Suddenly no more air

Laryngeal Cramp - Vocal Cord Dysfunction

It starts all of a sudden: a coughing blow, a swallowing or even when inhaling essential oils. The throat feels tight, no air gets into the lungs, as if someone is squeezing the throat shut with an iron grip. Mortal fear sets in. One struggles desperately for air, there is a rasping in the throat, the more one tries, the less one succeeds in drawing breath. The fear gets worse and worse, the feeling of suffocation increases. The heart races, you don't know what to do and you're struggling to breathe.

Then - after what seems like an eternity - the pressure in the throat eases again. The air flows slowly at first, then more steadily back into the lungs. The feeling of anxiety subsides a little. After a few minutes, the attack is over. The throat still feels raw, the heart is still pounding, you are completely exhausted and shaky inside. Above all, however, you feel extremely unsettled. What was that? Can this come back? Can I die from it?

Definition and frequency

Vocal Cord Dysfunction

The symptomatology, which is usually experienced as a maximum threat, has many names. It is called "laryngeal spasm", "laryngospasm", "laryngeal spasm", "glottic spasm", "laryngeal asthma", "hysterical croup", "Munchausen's stridor", "psychogenic stridor", "brittle asthma" or "functional laryngospasm".

More recently, the English term "vocal cord dysfunction" has gained acceptance.

Frequency

The symptomatology is little known, but it is not rare. However, there are few concrete numbers. In a study of respiratory distress in US recruits, it is said to be the cause in 15% of cases. When breathing cold air, 5% of U.S. Olympic athletes are said to have exhibited such symptomatology.

People suffering from asthma are particularly affected. About one-third of asthmatics are also said to suffer from VCD attacks. The main difference: in asthma, exhalation is unsuccessful; while in VCD, the air is mainly unable to be inhaled. At the same time, asthma sprays are ineffective in VCD.

If we assume that about 4% of all asthmatics also develop VCD, then about a quarter of a million people in Germany are affected.

The majority of those affected (about 80%) are women, as with other forms of increased sensitivity.

Trigger

External stimuli

A VCD attack is often triggered by external stimuli:

Ingestion, aspiration
Coughing
Inhalation of water (droplets)
infections, e.g. sinusitis
Inhalation of irritating substances (e.g. essential vapor inhalation for colds), perfumes, cleaning agents
After physical exertion
Inhalation of cold air
Psychological stress

Risk factors

Usually, several factors are present at the same time. For example, increased general sensitivity, lack of sleep, infections, an asthma condition and a specific trigger (cough, swallowing).

After a short time, the symptomatology is completely dominated by anxiety or panic. The affected person has the impression that he or she is on the verge of his or her own death. Accordingly, heart palpitations, sweating and trembling are typical accompanying symptoms.

The fear causes the person to gasp for air as violently as possible. However, the suction of the lungs intensifies the spasm of the vocal folds and additional swelling may occur. In short, anxiety and spasm reinforce each other.

Causes and Background

Multiple tasks of the larynx

The larynx has a variety of tasks. In addition to speaking and singing, it has an important protective function for the airways. It must close in time to protect the sensitive bronchi and lungs from fluid, food or dangerous gases. In heartburn (reflux), this protective reflex also prevents stomach acid from entering the airways.

The complete protective reflex is called "laryngospasm." It completely closes the airways. Nothing goes in, nothing goes out. Sensibly, however, it lasts only a few seconds, after which the spasm automatically releases and the air flows freely again. A life-saving device of the body!

VCD differs from "laryngospasm" primarily in the duration and completeness of the closure. VCD lasts longer (between 30 seconds to a few minutes) and at the same time a small amount of air still flows through the larynx because it is not completely closed.

While the glottis normally opens wide during inhalation to allow air to flow freely into the lungs, in VCD it closes almost completely, leaving only a small diamond-shaped gap open. Because of this misbehavior, we also speak of a "paradoxical" behavior of the vocal folds. Actually, they should open during inhalation.

VCD can be understood as an increased responsiveness of the larynx. The larynx is doing the right thing (protecting the bronchial system), but unfortunately at the wrong time, or too strongly, too soon, or in response to the wrong triggers.

Overlaps

Asthma - VCD - Reflux

There are differences between asthma and VCD. Most importantly: VCD sets in within seconds, inhalation (not exhalation) is impeded, and fortunately, attacks are shorter (seconds to a few minutes) and asthma medications are ineffective.

Common is triggering by irritants, stress, and physical exertion.

Nevertheless, sometimes bronchial asthma and VCD exist simultaneously. Then, of course, both diseases must be treated.

Reflux disease (reflux of stomach acid into the esophagus and so-called larynx) can also trigger both asthma and VCD.

Differences between asthma and VCD

Asthma vs. VCD(source)
Asthma	VCD
Lung function in interval conspicuous	Lung function in the interval inconspicuous
Hyperventilation rare	Hyperventilationfrequent
Onset and end slow	Start and end suddenly
Breath holding possible	Breath holding not possible
Nocturnal seizures frequent	Nocturnal seizures rare
Oxygen saturation decreased	Oxygen saturation normal
No lump feeling in throat	Frequent lumpy feeling in throat
Improvement on asthma medication	No improvement on asthma medication

VCD - MCS

VCD is often triggered by strong, e.g. pungent odors, but also perfume. Inhalations with strong smelling substances (e.g. essential oils) are therefore very unfavorable.

We therefore also occasionally find overlaps with odor sensitivity or MCS.

More about MCS

VCD - Hyperventilation

In recent years, we have frequently found overlap with chronic hyperventilation, which favors the tendency of smooth and striated muscles to seize and can possibly be considered one of the risk factors for VCD.

This finding is of high importance especially for the therapy and prevention of seizures.

More about hyperventilation

VCD - Swallowing fear

After one or more VCD attacks, a fear of swallowing can sometimes develop. Then eating solid and/or liquid food suddenly becomes difficult. A fear of swallowing that is difficult to overcome sets in. This is called swallowing anxiety or phagophobia.

More about phagophobia

Diagnosis

Self-test

Crucial for the diagnosis is an accurate medical history, since hardly ever a doctor will be present during a seizure.

Here are the most important questions:

Did the shortness of breath start suddenly, within a few breaths?
Was inspiration obstructed?
Was the tightness in the throat?
Was it a pronounced shortness of breath experienced as life-threatening?
Were asthma medications ineffective?
Did coughing trigger the attack?
Did everything normalize after a short time (after 2 min. at the latest)?

The more questions answered with "yes", the more likely a VCD is.

PITTSBURGH VOCAL CORD DYSFUNCTION INDEX

With only 4 questions, a questionnaire attempts to help distinguish asthma from VCD.

To the questionnaire

Supplementary examinations

In addition, pulmonary function tests and endoscopic examinations can be performed by the ENT physician, which provide further indications. (The safest examination would be during the attack, but this is poorly possible for obvious reasons).

Of course, further examination is necessary to rule out organic causes, including bronchial asthma, inflammatory changes, nerve disorders or other diseases.

Breathing disorders

Very often we find disorders of breathing. You can find information about them here.

The problem is that such changes in breathing are often unconscious. Therefore, you can do a self-test here, which will tell you if you have a respiratory disorder. You will receive an evaluation at the end of the test.

To the online test

Therapy principles

Therapy in general

As mentioned, the usual drugs (e.g. asthma medication or cortisone) are ineffective. Even sedatives do not work fast enough. Although short-term anesthesia would lead to success, it requires an emergency physician including intubation and ventilation options. Both are quite unlikely and also unnecessary.

In contrast, the first priority of all therapeutic measures is education. Despite the threatening symptoms, the symptoms are usually not dangerous! After a short time the shortness of breath subsides without consequences even without therapy. In extreme cases, unconsciousness may occur. But then, at the latest, the agonizing protective reflex is released.

The knowledge of the "harmlessness" is helpful, because so the vicious circle of (death) fear and cramping can be limited.

Basically, a distinction must be made between therapy during an attack and long-term preventive therapy.

Therapy during Attacks

Keep calm!

First rule in a seizure: stay calm! Of course, that's easy to say. Who wouldn't get scared when the air suddenly stops? But the calmer the person remains, the more they manage to remember previous successes, the less they panic, the faster a seizure passes.

Breathing technique

In addition, suitable breathing techniques are helpful during an attack.

Yawning inhalation: yawning with the mouth closed and inhaling through the nose at the same time.
Lips brake: Especially if exhalation is also obstructed, one should try to blow out the air against the slightly closed lips. It is also worth trying to suck in the air against the slightly closed lips. This should produce a clearly audible flow sound.
Control coughing: Coughing can trigger or exacerbate VCD. Therefore, it is important to reduce the stimulus to cough. This can be attempted by quiet breathing through the nose. Other options include panting breathing ("like a dog") or - if possible - drinking, swallowing or sucking a cough drop.
Breathing can be facilitated by a suitable sitting position with the arms propped up on a table or in the so-called coachman's seat, in which the bent forearms are supported on the thighs.

Of course, these breathing techniques must be practiced outside of the seizures so that they are then available.

Overpressure

By increasing the air pressure in the oral cavity, air flows more easily into the lungs. This is done, for example, by a commercially available CPAP ("continuous positive airway pressure") device used to treat obstructive sleep apnea. It works like an "upside-down" vacuum cleaner.

As a rule, even such a device will not be within reach during an attack. In this case, the well-tried mouth-to-mouth ventilation would still be conceivable, which also increases the air pressure and thus the flow velocity.

However, mouth-to-mouth ventilation is not without its pitfalls, since the mouth is closed first and this can increase anxiety.

If a suitable partner is available (e.g., spouse), it is recommended to practice this technique a few times. - A special experience!

Heliox

Prompt and reliable help is supposed to be possible by inhaling a special breathing gas consisting of a mixture of helium and oxygen in a ratio of 80:20 (so-called "Heliox" gas). This is used, for example, when diving at great depths. It has a lower flow resistance in the airways and enables the effective supply of oxygen through the small residual gap between the vocal folds.

As pleasing as this therapy possibility is, it will hardly ever be practically applicable, since a corresponding special diving bottle will not be at hand at the right time. Moreover, our own experience with it is rather mixed.

In cases with very frequent seizures, however, it should be considered whether a small gas cylinder with heliox including a breathing mask could be useful as an emergency therapy. Such devices are otherwise used by the fire department (e.g. Dräger PAS Colt) and would have to be filled with Heliox gas by a diving club, for example.

Interval during therapy

Non-specific measures

Nonspecific (but effective) therapies include reducing anxiety, e.g., through education or targeted psychotherapy, raising the general stimulus threshold ("hardening"), sleep hygiene, exercise, dietary optimization, relaxation procedures, and through general stabilization. Ultimately, these are measures that are also indicated for other functional disorders such as fibromyalgia syndrome or irritable bowel syndrome.

All therapies aim to dampen the increased sensitivity of the automatic processes and to stabilize the autonomic nervous system.

Specific measures

Specific therapies attempt to act specifically on the larynx and the surrounding tissue. Of course, any anatomical changes or diseases of the larynx (e.g., inflammations) that may be present must be treated in the first place.

Then it is a matter of training the larynx. Here one makes use of the extensive experience available in the field of speech training, vocal training and respiratory therapy.

Depending on personal preference, one will choose one or another form of therapy, although I myself have a great preference for vocal training, as it is associated with the greatest pleasure. This also applies to so-called unmusical contemporaries or those who sing at most in the bathtub.

VCD and CO2

Very often - in fact, almost always - we find a decrease in blood CO2 levels (respiratory hypocapnia) and signs of chronic hyperventilation in VCD. The diagnosis is easy to perform with appropriate measuring devices. In these cases, we also focus therapeutic measures on raising the level of carbon dioxide in the blood, which is possible through targeted breathing and relaxation exercises.

If this succeeds, the general tendency to cramp is reduced and thus this breathing training appears to be very suitable as a suitable preventive measure.

This can also be done at home with our apps.

Online apps

Suddenly no more air

Laryngeal Cramp - Vocal Cord Dysfunction

Definition and frequency

Vocal Cord Dysfunction

Frequency

Trigger

External stimuli

Risk factors

Causes and Background

Multiple tasks of the larynx

Overlaps

Asthma - VCD - Reflux

Differences between asthma and VCD

VCD - MCS

VCD - Hyperventilation

VCD - Swallowing fear

Diagnosis

Self-test

PITTSBURGH VOCAL CORD DYSFUNCTION INDEX

Supplementary examinations

Breathing disorders

Therapy principles

Therapy in general

Therapy during Attacks

Keep calm!

Breathing technique

Overpressure

Heliox

Interval during therapy

Non-specific measures

Specific measures

VCD and CO2

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