Don’t be fooled by this asthma mimicker.

In the fall of 2020, Michael Crane*, a 21-year-old man with a history of asthma and environmental allergies, becomes ill with the coronavirus. Before this illness, he managed his asthma well with corticosteroid inhalers. After the viral infection, he appears to have an asthma exacerbation, which leads to a prolonged period of distress, marked by persistent stridor upon inhalation and an increased reliance on medications. Mr. Crane’s provider increases his medication regimen to the maximum dosage of multiple bronchodilators and corticosteroid inhalers and monthly omalizumab, an anti-inflammatory immunoglobulin E injection. On this medication regimen, Mr. Crane continues struggling to breathe upon inhalation.

Despite various medical examinations with pulmonologists, including multiple chest X-rays and pulmonary function tests, which yield normal results, no conclusive explanations are discovered. Only after a referral to an ear, nose, and throat specialist in the spring of 2023 does anyone explore the possibility of vocal cord dysfunction. This specialist recommends that Mr. Crane see a speech therapist who specializes in vocal cord dysfunction. After just one session of inspiratory muscle strength training exercises with the therapist, Mr. Crane experiences marked improvement.

Eventually, he regains the ability to breathe effortlessly and his provider discontinues the asthma medication regimen. With the correct diagnosis and targeted therapy, Mr. Crane has the opportunity to lead a healthier, symptom-free life.

Asthma vs vocal cord dysfunction

Understanding the pathophysiology of vocal cord dysfunction and its differences with asthma can aid accurate diagnoses, effective treatment, and patient well-being. Providers should consider vocal cord dysfunction (also called paradoxical vocal fold dysfunction) when patients exhibit signs and symptoms that resemble refractory asthma.

Vocal cord dysfunction arises when the vocal cords constrict during inhalation, causing airway obstruction at the laryngeal level. Its manifestations frequently mimic the signs and symptoms of asthma, including dyspnea, coughing, choking, dysphonia, throat tightness, and wheezing.

The fundamental distinction between vocal cord dysfunction and asthma lies in the timing of respiratory distress. Vocal cord dysfunction causes difficulty during inhalation, sometimes accompanied by an audible inhale or stridor; asthma typically causes expiratory challenges and wheezing. Some patients experience both conditions, which can complicate the clinical picture and requires a comprehensive evaluation for accurate diagnosis and treatment.

Triggers

An array of triggers and factors influence vocal cord dysfunction. Understanding the factors that can induce or exacerbate the condition can help both healthcare professionals and patients.

Respiratory tract infections, including viral infections like the coronavirus, can trigger vocal cord dysfunction. These infections can lead to increased respiratory distress, which may exacerbate the abnormal closure of the vocal cords.

Physical activity and exercise also can serve as triggers. Intense physical exertion can cause the paradoxical closure of the vocal cords, resulting in symptoms such as stridor and difficulty breathing.

Other triggers encompass a range of factors. Croup, a childhood respiratory condition characterized by a barking cough and stridor, can induce vocal cord dysfunction episodes. In some cases, gastroesophageal reflux disease con-

­tributes to laryngeal edema and the irritation of the vocal cords, leading to their dysfunction. Postnasal drip, frequently associated with allergies or sinus issues, also may exacerbate symptoms.

Environmental or chemical irritants, whether in occupational settings or daily life, can irritate the airways and contribute to vocal cord issues. In addition, postoperative vocal cord injuries, particularly after surgeries involving the throat or airway (including prolonged or complicated intubation), can lead to temporary or even persistent vocal cord dysfunction.

Various psychiatric conditions, such as anxiety and panic disorders, sometimes play a role in inducing or exacerbating vocal cord dysfunction. Emotional stress and anxiety can lead to heightened muscle tension, including those surrounding the vocal cords, which may trigger episodes of abnormal vocal cord closure.

Treatment

Speech therapy serves as the gold standard treatment for vocal cord dysfunction. This comprehensive approach equips patients with the necessary skills to regain control over their breathing patterns and vocal cord function. Speech therapists teach essential skills—such as low abdominal breathing, biofeedback exercises, and rescue breathing—to empower patients in improving their respiratory health. This holistic treatment not only facilitates vocal cord retraining but also provides patients with the tools needed to effectively manage stress-related triggers, ultimately enhancing their quality of life.

Low abdominal breathing

Low abdominal breathing instills new breathing patterns, which benefit patients with vocal cord dysfunction. By focusing on slow, relaxed inhalation and encouraging full chest expansion, patients learn to engage their entire diaphragm. This crucial adjustment allows the vocal cords to remain open and ensures optimal function. Through consistent repetition, this exercise fosters muscle memory, effectively preventing the undesirable contraction of the vocal cords.

Biofeedback exercises

Many patients with vocal cord dysfunction inadvertently prioritize chest and shoulder breathing during inhalation, neglecting the active engagement of the diaphragm. To address this issue, speech therapists incorporate biofeedback exercises into therapy sessions.

While lying on their backs, patients relax with a book placed on their diaphragm. They take a deep breath sufficient enough to raise the book upon inhalation and lower it during exhalation. This process encourages deeper breathing, enhances diaphragmatic expansion, and alleviates undue pressure placed on the vocal cords.

Rescue breathing

When the vocal cords constrict during an acute episode of vocal cord dysfunction, patients can initiate rescue breathing to induce relaxation. This involves taking three short, forceful inhalations and exhalations through the nose, followed by three more through the mouth. The patient can repeat this sequence for 15 to 30 seconds or until breathing improves. To maintain respiratory stability, patients should then transition to normal relaxed breathing or low abdominal breathing exercises.

Asthma and differential diagnosis

Asthma presents some unique diagnostic challenges for providers, especially in the case of children who seem to “outgrow” it. Factors associated with an apparent improvement in symptoms include changes in lung development, reduced exposure to triggers, effective treatment, or an overall decrease in the frequency and severity of asthmatic episodes. However, asthma remains an incurable condition, which involves the chronic inflammation of the airways. Even if symptoms seem to diminish or become less frequent, the underlying inflammatory process persists.

Effective asthma management involves a com­prehensive treatment plan, which includes medications, trigger avoidance, and lifestyle adjustments as well as serial pulmonary function testing. Medications such as corticosteroids reduce inflammation, which help to control the asthma, and bronchodilators, which open the airways and provide relief from acute symptoms. However, these medications don’t eliminate the root cause of asthma; they merely provide a means to control its effects.

In addition, asthma can vary significantly among individuals. Some children may experience a substantial reduction in symptoms as they grow older, while others may continue to experience asthma-related challenges throughout their lives. This understanding reinforces the importance of continued medical supervision, regular check-ups, and adherence to prescribed treatments to ensure the best possible quality of life for the patient.

Mr. Crane’s case warranted a broader differential diagnostic approach, especially given his atypical symptoms and poor response to conventional asthma treatments after the coronavirus illness. The failure to consider vocal cord dysfunction as a potential diagnosis had far-reaching implications for Mr. Crane’s health and well-being. Because he displayed symptoms of consistent stridor on inspiration alongside normal chest X-rays and pulmonary function tests, the provider should have conducted a more comprehensive and prompt evaluation to explore the possibility of vocal cord dysfunction.

Earlier consideration of vocal cord dysfunction would have spared Mr. Crane the extended use of corticosteroid inhalants, prolonged use of which carries several potential adverse effects, including detrimental effects on bones, joints, adrenal glands, the GI tract, liver, eyes, lipids, and even a patient’s growth. In addition to avoiding these potential side effects, preventing unnecessary corticosteroid therapy also alleviates the patient’s economic burden and stress. Considering vocal cord dysfunction as a differential diagnosis also would have avoided the need for repeated chest X-rays, eliminating unnecessary radiation exposure and accompanying financial costs.

Expanding the differential diagnosis beyond the obvious can prevent the unnecessary use of medications with potential adverse effects and reduce the overall burden on both the patient and the healthcare system. This case serves as a reminder of the critical need for clinical vigilance and a comprehensive evaluation, particularly when conventional treatments yield limited or unsatisfactory results.

Transformative power

Vocal cord dysfunction and asthma, although distinct conditions, frequently present with similar and overlapping symptoms, making an accurate diagnosis critical to effective care. Timely recognition of vocal cord dysfunction and appropriate referral to specialists can significantly reduce diagnostic delay and lead to prompt, tailored treatment. Ultimately, patients can regain their quality of life and breathe effortlessly, underscoring the transformative power of accurate diagnosis and targeted interventions for respiratory health.       

*Name is fictitious.

Rachel Dedo is a nursing professional development specialist in labor and delivery/high risk obstetrics at Cleveland Clinic Hillcrest Hospital in Mayfield Heights, Ohio.

American Nurse Journal. 2025; 20(2). Doi: 10.51256/ANJ022553

References

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Mahoney J, Hew M, Vertigan A, Oates J. Treatment effectiveness for vocal cord dysfunction in adults and adolescents: A systematic review. Clin Exp Allergy. 2022;52(3):387-404. doi:10.1111/cea.14036

Malaty J, Wu V. Vocal cord dysfunction: Rapid evidence review. Am Fam Physician. 2021;104(5):471-5.

Manuszak K. How vocal cord dysfunction is different from asthma. August 27, 2020. University Hospitals. uhhospitals.org/blog/articles/2020/08/how-vocal-cord-dysfunction-is-different-from-asthma

The Ohio State University Comprehensive Cancer Center – Arthur G. James Cancer Hospital and Richard J. Solove Research Institute. Paradoxical vocal fold dysfunction (PVFD). May 4, 2023. healthsystem.osumc.edu/pteduc/docs/ParadoxicalVocalFoldDysfunctionPVFD.pdf

Keywords: vocal cord dysfunction, asthma, respiratory illness