treat vocal cord dysfunction with ativan

Laryngoscopy images (Video 1) demonstrate increased glottic tone and paradoxical vocal cord motion, which is most prominent during inspiration, consistent with inducible laryngeal obstruction (ILO), also known as vocal cord dysfunction. There is mild upper airway erythema without clinically significant glottic edema. The most appropriate next treatment to address this patient’s respiratory distress is lorazepam (choice C is correct).

Vocal cord dysfunction was first described in a series of patients presenting with episodic wheezing and shortness of breath that had previously been diagnosed as asthma. With what is now more commonly described as ILO, these patients had paradoxical vocal fold motion with functional laryngeal obstruction as the cause of their symptoms, classically with preferential anterior vocal cord adduction during inspiration with a posterior glottic chink as seen in this case. Epidemiologic studies of ILO have noted a female predominance, with triggers that include exertion (particularly in children), irritants (such as gastroesophageal reflux and rhinosinusitis), psychiatric disorders (such as conversion or factitious disorder, anxiety, or depression), and clinically significant emotional stress. Management of an acute ILO episode is often challenging and includes reassurance, breathing exercises (pursed lip exhalation, breathing through a straw), and treatment with anxiolytic medication. CPAP and inhaled helium-oxygen mixture have also been used in patients with severe respiratory distress, although data are limited to case reports only.

The Brighton Collaboration case definition was developed to standardize reporting of adverse events associated with vaccination, and it is a very specific and relatively sensitive tool to diagnose anaphylaxis on the basis of common features of its clinical manifestation. This case definition requires sudden onset and rapid progression of symptoms involving two or more organ systems, including rash, angioedema, respiratory distress with objective findings of bronchospasm or stridor, and hypotension or shock as major criteria. Epinephrine is the treatment of choice in acute anaphylaxis (choice A is incorrect).

Episodes of bradykinin-mediated angioedema can also occur due to medications (ie, nonsteroidal anti-inflammatory drugs, angiotensin-converting enzyme inhibitors) and acquired or hereditary C1-inhibitor deficiency. Diagnosis is often made by exclusion, although C1-inhibitor deficiency is often associated with a depressed C4 level. Management of medication-induced angioedema is largely supportive, and patients with C1-inhibitor deficiency can now be treated with purified C1-inhibitor concentrate, kallikrein inhibitor ecallantide, bradykinin β2-receptor antagonist icatibant, or fresh frozen plasma if these agents are not available (choice B is incorrect).

measure C4 complement level to differentiate hereditary from ace angioedema

Systemic corticosteroids are effective to reduce upper airway edema and facilitate ventilator liberation. Other common supportive measures include elevating the head of the bed, diuresis, corticosteroids, and administration of racemic epinephrine and β-agonists. The absence of upper airway edema and clear paradoxical vocal cord findings in this setting, however, would argue against treatment with epinephrine, ecallantide, or furosemide (choice D is incorrect).12345

A 50-year-old patient is admitted to the ICU for further management of presumed anaphylaxis. The patient developed sudden onset dyspnea soon after receiving the first dose of a novel coronavirus vaccine, with progressive respiratory distress and stridor despite an epinephrine auto-injector prompting rapid sequence intubation by paramedics on arrival. The medical history includes Crohn’s disease and generalized anxiety disorder.

On arrival, the temperature is 36.9°C, heart rate is 105/min, BP is 135/68 mm Hg, and Spo2 is 99%. The patient is sedated with propofol (Richmond Agitation-Sedation Scale score, -2) and receiving volume targeted assist-control ventilation with a tidal volume of 450 mL and no evidence of spontaneous respiratory effort. Peak inspiratory and plateau pressures are 15 and 12 cm H2O, respectively. Physical examination demonstrates no visible oropharyngeal swelling or rash. Breath sounds are mildly diminished in the bases without wheezing, and there is no edema.

The patient is treated with methylprednisolone, diphenhydramine, famotidine, and albuterol. Initial laboratory evaluation results are normal except for a mild leukocytosis with left shift, and the tryptase level is pending. A chest radiograph is normal. After a period of observation, the patient undergoes an uneventful spontaneous awakening and breathing trial and undergoes extubation after a normal cuff leak test. Soon after, the patient develops abrupt, recurrent respiratory distress and prominent stridor. Emergent bedside laryngoscopy is performed (Video 1). 

What is the most appropriate treatment at this time?

Footnotes

  1. SEEK Questionnaires ↩

  2. de Silva D, Singh C, Muraro A, et al; European Academy of Allergy and Clinical Immunology Food Allergy and Anaphylaxis Guidelines Group. Diagnosing, managing and preventing anaphylaxis: systematic review. Allergy. 2021;76(5):1493-1506. PubMed ↩

  3. Girard TD, Alhazzani W, Kress JP, et al; ATS/CHEST Ad Hoc Committee on Liberation from Mechanical Ventilation in Adults. An official American Thoracic Society/American College of Chest Physicians clinical practice guideline: liberation from mechanical ventilation in critically ill adults. Rehabilitation protocols, ventilator liberation protocols, and cuff leak tests. Am J Respir Crit Care Med. 2017;195(1):120-133. PubMed ↩

  4. Halvorsen T, Walsted ES, Bucca C, et al. Inducible laryngeal obstruction: an official joint European Respiratory Society and European Laryngological Society statement. Eur Respir J. 2017;50(3):1602221. PubMed ↩

  5. Patel G, Pongracic JA. Hereditary and acquired angioedema. Allergy Asthma Proc. 2019;40(6):441-445. PubMed ↩