- Speech and language therapy services for people with respiratory care needs are provided within an integrated multidisciplinary context
- All people with idiopathic or refractory chronic cough and inducible laryngeal obstruction (vocal cord dysfunction) should have access to an appropriate respiratory speech and language therapy service
- SLT services engage in evolving the respiratory SLT role, through continuous appraisal of service-provision and skill-mix
- The speech and language therapy profession has a responsibility to work towards improved clinical audit and research in the field of respiratory speech and language therapy
- Standardised training and competencies for the respiratory SLT role need to be agreed, to ensure professional integrity
Here you will find information about adult respiratory care and speech and language therapy.
The role of a respiratory speech and language therapist is emerging and becoming increasingly recognised as a legitimate speciality within the speech and language therapy profession. However, as this role is in its infancy, it is imperative that any SLT working within it adhere to current professional standards, guidelines and regulations.
It is recommended that any formalised respiratory role is included within an individual’s job description, with clear direction on roles and responsibilities, which conform and reflect current professional standards.
Please contact us if you have any suggestions or feedback on these pages.
Speech and language therapy is continually evolving, with new roles developing to fit changing needs and emerging evidence; the speech and language therapist’s role in adult respiratory care is one of these.
Transference of skills to respiratory population is evolving in the key areas of development:
- chronic cough
- inducible laryngeal obstruction
These conditions are not mutually exclusive, and often occur simultaneously.
Cough is a protective mechanism which represents the outcome of a complex reflex, initiated by activation of irritant receptors in the upper and lower airway (Farrer, Keenan and Levy, 2001). Excessive cough is the most common symptom for which patients seek medical advice (Schappert and Burt, 2006).
Patients complain of difficulty controlling coughing once an episode starts. Refractory chronic cough causes considerable physical, social and psychological morbidity (French et al., 1998). Complications of coughing occur frequently (Raj and Birring, 2007), such as:
- voice disorder
- urinary incontinence
- sleep deprivation
- relationship difficulties
- absence from work
The majority of cases of cough are due to viral upper respiratory tract infections, and usually last less than three weeks. However, many patients suffer from coughing lasting more than eight weeks in duration, defined as chronic cough.
Chronic cough may persist despite systematic evaluation and medical treatment of known triggers, often labelled as idiopathic. Currently, there are no effective, acceptable anti-tussive agents for the treatment of such patients. Pharmacological agents such as morphine and inhaled lidocaine may help a few patients, but unacceptable side effects limit their usefulness.
There is emerging evidence for the role of non-pharmacological treatment approaches and specifically speech and language therapy interventions (Gibson and Vertigan, 2009). In a recent systematic review of pharmacological and non-pharmacological interventions for cough, speech and language therapy was detailed as showing promise to successful treatment outcomes (Mollassiotis et al., 2010).
Inducible Laryngeal Obstruction (Vocal cord dysfunction)
Inducible Laryngeal Obstructuon (ILO) describes an inappropriate, transient, reversible narrowing of the larynx in response to external triggers. ILO is an important cause of a variety of respiratory symptoms (Halvorsen et al., 2017). Within this spectrum, vocal cord dysfunction (VCD) is a respiratory condition characterised by abnormal closure of the vocal cords during inspiration, expiration or both. During normal respiration, the vocal cords move away from the midline during inspiration, and slightly back towards the midline during expiration (England and Bartlett, 1982).
However, in patients with VCD, the vocal cords move paradoxically toward the midline during inspiration, or excessively so during expiration, resulting in airflow obstruction (Newman, Mason and Schmaling, 1995).
Frequently, patients complain of a tightness localised to the laryngeal area and suffer with symptoms of laryngeal tickle, pain, a choking sensation, cough and dysphonia (Newsham et al., 2002). Other symptoms include episodic, sudden onset ‘attacks’ of:
- difficulty breathing-in (and sometimes out)
- inspiratory (and sometime expiratory) wheeze and stridor
- a ‘strangled’ sensation
- globus pharyngeus sensation
Commonly associated triggers of ILO & VCD include:
- exposure to cold air/temperature changes
- inhalation of strong smells, such as perfumes or chemical cleaning agents
- cough, laughing, talking
- viral infections
- emotional stress
- food and drink (patient specific)
There is an overlap in chronic cough symptom presentation when compared with other laryngeal disorders, such as vocal cord dysfunction and hyper-functional voice disorder (Vertigan et al., 2006). However, the cause and mechanistic drivers of the conditions remain relatively unknown.
Consensus is emerging that chronic cough may be analogous to other sensory hyperalgesias where there is long-standing reduction in sensory nerve threshold to stimulation; conditions such as asthma, post-nasal drip and reflux may, therefore, act as triggers of a hyper-responsive cough reflex. The true aetiology of ILO is currently both under investigated and disputed.
Vulnerability and Risk Issues
Although not exhaustive, considerations of vulnerability and risk issues for the patient include:
- Potential for:
- reduced life expectancy
- repeat hospital admissions, increased length of stay and failed discharges
- steroid toxicity, resulting in Cushingoid syndrome
- increased risk of chest infections
- increase in co-morbidities, including malnutrition and secondary chest complications
- reduced quality of life
- inappropriate management
(Carter Young & Durant-Jones 1990, Odderson, Keaton and McKenna, 1995; McClave et al., 2002; Raj and Birring, 2007; Anderson and Coles 2013).
For an organisation not considering and providing a respiratory SLT service, the risks include:
- Increase in costs for primary and secondary care due to misdiagnosis and management;
- Increase in waiting times, hospital stays and failed discharges.
The Role of Speech and Language Therapy
Speech and language therapists are specialists in the assessment, diagnosis and treatment of upper-airway disorders. These include inducible laryngeal obstruction (e.g. vocal cord dysfunction), chronic cough and heightened laryngeal sensitivity. Specialised speech and language therapy has been proved to be beneficial for people with these conditions.
The aim of the treatment is to increase awareness of cough-control and reduce the irritation that triggers coughing. Therapy sessions include giving techniques to voluntarily control cough and reducing irritations in the throat.
It is vital therapy does not commence until a patient has been seen and diagnosed with a chronic cough by a respiratory physician.
Inducible Laryngeal Obstruction (Vocal cord dysfunction)
Speech and language therapy is the cornerstone for Inducible laryngeal Obstruction (ILO) management and treatment (Altman et al., 2000). A speech and language therapist’s skill mix enables a positive and insightful contribution to the entire ILO management pathway, and consequently they are acknowledged as a key member of the treating MDT.
Therapy programmes support preventing, controlling and reducing upper-airway breathing attacks. Therapy exercises include emergency breathing techniques, upper-airway control exercises and reducing airway irritation.
The potential irregularity and inconsistency of ILO attacks mean that a detailed case history is essential to diagnosis, and getting a clear description of symptoms from the patient is key. It is imperative this is done jointly with respiratory physicians, to ensure any medical co-morbidities are managed appropriately.
Therapy teaches patients to relax the upper airway and control the laryngeal area, utilising techniques commonly used in voice therapy. The emphasis should be on readily identifying and reducing excessive tension associated with respiration, during a variety of activities, and in a variety of settings.
By learning to detect increased tension, the patient can implement easier breathing behaviours, before an acute ILO attack occurs. This empowers a patient to gain laryngeal airway control.
Accountability and robust outcome measures are essential to attribute change in patient symptoms to effective speech and language therapy intervention. The VCDQ (Fowler et al., 2015) is a newly-validated and responsive questionnaire which can support this.
Management of Chronic Cough
Chronic cough may persist despite systematic evaluation and medical treatment of known triggers, often labelled as idiopathic. Currently, there are no effective, acceptable anti-tussive agents for the treatment of such patients. Pharmacological agents such as morphine and inhaled lidocaine may help a few patients, but unacceptable side-effects limit their usefulness.
Nonetheless, there is emerging evidence for the role of non-pharmacological treatment approaches, and specifically speech and language therapy interventions (Gibson and Vertigan, 2009). In a recent systematic review of pharmacological and nonpharmacological interventions for cough, speech and language therapy was detailed as showing promise to successful treatment outcomes (Mollassiotis et al., 2010).
The review concluded that higher-quality research designs, with cough being the primary outcome, were imperative to improve the evidence for cough management.
How speech and language therapy benefits idiopathic chronic cough
There is an overlap in CC symptom presentation when compared with other laryngeal disorders such as hyper-functional voice disorder (Vertigan et al., 2006) and VCD. SLTs routinely treat these comparable groups in everyday clinical settings.
However, in the UK, speech and language therapy within the CC population is limited, despite the current literature detailing interventions, which have been derived from adaptations of established speech and language therapy skills (Gibson and Vertigan, 2009). Vertigan et al.’s (2006) landmark study described the SPEICH-C treatment programme, based upon everyday clinical speech and language therapy methods applied to the CC population.
The components of the successful treatment programme included:
- education about the cough
- psycho-educational counselling;
- strategies to control cough; and
- upper airway health training to reduce laryngeal irritation.
In a parallel group randomised controlled trial, SPEICH-C improved symptom frequency and severity ratings for breathing, cough, voice, upper airway and overall symptom limitation in refractory CC compared with a sham treatment.
Suppressing cough in a patient where it is functionally beneficial (e.g. in bronchiectasis) could potentially have adverse consequences. Therefore, it is important to note that speech and language therapy should only be commenced as a treatment option following a full respiratory medical work up, as defined by the British Thoracic Society recommendation for the management of CC (Morice, McGarvey and Pavord, 2006) and within a multidisciplinary setting.
Management of Inducible Laryngeal Obstruction (Vocal Cord dysfunction)
The potential irregularity and inconsistency of ILO attacks mean that a detailed case history is essential to diagnosing the condition. Visualising the paradoxical movement of the vocal cords with nasendoscopy is recommended as the gold standard (Morris and Christopher, 2010). SLTs using this tool should follow RCSLT guidelines (Nasendoscopy PP). Pulmonary function tests and oxygen status are supplementary diagnostic tools.
Getting a clear description of symptoms from the patient is a key to diagnosis. When a patient describes difficulty breathing-in, with restriction at the throat level, further investigation is warranted. VCD frequently mimics asthma presentation because of the episodic restricted airflow and respiratory sounds. Often a diagnosis of VCD is made after treatment for asthma stretching over a period of a few years has been unsuccessful.
As VCD frequently co-exists with asthma (Ayres and Mansur, 2011), diagnosis can be challenging, and patients must be taught how to differentiate between the two conditions. In view of the multiple medical conditions that can co-exist with VCD, patients must undergo assessment by a specialist respiratory physician in order to ensure that these are either excluded, or adequately treated before VCD-specific therapy is commenced.
The classic finding for VCD is inspiratory vocal cord adduction of the anterior two-thirds of the vocal cords with a posterior diamond shaped chink (Christopher et al., 1983). However, abnormal adduction of the true and false vocal cords on both inspiration and expiration is recognised (Echternach et al., 2008). It is now suggested that greater than 50% inspiratory closure of the vocal cords is sufficient for diagnosis (Morris and Christopher, 2010).
During laryngoscopy, the laryngeal vestibule is visualised at rest, whilst deep breathing and during phonation. If the patient is asymptomatic, they are challenged with environmental or physical triggers in an attempt to elicit an ILO attack. Stress or provocation testing should only be carried out in a multi-disciplinary setting with medical support, in case of complications or adverse reactions. Assessment when asymptomatic usually shows normal laryngeal function and does not exclude diagnosis (Pargeter, Stonehewer and Mansur, 2011).
In summary, specifically the change in laryngeal features from baseline to maximal point of obstruction should be described, whether the obstruction to airflow is glottic or supraglottic and whether it is during inspiration or expiration. (ref ELS statement (ref : ILO official joint statement, ERS/ELS statement, 2017 Eur Respir J 2017; 50:1602221)).
Pulmonary function tests and emerging diagnostic tools
Flow-volume loops may show inspiratory loop truncation representing extra-thoracic airflow obstruction. However, lung function is frequently poorly tolerated and non-reproducible in patients with ILO. Normal flow-volume loops are not sensitive enough to exclude diagnosis (Ruppel, 2009) and should not influence the decision to perform nasendoscopy (Watson et al., 2009). Likewise, inspiratory airflow limitation is often seen due simply to poor technique or posture.
There are some emerging experimental tests including impulse oscillometry, which can discriminate between central versus peripheral airway obstruction, and may be more sensitive than spirometry (Hira and Singh, 2009). Airway fluoroscopy, plethysmography (measuring functional residual capacity, total lung capacity and airway resistance) and colour Doppler ultrasound imaging of vocal cord movement are non-invasive tools that have not been standardised against nasendoscopy.
With MDT involvement, ILO is often well managed such that patients become asymptomatic. Recommended MDT personnel include an SLT, respiratory physician, respiratory physiotherapist, clinical psychologist and an otolaryngologist. At times, ILO will reoccur, but with taught techniques, patients have a better understanding of the reasons for their symptoms and feel more in control.
Sniffing and panting manoeuvres can abort acute attacks, by inducing vocal cord abduction. Heliox gas mixture can alleviate symptoms by enhancing upper airway laminar air flow and reducing dyspnoea feeling (Weir, 2002).
Critical to successful long-term ILO management is patient education. Video or photographic demonstration of the cause of a patient’s symptoms enables proper understanding and allows patient engagement with therapy. Identifying specific triggers and how to avoid them; techniques to prevent, control and resolve attacks as they occur form the mainstay of treatment.
This is usually led by a specialised SLT (Pargeter and Mansur, 2006), working in close cooperation with respiratory physician, otolaryngologist, physiotherapist and clinical psychologist. (Clinical psychology intervention is often indicated and includes management of stress and anxiety, psycho-behavioural therapy and coping strategies. Physiotherapy is often required for patients with ILO, as a high proportion of these patients also reveal a dysfunctional breathing pattern (Pargeter, Stonehewer and Mansur, 2011)).
How speech and language therapy benefits vocal cord dysfunction
Speech and language therapy has been identified as the cornerstone for VCD management and treatment (Altman et al., 2000). An SLT’s skill mix enables a positive and insightful contribution to the entire ILO management pathway. Consequently, s/he is acknowledged as a key member of the treating MDT.
Often, SLTs lead laryngoscopy examinations and are instrumental in resolving acute attacks when a patient becomes severely symptomatic. However, it is noted that this is a group of patients that could have morbidity in the outpatient clinic and thus medical personnel must be physically present and resuscitation equipment at hand.
Speech and language therapy teaches patients to relax the upper airway and control the laryngeal area utilising techniques commonly used in voice therapy. Ultimately, the emphasis should be on readily identifying and reducing excessive tension associated with respiration, during a variety of activities and in a variety of settings. By learning to detect increased tension, the patient can implement easier breathing behaviours before an acute ILO attack occurs. Accountability and robust outcome measures are essential to attribute change in patient symptoms to effective speech and language therapy intervention, the VCD (Fowler et al., 2015) is a newly-validated and responsive questionnaire which can support this.
Here you will find relevant national guidance relating to this topic area.
Please contact us if you have any suggestions.
NICE Guideline (2010) CG101: Chronic obstructive pulmonary disease in over 16s: diagnosis and management
NICE Guideline (2011) CG121: Lung cancer: diagnosis and management
NICE Guideline (2014) CG191: Pneumonia in adults: diagnosis and management
Key contacts for respiratory care
For more resources see Learning
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