triggers include inhaled irritants, stress, and anxiety.

Studies show that up to five percent of athletes have VCD-EILO. Common symptoms are shortness of breath, tightness in the neck or throat area, a sudden drop in exercise performance, and stridor, which is a high-pitched, harsh laryngeal breathing noise that occurs when the vocal cords are closed during inspiration. Athletes describe the sensation of stridor as “breathing in through a straw.”

Because individuals with VCD-EILO often present with shortness of breath, many clinicians are quick to diagnose them with asthma. Although some athletes with asthma may also have VCD-EILO and vice versa, the two conditions are not directly related.

In fact, they differ in several key ways. During an episode, clinicians should pay close attention to what triggered it, when it began, where the athlete felt the breathing restriction, and how long it took for symptoms to resolve once exercise ceased. Unlike asthma sufferers, those with VCD-EILO typically have episodes early in an exercise session. In addition, they feel the breathing restriction in the throat rather than the chest, and their symptoms usually dissipate once they stop physical activity.

Another factor for clinicians to consider is the breathing sound the athlete makes while experiencing distress. Stridor comes from the throat and occurs during inspiration. A wheeze associated with asthma, however, originates in the chest and happens during expiration.

Athletes with VCD-EILO who are misdiagnosed with asthma often find their prescribed inhalers provide little to no relief of symptoms. We experienced this recently with “Rachel,” an IC track athlete who was referred to Mike by her coach after she had trouble breathing during practice. Rachel reported that she had been experiencing breathing difficulties associated with intense exercise since she was eight years old. As a youth, her physician diagnosed her with exercise-induced asthma, and she was instructed to use an Albuterol inhaler 15 to 20 minutes prior to running. The medication did little to reduce symptoms, which continued throughout middle school and high school—becoming more severe in college as the intensity of competition increased.

DIAGNOSTIC PROCESS

The athletic trainer’s role in diagnosing VCD-EILO is significant. They are in a unique position to recognize VCD-EILO, as they are typically present at practices and games when episodes are likely to occur. Plus, athletic trainers know when athletes aren’t responding normally to training and competitions.

When an athlete does experience shortness of breath during exercise, athletic trainers should include VCD-EILO in their differential diagnosis. Once they recognize the disorder, they should refer the athlete to a physician who is familiar with it.

The gold standard for diagnosis by a physician is an exercise provocation test done in conjunction with a flexible fiber optic laryngoscopy. This procedure involves threading an endoscope through the athlete’s nasal passage down to just above the level of the vocal cords and having them exercise until they experience symptoms. The physician can then examine the upper-airway obstruction in real time to determine a definitive diagnosis.

PROPER CARE

Once a diagnosis of VCD-EILO has been established, the athlete is often referred to an SLP. These professionals are the ideal treatment providers because they have specific education and training on voice and laryngeal anatomy, physiology, and related disorders. SLPs are also knowledgeable about the relaxation and breathing exercises that can effectively remediate symptoms.

The SLP starts by conducting a diagnostic evaluation, which consists of obtaining a complete history of the athlete’s chief complaints and symptoms. In addition, the athlete’s breathing patterns are evaluated to determine if they breathe primarily through their nose or mouth and if their breathing is deep or shallow, or abdominal or thoracic. The most effective breathing pattern to reduce or eliminate a VCD-EILO episode is deep abdominal/diaphragmatic nasal breathing. Training may be needed to encourage this practice and incorporate it during exercise.

Next, the SLP develops a rating system with the athlete to analyze each future VCD-EILO episode. Ranking and logging each incident in terms of frequency, intensity, and duration will help determine if there is a pattern to the episodes and will quantify information that can be used for comparison as the athlete recovers.

The SLP begins treatment by increasing the athlete’s awareness of the sensations they feel just prior to an episode. This consciousness will help them recognize an episode’s onset so they can introduce management strategies to prevent it.

Since VCD-EILO episodes can be triggered by stress and anxiety, they often have both a physical and emotional impact. Therefore, stopping symptoms before they start also lets athletes feel like they have control over their disorder. This confidence can go a long way in managing the condition.

The athlete generally learns the management strategies, which can include relaxation exercises and specific breathing techniques, over several sessions with the SLP. The exercises are relatively easy to pick up, but the challenge is keeping athletes from reverting to old breathing patterns, especially during intense physical exertion when they are most likely to experience an episode.

The goal of treatment is to first decrease the intensity and duration of VCD-EILO episodes and then decrease their frequency or eliminate them completely. Many athletes report that if they consistently incorporate the management strategies, they can control the disorder so it does not affect their performance. Some even report that symptoms go away entirely.

Rachel was referred to Mary after being diagnosed with VCD-EILO by an IC team physician. Mary completed an evaluation and six subsequent therapy sessions with Rachel, educating her about VCD-EILO and teaching her progressive relaxation exercises, abdominal breathing, and a series of recovery breathing techniques. Over time, Rachel found the treatment was successful in reducing the frequency, duration, and intensity of her episodes. In the final two weeks of therapy, she reported no episodes at all.

Once the athlete gets a handle on VCD-EILO, athletic trainers can work closely with SLPs to ensure the relaxation and breathing techniques learned in treatment are carried over to the playing field. It is helpful for athletic trainers to have a basic understanding of the exercises so they can reinforce them with the athlete.

Another helpful role for athletic trainers is checking in during training and competitions to monitor how the athlete performs. Workouts should be ranked from easy to hard to track how the athlete handles increased intensity. In Rachel’s case, Mike evaluated her on a daily basis during workouts and provided regular updates to Mary on her progress.

Since we have teamed up, we’ve seen an increased awareness about VCD-EILO both on our campus and in our respective professions. When sports medicine providers are better informed about VCD-EILO, the athletes benefit. Our hope is that our continued efforts will improve the rates of diagnosis and effective treatment of this elusive condition, allowing athletes to breathe more easily.

 

Sidebar: DURING AN EPISODE

After undergoing therapy and learning effective management strategies for vocal cord dysfunction-exercise-induced laryngeal obstruction (VCD-EILO), the frequency of episodes is expected to decrease. However, if an athlete does have an attack during training or competition, athletic trainers need to be ready.

The first step is to recognize the onset of the episode, based on the particular athlete’s triggers. Then, remind them to initiate diaphragmatic breathing, and if necessary, recovery breathing exercises. Episodes can be highly stressful, so athletic trainers should provide reassurance to help reduce the athlete’s anxiety. They will also have to decide whether to remove the player from training or competition based on their presentation.

If the athlete continues to have episodes after therapy, the athletic trainer should refer them back to the speech-language pathologist (SLP). The SLP will review any episodes that occurred, analyze the events leading up to each one, and suggest changes to minimize the risk of subsequent attacks.

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