Respiratory Retraining Research Articles

Long-Term Outcomes of Respiratory Retraining Therapy for Exercise-Induced Laryngeal Obstruction

ObjectiveTo assess the long-term outcomes and efficacy of respiratory retraining therapy in patients with exercise-induced laryngeal obstruction (EILO). MethodsA retrospective chart review and prospective questionnaire-based survey was conducted on 88 patients who received respiratory retraining therapy for EILO at our institution over the past 5 years Results34 patients were included in the final analysis, with a mean age at symptom onset and age at initial evaluation of 13.67 ± 2.96 and 15.12 ± 3.48, respectively. We found a statistically significant difference in the pre-treatment and post-treatment Dyspnea Indices following respiratory retraining therapy, with a mean difference of 12.03 ± 7.18 (p < 0.001). When asked about the effectiveness of respiratory retraining therapy, the majority of patients (n = 28) reported improvement (13.3% “a little”, 13.3% “somewhat better”, 53.3% (“a lot better”, and 13.3% complete resolution of symptoms. Only 2 patients (6.7%) responded that their breathing “did not get better.” The most effective therapy techniques cited by patients were abdominal breathing (n = 10), ratio breathing (n = 5), and pursed lip or “straw” breathing (n = 5). ConclusionRespiratory retraining therapy represents an effective technique in both the short-term and long-term management of EILO. This therapy remains the first line in management of EILO due to its ease of administration, non-invasive nature, and durable effect on breathing function.

Chronic Cough: Evaluation of Patients’ Motivation to Undergo Cough Suppression Therapy

Chronic cough is a persistent cough lasting greater than eight weeks. The prevalence rate is estimated to be 9% to 33% in the United States. There are several treatment modalities described in current literature including medical, surgical, and behavioral interventions. Behavioral intervention with a speech-language pathologist (SLP) includes education on laryngeal hygiene and the voluntary control of cough as well as respiratory retraining to suppress or reduce the duration of cough. Cough suppression therapy, like other behavioral therapies, requires patient motivation and commitment to participation and completion in therapy. This study was a prospective cross-sectional survey at a single academic institution. Adult patients evaluated by a laryngologist for chronic cough regardless of their primary etiology were included. Patients who were tracheostomy dependent, on oxygen therapy, had vocal fold paralysis/immobility, or had undergone previous laryngeal surgery were excluded. Patients were surveyed at the end of the initial clinic visit or at the beginning of the first cough suppression therapy session. Subjects reported their motivational factors for undergoing cough suppression therapy. The majority of patients, 21 (58.33%), identified as female, 15 patients (41.20%) identified as male, and no patients identified as transgender, nonbinary, and/or other gender. The patients in this study had a mean age of 57.75 (12.12) years. 35 patients (97.22%) were interested in cough suppression therapy. The mean presenting cough severity index (CSI) was 19.39 (10.28) with the mean cough duration of 8.69 (12.10) years. Patients primarily sought cough suppression therapy due to intrinsic factors rather than extrinsic influence. By understanding the relationship between symptomatology and patient motivation, clinicians can better counsel their patients and improve methods to assess candidacy for behavioral treatment.

Treatment effectiveness for Vocal Cord Dysfunction in adults and adolescents: A systematic review.

To determine whether treatment effectiveness can be established for a range of vocal cord dysfunction (VCD) interventions in adolescents and adults. A systematic review of the literature and risk of bias appraisal was completed using the Joanna Briggs Institute Critical Appraisal Tools. Data were qualitatively synthesized in the broad intervention groups of glottic airway and respiratory retraining, pharmacological therapies, airway device therapies and psychological therapies. Nine electronic databases, two clinical trial registries and the grey literature were searched from inception to September 2021 for articles on VCD interventions or equivalent terms. Studies were included if they were randomized controlled trials, non-randomized controlled trials, quasi-experimental pre- and post-test studies and within-subject repeated measure designs, participants were 13years or older, VCD was diagnosed using laryngoscopy or CT larynx, VCD intervention was provided and outcome measures reported on VCD symptoms. The search yielded no randomized controlled trials. There were 17 quasi-experimental studies that met the eligibility criteria, and these studies reported on glottic airway and respiratory retraining, botulinum toxin injections, inspiratory muscle strength training and amitriptyline; all were associated with VCD symptom reduction. In addition, 2 within-subject repeated measure studies reported inspiratory muscle strength training and respiratory retraining to be effective in reducing symptoms in participants with exertional VCD. The included studies were reported in full-text publications (11) and conference proceedings (8). There was a high risk of bias and low quality of evidence across all intervention areas. Glottic airway and respiratory retraining, botulinum toxin injections, low-dose amitriptyline and inspiratory muscle strength training devices have been associated with symptom reduction in adults and adolescents with vocal cord dysfunction. Limited objective data exist to support the effectiveness of these interventions, and robust controlled trials are needed in this area. Systematic Review Registration: CRD42018092274 (PROSPERO).

Treatment Updates in Postural Tachycardia Syndrome

Postural tachycardia syndrome is a common condition characterized by the presence of orthostatic intolerance in conjunction with excessive postural tachycardia. This review will focus on treatment updates in postural tachycardia syndrome and will include a discussion of rehabilitative, vasopressor, heart rate modulation, volume expansion, and immunomodulatory treatment strategies. A recent study added to existing literature the benefits of exercise retraining in postural tachycardia syndrome (POTS) patients who were able to successfully complete a 3-month exercise regimen. Another recent, novel study reported the benefits of respiratory retraining in POTS patients reporting breathlessness. The benefits of volume expansion in the treatment of POTS were strengthened by 2 recent studies, including a study demonstrating the value of oral rehydration salts in improving hemodynamic parameters in POTS patients and another prospective study demonstrating the value of IV saline infusions in POTS patients. A recent meta-analysis reviewed the efficacy of ivabradine in the treatment of POTS, while another systematic review and meta-analysis reviewed the benefits of metoprolol in the treatment of childhood and adolescent POTS. Also included in this review is that of a large clinical trial comparing propranolol and bisoprolol alone and with pyridostigmine, demonstrating efficacy of beta blockers and an absence of any clear additive benefit with pyridostigmine. A retrospective review of droxidopa in a large POTS cohort reported improvement in only 27% of POTS patients. Recent approaches to the pharmacologic and non-pharmacologic treatment of cognitive dysfunction and fatigue in POTS patients were reviewed. Finally, a retrospective series of the benefits of intravenous immunoglobulin in POTS suspected of being autoimmune is reviewed. The treatment of postural tachycardia syndrome is complex and nuanced, requiring a combination of lifestyle and pharmacologic treatments in most patients. This review provides treatment updates for this enigmatic condition.

Alternatives to Acid Suppression Treatment for Laryngopharyngeal Reflux.

Laryngopharyngeal reflux (LPR) and associated symptoms can be refractory to treatment with acid suppressing medication. We investigated the role and evidence for complementary and alternative medicine (CAM) for LPR in this systematic review. Complementary and alternative treatment was defined in this systematic review as any non-acid suppressing medication, treatment, or therapy. A literature search was performed by two authors in consultation with a medical librarian using controlled vocabulary for "complementary and alternative medicine" and "laryngopharyngeal reflux" in the databases PubMed and EMBASE, with supplemental searches with Google Scholar. Twenty articles were included in this review for the modalities: alginate, diet modification, prokinetics, respiratory retraining, voice therapy, rikkunshito (RKT), hypnotherapy, and sleep positioning. The studies were analyzed for bias based on the Cochrane criteria for RCTs and Methodological Index for non-RCT (MINORS) criteria for all other studies. For each modality a level of evidence was assigned to the current body of evidence using the GRADE approach. There is mixed evidence with a high degree of bias and heterogeneity between studies for the modalities presented in the paper. Based on this review, an anti-reflux diet is recommended for all patients and there is some low-quality evidence to support alkaline water. For patients with predominant vocal symptoms there is evidence that supports voice therapy. There is insufficient evidence to recommend prokinetics at this time. For patients with predominant globus symptoms, alginate, RKT, and relaxation strategies may be used in conjunction with acid suppressing medications for symptom relief.

Respiratory Laryngeal Dystonia: Characterization and Diagnosis of a Rare Neurogenic Disorder.

Respiratory laryngeal dystonia (RLD) is poorly understood and rarely reported in the literature. Patients have atypical laryngeal movement resulting in airway obstruction. This motion is neurogenic in nature, is constant while awake, nonepisodic, and non-trigger dependent. Given its rarity, it is often misdiagnosed for inducible laryngeal obstruction; however, it is refractory to medical and behavioral management. Although this condition has been addressed in the literature, this report is the largest case series characterizing presenting symptomology, multimodal treatment outcomes, and longitudinal course of these patients, and proposes a set of diagnostic criteria to aid in clinical identification of RLD patients. Our objectives were to characterize RLD clinically and offer diagnostic guidelines to clinicians. A prospective case series with a retrospective analysis at a tertiary referral center. A review of clinical records and videostroboscopic analysis of 16 patients treated for respiratory laryngeal dystonia from October 2005 to October 2018 was performed. Sixteen patients with respiratory laryngeal dystonia were included. The common features of this group were persistent, nonepisodic dyspnea and stridor with laryngoscopic evidence of paradoxical vocal fold motion. Our patients had no structural neurologic abnormalities. These patients typically failed respiratory retraining therapy and medical management of laryngeal irritants. In our series, 100% of patients underwent respiratory retraining therapy, 68.8% received laryngeal botulinum toxin injection, and 31.3% required tracheostomy. RLD is a rare and challenging condition. The disorder can be severely disabling, and treatment options appear limited. A multidisciplinary approach may be helpful. Some patients responded to laryngeal botulinum injection and medical management, whereas others required tracheostomy for symptom control. Laryngoscope, 2020.

A Trigger Reduction Approach to Treatment of Paradoxical Vocal Fold Motion Disorder in the Pediatric Population

Paradoxical vocal fold motion disorder (PVFMD), or induced laryngeal obstruction (ILO), is a clinical phenomenon characterized by inappropriate adduction of the true vocal folds during inspiration. The resultant episodes of acute respiratory distress marked by exercise-induced cough, inspiratory stridor, throat tightness, and shortness of breath are often misattributed to asthma despite normal pulmonary function testing results. Although the pathogenesis of the disease remains unclear, the etiology is likely multifactorial with an inflammatory, neurological, and psychiatric basis. Our trigger reduction approach, consisting of a plant-based, Mediterranean-style diet to treat laryngopharyngeal reflux and sinus toilet, aims to dampen the peripheral neuronal hyperexcitability of the laryngopharyngeal tissues that is hypothesized to contribute to this disorder. The primary objective of the present study was to assess for therapeutic efficacy by analyzing pre- and post-treatment subjective scores using four validated indices: Voice Handicap Index (VHI), Reflux Symptom Index (RSI), Dyspnea Index (DI), and Cough Severity Index (CSI). A retrospective chart review of all patients age ≤18 years seen by the senior author between 2012 and 2018 who reported laryngeal spasm (J35.5) as a presenting complaint with no underlying organic diagnosis that otherwise explained the symptom identified the study cohort. Patients were excluded if another cause of their laryngeal spasm was identified or their medical records were incomplete. Of 80 patients, 24 met the criteria. The most frequent presenting symptom was exercise-induced dyspnea (79%). Of the four measured indices, only a change in DI (P = 0.024) met statistical significance. Of 24 patients, 18 (75%) demonstrated a reduction in DI following our treatment protocol. Using reduction in DI as a continuous variable to assess response, the patient cohort experienced a 4.62 (95% confidence interval [CI]: 0.65-8.6) mean point reduction. Using the eight-point reduction (improvement) in DI as an accepted clinical response to treatment, 8 of 24 patients (33%) experienced a clinically relevant response. Changes in CSI (P = 0.059), RSI (P = 0.27), and VHI (P = 0.25) did not meet statistical significance. Of 24 patients, 8 (33%), 11 (46%), and 7 (29%) demonstrated a reduction in CSI, RSI, and VHI following our trigger reduction protocol, respectively. The patient cohort experienced a mean point reduction of 1.8 (95% CI: -0.1 to 3.7), 1.3 (95% CI: -1.1 to 3.7), and 1.3 (95% CI: -1.0 to 3.6) in CSI, RSI, and VHI, respectively. Paradoxical vocal fold motion disorder is a multifactorial disease that poses diagnostic and therapeutic challenges. Early diagnosis and treatment are critical to ensure patient safety, satisfaction, and reduction in health care costs, as mistreatment with asthma pharmacotherapy, intubation, or tracheostomy may exacerbate their dyspnea and lead to preventable hospitalizations. Our results demonstrate that a trigger reduction approach consisting of a plant-based, Mediterranean-style diet and sinus toilet alone may not achieve a clinically meaningful response in the majority of patients. However, given their favorable safety profile, our therapeutic regimen, along with respiratory retraining therapy, may provide symptom relief for selected patients who would otherwise continue to suffer.

Prospective Effects of Manual Diaphragmatic Release and Thoracic Lymphatic Pumping in Childhood Asthma.

Manual noninvasive respiratory techniques have traditionally been used to treat respiratory pathologies. The aim of this study was to analyze the effects of the diaphragmatic release technique and the thoracic lymphatic pump technique versus conventional respiratory retraining in children with asthma. Using a quasi-experimental design, 60 children with asthma were allocated to undergo the diaphragmatic release technique (n = 20), thoracic lymphatic pump technique (n = 20), or conventional respiratory retraining (n = 20) in this study. Serum immunoglobulin E levels, diaphragmatic mobility, pulmonary function, and P(A-a)O2 were assessed before and after 12 treatment sessions that were conducted over nonconsecutive days in a 4-week program. After 12 treatments, the changes in the serum immunoglobulin E level for each group was not significantly different from the other groups. Compared with conventional respiratory retraining, the diaphragmatic release technique was associated with a significant improvement in FVC (P = .001) and FEV1 (P = .002); the thoracic lymphatic pump technique showed no differences. With regard to diaphragmatic mobility, both the diaphragmatic release technique and the thoracic lymphatic pump technique yielded significantly favorable effects when compared with conventional respiratory retraining (P < .001 and P = .01, respectively). Further, no significant between-group differences were detected in terms of the P(A-a)O2 (P = .07). The thoracic lymphatic pump technique and conventional respiratory retraining approaches were helpful interventions that could be used to alleviate the symptoms of childhood asthma. Nevertheless, the diaphragmatic release technique was a potentially more effective intervention.

Exercise Induced Laryngeal Obstruction in a Collegiate Runner: A Case Report of a Novel Therapy

A 23-year-old male Division I distance runner presented with several years of exertional stridor (high-pitched inspiratory noise caused by airflow obstruction), previously diagnosed as exercised-induced laryngeal obstruction (EILO), a condition formerly known as vocal cord dysfunction and exercised-induced paradoxical vocal fold motion. Over the course of roughly 3 years, the patient had previously failed conventional and invasive respiratory therapies for EILO including respiratory retraining, inspiratory muscle training, reflux suppression, allergy suppression, amitriptyline, performance psychology, and injection of botulinum toxin to the larynx. At a referral center that specializes in the treatment of EILO, the patient's diagnosis was confirmed through the use of a new procedure called continuous laryngoscopy during exercise. He underwent three sessions of a unique procedure called therapeutic laryngoscopy during exercise (which relies on real-time laryngoscopy footage as biofeedback during exercise) and learned novel breathing techniques to address the problem. It is common to misdiagnose exercise induced respiratory problems based on patients-described symptoms alone. Athletic trainers should be able to recognize EILO cases and feel comfortable contacting and collaborating with expert providers on appropriate treatment. This case is also important in that it documents a treatment failure of laryngeal injection of botulinum toxin for EILO, something not previously reported in the literature.

The Olin EILOBI Breathing Techniques: Description and Initial Case Series of Novel Respiratory Retraining Strategies for Athletes with Exercise-Induced Laryngeal Obstruction

Exercise-induced laryngeal obstruction (EILO), the condition previously known as paradoxical vocal fold motion and vocal cord dysfunction, is characterized by inappropriate glottic or supraglottic obstruction during high-intensity exercise, causing exertional dyspnea, frequently with stridor. EILO is definitively diagnosed through upper-airway visualization during a characteristic episode. Although respiratory retraining is a primary therapy for EILO, many patients report symptom persistence despite adequate performance of traditional techniques. This report describes three novel breathing techniques for EILO, the Olin EILOBI (EILO biphasic inspiratory) breathing techniques. We include a teaching process and case series with patient-reported assessments. Following descriptions of the techniques and teaching process, we present data from a questionnaire offered to all patients who learned at least one of the techniques between September 2015 and March 2017. Subjects evaluated (1) expectation setting, (2) teaching processes, (3) their ability to implement the techniques during high-intensity exercise, and (4) perceived clinical effectiveness. Ninety-five percent of eligible patients participated, a primarily young, female, and Caucasian sample. Over 50% of subjects competed at the high school varsity level. Sixty-two percent of subjects perceived reasonable expectations, and 82% positively evaluated the teaching process. Seventy-nine percent were able to employ their technique in the high-intensity activity of choice, and 66% perceived clinical effectiveness with the techniques. The Olin EILOBI breathing techniques are novel respiratory retraining techniques for use in high-intensity exercise. Case series subjects reported reasonable expectations, a helpful teaching process, the ability to use these techniques during high-intensity exercise, and perceived clinical effectiveness.

The Fortuitous Discovery of the Olin EILOBI Breathing Techniques: A Case Study

Exercise-induced laryngeal obstruction (EILO) is the term for the condition previously named vocal cord dysfunction and paradoxical vocal fold motion. It is defined by glottic or supraglottic obstruction during periods of intense exercise. Not all patients respond to conventional therapy with speech-language pathology, behavioral health interventions, and treatment of contributing conditions. In this edition of Journal of Voice, the authors describe a novel series of respiratory retraining techniques, now called Olin EILOBI (EILO biphasic inspiratory) breathing techniques, specifically designed for athletes with EILO. This case presentation describes the discovery of one of these techniques during a session of therapeutic laryngoscopy during exercise. The patient was an adolescent with EILO who demonstrated a positive response to therapy with a variant of these techniques over a few days, having previously struggled with symptoms despite multiple sessions of conventional respiratory retraining over the course of months.

Fisioterapia em jovem gestante com sequelas pós Síndrome de Guillain-Barré: relato de caso

Aims: To describe the assessment, the prescription of physical therapy procedures, and the outcome of a young pregnant woman with Guillain-Barré syndrome.Case Description: A 20-year-old, 12-week pregnant, primiparous woman diagnosed with Guillain-Barré syndrome 6 years ago presented with gait disorders and lumbopelvic pain and sought medical care at the teaching outpatient clinic of physical therapy affiliated with UNIVATES, located in Lajeado, state of Rio Grande do Sul, Brazil. The examination revealed lower limb hypotrophy, peroneal and tibial denervation, abdominal and paravertebral muscle weakness, thoracic hyperkyphosis, lumbar hyperlordosis, anterior pelvic tilt, and loss of static and dynamic balance. After pregnancy was confirmed, the treatment focused on postural adjustments. The increase in both abdominal strength and proprioception allowed crutch walking. Lumbar hyperlordosis, measured by computed biophotogrammetry, decreased by approximately 20 degrees, comparing the beginning and the end of the same physical therapy session. After 16 weeks of physical therapy, there was increase in the muscle strength of knee extensors and hip flexors bilaterally, from an average of 3.5 and 3 to 5 and 4 degrees, respectively. The patient had an uneventful natural delivery at 37.5 weeks’ gestation, and the neonate was healthy.Conclusions: Physical therapy received by a young pregnant woman with sequelae of Guillain-Barré syndrome was effective in the modulation of muscle tone, respiratory retraining, enhancement of trunk control, improvement of static balance, reduction of postural changes, and relief of lumbopelvic pain, eventually contributing to natural delivery.

The Association Between Neck Pain and Pulmonary Function: A Systematic Review.

The aim of this study was to systematically review the evidence on respiratory function changes in patients with chronic neck pain. MEDLINE, Elsevier, ProQuest, PubMed, Scopus, Springer, and Google scholar electronic databases were explored thorough December 2015. English-language studies investigating cervical musculoskeletal and respiratory parameters in patients with chronic neck pain were included. Characteristics of the patients, sampling method and size, musculoskeletal and respiratory parameters studied, and appropriateness of the statistical tests were considered. Studies were rated based on study design and performance. Of the 68 studies reviewed, 9 observational studies met our inclusion criteria. Significant difference in maximum inspiratory and expiratory pressures were reported in patients with chronic neck pain compared to asymptomatic subjects. Some of the respiratory volumes were found to be lower in patients with chronic neck pain. Muscle strength and endurance, cervical range of motion, and psychological states were found to be significantly correlated with respiratory parameters. Lower Pco2 in patients and significant relationship between chest expansion and neck pain were also shown. Respiratory retraining was found to be effective in improving some cervical musculoskeletal and respiratory impairment. Functional pulmonary impairments accompany chronic neck pain. Based on the observed association, investigation of the effectiveness of management of CNP on respiratory function is strongly suggested.

Measuring Quality of Life in Pediatric Paradoxical Vocal Fold Motion Using the SF-36v2

Paradoxical vocal fold motion (PVFM) consists of intermittent adduction of the vocal folds during inspiration, resulting in stridor and worsened by anxiety and stress. The purpose of this study was to assess the impact of PVFM on quality of life in our pediatric patient population. This is a prospective, descriptive survey study. Thirty-nine consecutive patients (ages 12-17 years) presenting with a PVFM diagnosis for respiratory retraining sessions with speech-language pathology were recruited. Patients completed a brief demographic questionnaire and the Short Form 36, version 2, a validated tool for measuring health-related quality of life. There were 31 (79%) girls and 8 (21%) boys with a mean age of 15.5 years. Subjects reported regular participation in competitive extracurricular activities, including track or cross country (30.8%), swimming (17.9%), and cheerleading or dancing (15.4%). Of the patients in the study, 46.2% were straight-A students. On the SF-36 (population averages normalized to a score of 50), the general health of patients with PVFM was better than that of the general population (53.27); however, their physical health limited their role activities more severely (42.82). In addition, a greater proportion of the group with PVFM was at risk for first-stage depression screening when compared with the general population (28% versus 18%). We demonstrate a measurable detrimental impact of PVFM on health-related quality of life. This is consistent with previously published literature showing a preponderance of females with PVFM, most of whom are high achievers academically and athletically.

Therapeutic laryngoscopy during exercise: A novel non-surgical therapy for refractory EILO.

Exercise-induced laryngeal obstruction (EILO) may affect as many as 6% of the adolescent population, with some patients experiencing symptoms refractory to conservative interventions. This report describes therapeutic laryngoscopy during exercise, a novel, non-surgical intervention that harnesses real-time laryngoscopy video as biofeedback to control laryngeal aperture during high-intensity exercise. Additionally, we quantitate patient-reported perceptions of procedure safety, tolerability, learning value, and effectiveness. Clinical EILO patients with symptoms refractory to conventional respiratory retraining and other therapies were referred for the procedure which features laryngoscopy video as biofeedback during serial physician-guided 1-min exercise sprints. We quantify perceptions of procedure safety, tolerability, learning value, and effectiveness through questionnaires offered to all patients as well as observers of the procedure. Forty-one patients and 37 parent observers were approached for feedback; 88% of patients and 95% of observers consented to participation. Patients and observers reported perceptions of safety and tolerability (81% and 86%, respectively), learning value (78% and 91%, respectively), and effectiveness (58% and 80%, respectively) with patient age predicting some responses. Seventy-five percent of patients noted that "Since the procedure, my breathing during exercise has improved," and 85% of this group noted that therapeutic laryngoscopy during exercise was "the most important therapy leading to my breathing improvement." The procedure also provided insight into the psychological experience of patients, a domain not clinically apparent prior to the procedure. Our data support further study of therapeutic laryngoscopy during exercise as a possible intervention for patients with refractory EILO. Pediatr Pulmonol. 2017;52:813-819. © 2016 Wiley Periodicals, Inc.

Evaluation of a tablet-based instruction of breathing technique in patients with COPD

PurposeTablet computers are a convenient audio-visual aid for patient education. Teaching patients with chronic obstructive pulmonary disorder (COPD) appropriate therapeutic breathing techniques and encouraging them to practice regularly has been recognized as an effective care strategy. The purpose of this study was to evaluate the effectiveness of using a tablet computer with the Breathing Easier Support Toolkit (BEST), a supplemental software application we developed that instructs and assists COPD patients during the process of respiratory retraining. Patients and methodsFrom May 2013 to September 2014, participants were randomly assigned to an experimental group (n=36) or a control group (n=35). Correct breathing technique, practice frequency, application of breathing technique, self-efficacy, quality of life, and patient feedback on the tablet-computer education were evaluated with blinded assessments at baseline and immediate, 1-month, and 3-month follow-up assessments after training completion. Data analysis consisted of basic characteristics and outcome indicators presented in terms of descriptive statistics; inferential statistics were estimated by generalized estimating equations. ResultsThe participants were mostly male (83.1%) with an average age of 71.5 (SD=11.4). Both the experimental and control groups showed statistically significant improvement in correct breathing technique and application of breathing technique from baseline for each follow-up (p<0.001). A significantly increase in self-efficacy for the experimental group was found immediately after completing the breathing retraining program compared to the control group (p=0.045). ConclusionOur tablet computer-assisted educational aid did not provide an improvement over the traditional method for teaching breathing techniques to elderly patients with COPD. The results only showed an immediate effect on the self-efficacy of the breathing technique. The elderly did not use the tablet computer actively and the research was conducted without intervention after discharge, which may be a reason why the effect did not last. Further research to evaluate the effectiveness of such a strategy for the elderly is needed in the future.

The Role of Voice Therapy in the Treatment of Dyspnea and Dysphonia in a Patient With a Vagal Nerve Stimulation Device

Vagal nerve stimulators (VNS) are implanted to treat medically refractory epilepsy and depression. The VNS stimulates the vagus nerve in the left neck. Laryngeal side effects are common and include dysphagia, dysphonia, and dyspnea. The current case study represents a patient with severe dyspnea and dysphonia, persisting even with VNS deactivation. The case demonstrates the use of voice and respiratory retraining therapy for the treatment of VNS-induced dysphonia and dyspnea. It also highlights the importance of a multidisciplinary approach, including laryngology, neurology, and speech-language pathology, in the treatment of these challenging patients.

Laryngeal Hypersensitivity in the World Trade Center–exposed Population

Upper airway symptoms among responders to the terrorist attack on 9/11 are progressive and multifactorial. For those symptoms that are laryngeal in origin, we are using a multidisciplinary approach that includes respiratory retraining and laryngeal desensitization through a speech pathologist trained in airway disorders. Our treatment paradigm and laryngeal hypersensitivity are discussed in this essay.

Paradoxical vocal fold motion: respiratory retraining to manage long-term symptoms

Paradoxical vocal fold motion (PVFM) is a laryngeal disorder characterized by abnormal adduction of the vocal folds during respiration. It is caused by a multitude of etiologies and their interactions. In the current study, a 24-year-old female patient with a 12-year complaint of shortness of breath was diagnosed with paradoxical vocal fold motion following nasal endoscopy, spirometry testing and detailed case history analysis. She had no history or indication of laryngopharyngeal reflux or chronic cough. She performed respiratory retraining exercises three to four times daily for a period of four weeks, and continued daily exercises for two additional months as needed. After four weeks of treatment, abnormal vocal fold adduction continued to be seen on endoscopy and the patient was mildly symptomatic. One month post-treatment, there was no abnormal vocal fold adduction and the patient reported rare shortness of breath. At three months post-treatment, there was no abnormal vocal fold adduction and the patient no longer reported shortness of breath. She reported normal breathing with no symptoms one year later. The results suggest that non-pulmonary related shortness of breath treated with respiratory retraining can effectively eliminate dyspnea in patients with long term breathing difficulties caused by paradoxical vocal fold motion. Resolution may require treatment over an extended period of time.

Respiratory Retraining Therapy in Long-Term Treatment of Paradoxical Vocal Fold Dysfunction

Objectives: Paradoxical vocal fold dysfunction (PVFD) is a disorder in the larynx featuring involuntary adduction of the vocal folds during the inspiratory phase of breathing. The symptoms include acute episodes of dyspnea and bouts of coughing. To date, there is no universally acknowledged treatment for PVFD, though respiratory retraining therapy is the treatment of choice. Aims: The purpose of this work was to evaluate the results of long-term respiratory retraining therapy in cases of PVFD. Patients and Methods: We treated 20 patients with PVFD for 2 years: 10 subjects were submitted to a cycle of respiratory retraining therapy every 12 months (receiving a total of 3 cycles) while 10 were given a cycle every 3 months (for a total of 9 cycles) no matter what their clinical conditions were. Results: The results show that long-term respiratory retraining is particularly efficacious if the cycles of treatment are repeated, no matter what clinical conditions are present. In fact, when only one cycle of retraining treatment is given a year, there is initial improvement followed by progressive worsening. Conclusions: Long-term respiratory rehabilitation is effective, especially if the treatment is given at least once every 3 months.