When It’s Not Asthma, Think Larynx

“If the asthma is under good control but they are still having these episodes, then I do think that maybe they have a PVFMD component to their breathing issue.” Dr. R. Jun LinPatients come into clinic short of breath. It hits during exercise, it looks dramatic, and they may even describe noisy breathing or the feeling that they “can’t get air in.” So we do what clinicians do: we think asthma. We try inhalers. But sometimes, no matter how many puffers are thrown at the problem, nothing changes.That’s when it may be time to look higher, to the larynx.On this episode of The Allergist, Dr. Mariam Hanna is joined by Dr. R. Jun Lin, a fellowship-trained laryngologist and chief of the Division of Laryngology at the University of Toronto, for a practical discussion of vocal cord dysfunction, inducible laryngeal obstruction, and paradoxical vocal fold motion disorder. Dr. Lin walks through how these patients present, how to distinguish laryngeal obstruction from asthma, when both may be present, and why respiratory retraining therapy is often the cornerstone of care.Key PointsVCD, ILO, EILO, and PVFMD describe the same basic problem through different specialty lenses.The key clue: trouble breathing in, not out.In teens, it often shows up during warm-up or early competition.In adults, common triggers include perfume, bleach, gasoline, cooking fumes, cold air, humidity, speaking, or laughing.Asthma and PVFMD can coexist. If asthma is controlled but symptoms persist, think larynx.Laryngoscopy is often normal in PVFMD, but helps rule out structural causes.Respiratory retraining therapy is the cornerstone of treatment.Pursed-lip breathing can reduce the severity and duration of episodes, but patients need to practise it before symptoms peak.Food triggers, urticaria, tongue swelling, or rash point away from PVFMD.Botox is a last resort, not first-line treatment.For clinicians, this episode is a reminder that not every dramatic breathing episode starts in the lower airway. When the history points to trouble getting air in, especially with poor response to inhalers, PVFMD deserves a place on the differential.Have an idea for the show or a comment, send us a text!Visit the Canadian Society of Allergy and Clinical ImmunologyFind an allergist using our helpful toolFind Dr. Hanna on X, previously Twitter, @PedsAllergyDoc or CSACI @CSACI_caThe Allergist is produced for CSACI by PodCraft Productions