Asthma and Vocal Cord Dysfunction

Amy L. Marks DO, FACOP

Pediatric Allergy and Immunology

Assistant Professor of PediatricsAssistant Professor of Pediatrics

Oakland University William Beaumont School of Medicine

Objectives:

• Understanding the basic principles of asthma and vocal cord dysfunction

• Treatment and management of asthma in the pediatric populationpopulation

• Treatment and management or vocal cord dysfunction in the pediatric patient population

2

Case Presentation

• 14 year old girl presents to your office with SOB while participating in competitive indoor soccer. This occurs with both practice and competition. Onset is sudden and can happen without over-Onset is sudden and can happen without over-exertion.

• She reports symptoms of SOB with activity in the past with outdoor travel soccer May thru June.

• She does have significant seasonal allergies

3

Case Presentation

• Her past medical history is remarkable for a recent soccer injury with a concussion and whiplash.

– Family history for seasonal allergies

• Her PCP has given her an albuterol inhaler to use prior to activity without improvement

• Symptoms now occurring more frequently and onset more sudden, unable to speak with difficulty “getting air into her lungs”

4

Case presentation

• Spirometry with evidence of mild obstruction

– 8% reversibility post bronchodilator on FEV1

• Skin testing revealed significant positives to tree, grass, weed, and ragweed pollengrass, weed, and ragweed pollen

• Negative to mold, dust mite, cat dog and cockroach

5

Flow Volume Loop

6

Case presentation

• Started on Beclomethasone dipropionate HFA 40mcg 2 puffs bid with spacer

– Device instruction with demonstration in the office

• Albuterol inhaler for rescue• Albuterol inhaler for rescue

– Use and symptom diary recommended

• Treatment of seasonal allergies initiated with detailed trigger discussion

– Cetirizine, Fluticasone (nasal)

7

Asthma

A complex disorder with variable and recurring respiratory symptoms

-airflow obstruction

-bronchial hyper-responsiveness

bronchospasm

-underlying inflammation

-mucous production and plugging

Pathogenesis of Asthma

-Infiltration of inflammatory cellseosinophils, neutrophils, lymphocytes, mast cells

-Hypertrophy of airway smooth muscle in smaller airways airways

-Hyperplastic smooth muscle in larger airways

-Increased airway wall thickness

-Damages epithelial cells are seen in chronic asthmatics

9

10

11

Diagnosis of Asthma

• Transient early wheezers ( most prevalent type)

– Wheeze less than 3 yrs old and resolved by age 6

• Persistent wheezers

– Wheeze less than 3 yrs of age and continues through – Wheeze less than 3 yrs of age and continues through 6 yrs of age

• Late-onset wheezers

– Children whose onset of wheeze was at 6 years of age

12

Onset of Symptoms in Children Onset of Symptoms in Children With AsthmaWith Asthma

20% 30%1-2 years <1 year

McNicol and Williams. BMJ. 1973;4:7-11; Wainwright et al. Med J Aust. 1997;167:218-222; Dodge et al. J Allergy Clin Immunol. 1996;98:48-54.

30%

20%

>3 years

2-3 years

Asthma

• Affects more than 7 million children in the US

• 80% of asthmatics diagnosed before the age of 5

• Symptoms include

– Cough, Wheeze, Breathlessness– Cough, Wheeze, Breathlessness

– Chest tightness or pressure

– Chest pain

14

Risk factors for development of asthma in children

• Genetic characteristics

• Environmental Exposures

• Contributing Factors

15

Genetic characteristics of Asthma

• Atopy

– body’s predisposition to develop an antibody (IgE) in response to exposure to environmental allergens

• IL-4 Gene• IL-4 Gene

• Beta 2 adenoreceptor gene

• ADAM 33

16

Genetic Predisposition and Environmental Interactions are thought to determine Asthma Phenotype

-ATOPY: strongest identifiable predisposing factor

-Allergen exposure plays a complex roll: both onset and triggering of asthma

-A child’s sensitization to Alternaria by six years of age is associated with persistent asthma by 11-years-old

- In older children, exposure to higher levels of dust mites correlates with wheezing and airway hyper-responsiveness.

-Gender differences are seen (eg, boys have a higher prevalence than girls until the ages of 15-17, the opposite is seen after that age)

Atopy and Asthma

• 30% of children with food allergy have asthma and respiratory allergy

– Food allergy is a risk factor for life threatening asthma

• Family history• Family history

– Children with one parent asthmatic are 2.6 times more likely to have asthma

– Both parents 5.2 times more likely

18

Asthma Risk Factors

• Allergy and eczema

• Food allergy

• Early RSV infection

• Parental asthma• Parental asthma

19

Asthma Symptoms

• Cough

– Nocturnal

– Seasonal cough

– Cough secondary to exposures– Cough secondary to exposures

• Cold air, exercise, laughing, smoke

– Cough > 3weeks

• Although wheezing is considered hallmark for asthma, cough is often the sole complaint

20

Asthma Symptoms

• Wheeze

– High pitched-musical sound

• Air forced through narrow airways

– Polyphonic (varied pitch)

• Central Airway obstruction• Central Airway obstruction

– Harsh expiratory monophonic wheeze

• tracheobronchomalacia

• Upper airway obstruction

– single pitched inspiratory stridor

• VCD

21

Atopic Asthma

• Atopic Asthma

– Symptoms worse in certain pollen season

– Other allergic symptoms typically flare concurrently with chest complaintswith chest complaints

• Rhinitis, conjunctivitis, eczema

• Essential to treat atopic symptoms to help alleviate asthma exacerbations

– Oral antihistamines, nasal sprays, eye drop, topical steroids, moisturizers

22

Exercise Induced Bronchospasm

• Exercise induced bronchospasm (EIB) may be the only manifestation of asthma in children

• Symptoms

– SOB, chest tightness and cough– SOB, chest tightness and cough

– Several minutes into exercise

– Resolution of symptoms with rest over 30-60 minutes

• EIB that is difficulty to control indicates inadequately controlled underlying asthma

23

Diagnostic evaluation for Asthma

• History

• PFT with bronchodilators

• Trial of bronchodilators

• Testing for aeroallergy sensitization• Testing for aeroallergy sensitization

• Consider imaging

24

Asthma Management

• Avoidance of triggers and management of co-morbidities

– GERD ( 45-65% of asthmatics)

– Atopy– Atopy

– Sleep apnea

– Vocal cord dysfunction

25

Asthma PharmacotherapyStepwise approach

• Step 1

– Short-acting b-agonist as needed (indicated for all patients)

• Step 2

– Low-dose ICSs or leukotriene modifiers

• Step 3

– Low-dose/medium-dose ICS

– low-dose/medium-dose ICSs plus LABA– low-dose/medium-dose ICSs plus LABA

• Step 4

– High-dose ICSs and LABA plus systemic oral corticosteroids

• Biologic therapy

– Omalizumab (Anti-IgE)

– Mepolizumab ( Anti-IL-5)

26

Omalizumab

• Anti- IgE therapy

• Recombinant, humanized, monoclonal IgG1k anti IgE antibody that binds to the Fc region of IgE, preventing IgE from binding to the cell surface preventing IgE from binding to the cell surface receptors of mast cells and basophils

• Inhibiting the release of inflammatory mediators that can cause an asthma exacerbation

27

NIH Guidelines on Asthma

• www.nhlbi.nih.gov/guidelines/asthma/08_sec4_lt_0-11.pdf

28

29

30

31

The Global Initiative for Asthma

• http://www.ginasthma.com

• Classification of Asthma Severity byClinical Features Before TreatmentClinical Features Before Treatment

32

• Intermittent

• Symptoms less than once a week

• Brief exacerbations

• Nocturnal symptoms not more than twice a month

• • FEV1 or PEF ≥ 80% predicted

• • PEF or FEV1 variability < 20%

• Moderate Persistent

• Symptoms daily

• Exacerbations may affect activity and sleep

• Nocturnal symptoms more than once a week

• Daily use of inhaled short-acting 2-agonist

• • FEV1 or PEF 60-80% predicted

• • PEF or FEV1 variability > 30%• • PEF or FEV1 variability < 20%

• Mild Persistent

• Symptoms more than once a week but less than once a day

• Exacerbations may affect activity and sleep

• Nocturnal symptoms more than twice a month

• • FEV1 or PEF ≥ 80% predicted

• • PEF or FEV1 variability < 20 – 30%

• • PEF or FEV1 variability > 30%

• Severe Persistent

• Symptoms daily

• Frequent exacerbations

• Frequent nocturnal asthma symptoms

• Limitation of physical activities

• • FEV1 or PEF ≤ 60% predicted

• • PEF or FEV1 variability > 30%

33

34

Case presentation

Continues to have “episodes” now more frequent and more severe.

– No improvement of symptoms on Beclomethasone dipropionate HFAdipropionate HFA

• 95% compliance

– Albuterol not helping with symptoms

• ER visits twice with one call to 911 from school

– Now episodes happening outside of sports

35

Asthma or something else?

• Post infectious

• GERD

• Smoking• Smoking

• Psychogenic

• Structural Abnormality

• Vocal cord dysfunction

• CF

36

Case presentation

• At her most recent ER visit, no wheeze, no cough and no response to bronchodilator

• CXR normal

• Evaluated by ENT, no evidence of structural • Evaluated by ENT, no evidence of structural abnormalities

– No mass visualized

37

Vocal Cord Dysfunction (VCD)

• VCD is a form of “functional” or nonanatomic upper airway obstruction

• Characterized by paradoxical or paroxysmal vocal cord movement

• Vocal cords adduct (close) during inspiration or • Vocal cords adduct (close) during inspiration or early expirations rather than abduct (open)

– Intermittent

• Diagnosis suspected by history of inspiratory wheeze and throat tightness

38

Symptoms of VCD

• Intermittent onset of:

– Dyspnea

– Cough

– Stridor– Stridor

– Wheeze

– Throat or chest tightness

– Hoarseness

All of variable severity

39

VCD

• Symptoms often mimic asthma however they are typically un-responsive to asthma medications

• Pathogenesis is still unknown

– Psychogenic and neurogenic factors– Psychogenic and neurogenic factors

– Intrinsic or extrinsic irritants on a hyperresponsive larynx

• Appears to be gender related and highest among females

– Associated with “type A personalities” and GERD

40

VCD and concurrent diagnosis

• Asthma

• Chronic rhinosinusitis with post nasal drainage

• GERD

• Atypical (laryngopharyngeal) reflux• Atypical (laryngopharyngeal) reflux

• VCD may masquerade as or coexist with severe asthma

41

Diagnosis of VCD

• Suggested by flow volume loops which may reveal blunting of the inspiratory loop

– Methacholine challenge

• Definitive diagnosis made by fiberoptic rhino-• Definitive diagnosis made by fiberoptic rhino-laryngoscopy which reveals paradoxical motion of the vocal cords

42

Flow Volume Loops

43

Flow Volume Loop

44

VCD

45

VCD

46

Treatment of VCD

• May respond to breathing re-training

• Diaphragmatic breathing

– Relaxation of larynx with conscious activation of the diaphragmdiaphragm

• Speech pathologist are essential for treatment and breathing training exercises for theses patients

47

Asthma and VCD

Asthma

– Responds to bronchodilators and inhaled steroids

– Night time symptoms

VCD– Fail to respond to asthma

medications

– Sensation of airflow obstruction in the upper airway– Night time symptoms

– Atopy

– Diagnosed at a young age

airway

– Symptoms in throat with choking and stridor

– Teenage

– Excercise related

48

Asthma and VCD

Questions? Questions?

49