|
 Scenario
A 25 year old school teacher presents to the ER with chest
tightness, dyspnoea and wheezing, unresponsive to
repeated inhaled Beta 2 agonist use. The attack occurred
suddenly while writing on the black board with white chalk
in the class room. The patient has a history of frequent visits
to the emergency department and urgent care for asthma
exacerbations. However, in-between the exacerbations she
has normal pulmonary function.
Past Medical History: previous hospitalization for asthma
four times in the past 2 years and intubation once, 1 year
ago.
Medication: Ventolin (Salbutamol) MDI, Seretide Diskus
(Fluticasone / Salmeterol) 500 mcg/50mg BID,
Allergy: no known drug allergy
Family History: negative for history of asthma
On physical examination: She was diaphoretic and in
moderate discomfort with a Heart Rate of 110 BPM, Blood
Pressure of 140/90mmHg, Respiratory Rate of 26/min,
oxygen saturation is 95% with patient breathing room air.
Musical inspiratory and expiratory wheezes were heard on
chest examination, and she had a normal cardiovascular,
gastrointestinal and neurological examination.
She was treated with methylprednisolone, 125 mg
intravenously, and given three treatments with nebulized
albuterol/ipratropium. Two hours later, she was still
wheezing, anxious, and appeared to be in moderate
respiratory distress.
Oxygen saturation on room air remained 96%; pulse rate
was 100/min and respiration rate 24/min.
An eager new emergency specialist performed spirometry
(Figure 1) and laryngoscopy (Figures 2 a&b) before he
attempted intubation of the patient.
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Figure 1.
Flow volume loop
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Figure 2a. Laryngoscopy
during expiration
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Figure 2b. Laryngoscopy
during inspiration
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Figure 3. A normal
layngoscopy in inspiration
phase.
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Figure 4. A diagram of the
vocal cords during normal
breathing.
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A Normal vocal cords at
mid-inspiration.
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B Vocal cord dysfunction
with posterior chinking
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Work up showed the following:
* Normal CBC and chemistry
* Her ABG showed PaO2 95mmhg, PaCO2 36
and PH
7.46
* Chest radiography (x-ray) reported as
normal by
emergency radiology specialist
* Pulmonary Function Tests 3/2/06
* FVC 4.1 L (85%)
¦* FEV1 2.5 L (68%)
* FEV1/ FCV % = 61%
¦ Flow volume loop (Figure 1)
Questions:
* What is the most likely diagnosis?
* What are the clues to the diagnosis
and what is
the diagnostic test?
* What is the management of this
condition?
The answers:
* What is the most likely diagnosis?
Vocal Cord Dysfunction (VCD) with or
without mild
intermittent asthma
VCD is a relatively uncommon condition that closely
mimics asthma, characterized by intermittent symptoms,
which makes endoscopic confirmation logistically
difficult, and by the very nature of a somatoform
disorder, diagnosis of the condition is elusive (1).
Isolated VCD has a negative Methacholine challenge but
would be positive in those with concurrent VCD and asthma.
Nevertheless, many VCD patients are misdiagnosed as
asthmatics for years and develop iatrogenic complications
related to steroid therapy, which does not provide significant
benefit (2-7).
* What are the clues to the diagnosis
and what is
the diagnostic test?
Patients with vocal cord dysfunction typically have frequent
exacerbations that do not respond to the usual asthma
therapy. They often have throat or neck discomfort,
inspiratory wheezing, and anxiety. Many of these patients
have asthma as well as vocal cord dysfunction. The following
would help in making the diagnosis:
* Oxygen saturation is typically normal
in these
patients despite what seems to be a
severe
exacerbation (3). SUGGESTIVE of
DIAGNOSIS.
* Flow volume loops in which the inspiratory and
expiratory flows are recorded while a
patient is
asked to breath as deeply as possible
and then
to exhale as much as possible. In
patients with
vocal cord dysfunction, the inspiratory
limb
of the flow volume loop is “cut off”
because
of narrowing of the extra-thoracic
airway (at
the level of the vocal cords) during
inspiration
due to negative intra-thoracic pressure
(Figure
1), compared to asthma where the
inspiratory
loop is normal and there is abnormality
in the
expiratory loop called scooping (8).
SUGGESTIVE
of DIAGNOSIS.
* Laryngoscopy, especially when done
while the
patient is symptomatic, can reveal
characteristic
adduction of the vocal cords during
inspiration
(1,2,3,9,10). DIAGNOSTIC.
*( What is the management of this
condition?
Recognition of vocal cord dysfunction is
essential to
preclude affected patients being
prescribed lengthy courses
of systemic corticosteroids and to start
therapies for vocal
cord dysfunction, which include speech
therapy, relaxation
techniques, and treating such underlying
causes as anxiety
and gastroesophageal reflux disease
(1,2,3,10)..
References
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