Airway Corner – Vocal Cord Dysfunction

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Nurses Edition Commentary

Mizuho Spangler, DO, Lisa Chavez, RN, and Kathy Garvin, RN
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Lennard O. -

Hi people, that was really interesting. And since you had so much success with your experimental treatment and there seems to be nothing on it in the literature, I would ask you to write this up as a case report. I feel like there are so many interesting cases happening and "the literature" does not know about it.
Incidentally, someone should devise an easier system for case reports like a real data base. Do we really need peer reviewed journals for single cases?

Steve Carroll -

I had this exact same case! 50ish yo woman brought in priority 1 from EMS with presumed asthma exacerbation, sats low 90s but better on BiPAP. She was sweaty, agitated and I actually heard wheezing on exam. What I thought was weird was that she was so tachypenic but had a such a good sat on BiPAP- something didn't seem right. However, after multiple nebs, mag, and steroids I didn't think she was turning around. At some point I became aware that she had a history of anaphylaxis and had injected her self with epi at home...wait for it...3 times! (0.3mg per dose) but she had no rash and didn't have stridor. I was worried she was a crashing asthmatic so my plan was to do DSI to fully pre-oxygenate her before intubation. So I get all set up for a tube and the nurse pushes the ketamine and the patient immediately chilled out- RR of 12, 100% sats, not sweating, and not wheezing any more. Just as the nurse was pushing the ketamine the patient's husband had said "she does have vocal cord dysfunction". I let her ride the BiPAP until the ketamine wore off and she woke up totally fine- except for the dysphoria because the nurse pushed the ketamine too fast. I come to find out that she has laminated cards full of her "allergies" to include xopenex (but not albuterol) and even the "perservatives" in epi-pen (she has vials of 1:1000 epi that she uses for her "anaphylaxis"). After she woke up, she kept insisting that this was her anaphylaxis that was acting up, despite my explanations that anaphyaxlis or asthma doesn't instantly resolve with ketamine (which I am sure is now on her list of allergies). I'll drop you an email- would be happy to combine our case reports into a 2 case series.

Great segment

Steve

Darren B., M.D. -

Thanks for the feedback and another case. I will definitely entertain a case report. In the age of FOAM, podcasts, blogs and social media we may be better able to disseminate these cases outside of traditional academic venues. In fact I suspect we have reached more providers here on EM:Rap then would be likely to read a case report in most journals!

Brooks W. -

Great segment!

Perhaps it’s the area I work in, but I’ve seen a number of these patients in the ED, and I’m only a few years out from my oral boards.

There was the lady literally begging for intubation (better with benzo), the woman with “anaphylaxis” with no rash (got better with benzo), and the young male whose asthma only responded, he swore, to morphine (got better with morphine).

Personal observations:
- VCD patients have a peculiar talent to whip the anxiety level up in the ED. Forget laryngoscopy – “entrained anxiety” is the pathognomonic feature!
- If a patient reports > 5 intubations for their “asthma,” it probably isn’t asthma.
- They usually just don’t look like a patient suffering from a “real,” organic problem. Something about the way they sit, the way their chest moves, they way they act… it should strike you as inauthentic.

In much the same way that you can usually differentiate pseudoseizures from real, or conversion disorder from a true CVA, VCD patients just don’t walk and quack like a duck.

Darren B., M.D. -

Brooks, thank your for the great pearls. I totally concur. Sounds like you may have inadvertantly ended up working in a VCD "Center of Excellence" but these cases are definitely more prevalent than commonly realized - much like cannaboid hyperemesis, once you are aware you will be surprised how often you make the diagnosis. And I was speaking to one of our speech therapists last week and she told me this is one of her favorite referrals because she can usually effect a cure in 2 visits.

Paul C. -

Agree with Brooks. I have also taken care of a number of patients doing this over the years, including one teenage patient who's mother told me, "Everyone else treats him wrong. They give him nebulizers and shots and you just give him medicine (ativan) and he gets all better". There were big clues for you in this case including normal sat. and the patient's ability to talk when he needed to talk. How crazy does a patient have to be, to ask to be intubated?
I put this in the same category as conversion disorder, pseudoseizures, fibromyalgia, and other such processes.

Ramsey T. -

VCD is quite common in pediatrics, especially among high-achieving adolescent girls. There was even a special outpatient clinic for VCD at the children's hospital where I trained in residency. I agree with Brooks - these patients have a particular air about them. I love the phrase "entrained anxiety"!

Michael N. -

I wrote this is and then read the posts, wholeheartedly agree with Brooks,

I had a similar patient. 40ish female, hx of asthma, presented acutely (ie not infectious), looked like she was in major respiratory distress. Neck had tracheostomy scar. RR 50-60. Pulse ox 99%, HR 140s and all I could appreciate on exam was upper airway sounds and stridor transmitted everywhere, no rash/angioedema/wheezing so did not think it was allergic. Reviewed chart quickly turned up 2 recent ICU stays following intubation, and a long list of intubations in the past. We did nebs for no reason and then did 2mg IM Ativan because difficulty with access. Patient was literally punching herself in neck, quite forcefully I may add, begging to be intubated. IV access obtained, 1mg/kg of Ketamine and 10mg of glycopyrrolate given. Immediately dissociative and then woke up pleasant as a peach telling me she felt "weird, but better" and we discharged her 1hr later. Have to admit I thought a lot of this was supratentorial (Started acutely after fight with boyfriend), but perhaps this was a case was actually vocal cord dysfunction as she told me she had been intubated around 20 times before, glad I didn't make it 21.

Mike J., M.D. -

I too, seem to work in a VCD center of excellence! Over the last 17 years have had about 6-7 of these pts. One of the most educational was a pt who presented for the second time with profound stridor, stating he had severe asthma. He was placed on BiPap to minimal avail and in preparation for intubation, induced with Propofol. The educational portion came when his respiratory mechanics completely normalized with sedation! His flow/volume loop completely normalized. Rather than intubating him, we simply let the Propofol wear off thus clinching the dx. Not all pts are that simple however, we had another pt who was maintained on BiPap and Precedex and admitted to the ICU for observation for almost 48 hours prior to recovery. She had to be transitioned from Propofol because our institution did not allow propofol to be used other than for procedural sedation or post intubation sedation.

Erik D. -

I've had two patients over the years who actually went into negative pressure pulmonary edema from presumed VCD from inspiring forcefully against closed vocal cords.
The one I remember distinctly was a 70'ish yo female, had minor fender bender, boarded/collared by EMS. En route had onset of SOB, and arrived in respiratory distress, frothy pink sputum, clearly pulmonary edema- poor EMS crew looked shell-shocked since she looked fine when they started. I had to intubate her on arrival. Wondered if she had cardiac contusion causing CHF, but bedside echo looked ok. Just then family showed up and told me she got intubated a year before after she got upset at a funeral. She had a thyroidectomy and they injured one of her recurrent laryngeal nerves according to family. Since then she'd had episodes of VCD. We presumed the stress of the MVA/board/collar caused the VCD, and trying to inspire forcefully against closed vocal cords caused negative pressure pulmonary edema. She was better by the next day, extubated and went home.

Darren B., M.D. -

Thanks everyone for the cases. By way of caution, we just had an interesting case. Presented with stridor and really seemed to be VCD. She got better rather quickly with just reassurance and by the time I scoped her the stridor was gone. The airway looked perfect down to the level of the cords and motion was normal at that time. Since we could not see below the cords I got soft tissue neck x-rays just to be safe and there appeared to be some narrowing so we got a CT. That too appeared to show some narrowing but patient remained asymptomatic so we set her up with prompt out-patient ENT follow up. When they scoped her in the clinic she had nearly complete upper airway obstruction from idiopathic subglottic stenosis - to my knowledge she had never been intubated! Rare case but it illustrates that the diagnosis should be one of exclusion if you can't document paradoxical vocal fold movements and all patients need a good ENT exam.

Ryan R., A -

Nasal laryngoscopy was mentioned and seems like it would be a very useful tool in the ED. Does anyone know what brand and model is best for ED use?

Darren B., M.D. -

Ryan, I try to visualize the upper airway any chance I get including patients with severe pharyngitis, foreign body sensations and now suspected VCD. The nasal route is usually the easiest but oral is an option. With nasal you obviously need a flexible endoscope whereas with oral you can potentially use regular DL/VL equipment if you can achieve adequate anesthesia. For nasal I usually just spray the nose with decongestant and then place a small NPA coated with lidocaine jelly, which should be less uncomfortable than a nasal tampon, which I then remove just prior to the procedure. A spray or two of Cetacaine or Hurricaine is optional but a nice touch. In terms of scopes you have two choices, a short and small diameter nasopharyngoscope which is intended only for diagnostic looks or a larger and longer intubating scope. The former is much easier to use but does not give you the option of flexible endoscope intubations. A video screen makes it way easier to use and share the love than an old fashioned eyepiece BUT there is an awesome adaptor from Clarus that allows you to attach your smartphone and turn it into a small video display for $500, not to mention you can record or take pictures for ENT.

Neal T. -

How about aerosolized lidocaine? Helpful for harmful in VCD?

Darren B., M.D. -

I discussed this with Dr. Kraai and neither of us could think of a reason it would be harmful at non-toxic doses. However, it is not necessarily effective. Case in point occurred just today. Patient with 5 hours of post-op stridor at an outside hospital presumed to be VCD after thorough work up ruled out all other etiologies and paradoxical VC movement was noted on direct visualization. They had tried IV midazolam, nebulized lidocaine and even atomized lidocaine sprayed directly on the cords. After consultation the patient was given 1 mg/kg of ketamine and the stridor resolved!

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It is Hard to Breathe When Your Vocal Cords Don’t Work! Full episode audio for MD edition 251:25 min - 293 MB - M4AEM:RAP 2015 Février Résumé en Francais Français 60:40 min - 50 MB - MP3EM:RAP 2015 February Canadian Edition Canadian 14:10 min - 12 MB - MP3EM:RAP 2015 Febrero Resumen Español Español 95:30 min - 76 MB - MP3EM:RAP 2015 February Aussie Edition Australian 88:33 min - 81 MB - MP3EM:RAP 2015 February MP3 279 MB - ZIPEM:RAP 2015 February Summary 2 MB - PDFEM:RAP 2015 Español Febrero Summary 939 KB - PDFEM:RAP 2015 February:Board Review Answers 375 KB - PDFEM:RAP 2015 February:Board Review Questions 374 KB - PDF