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• W4386086822 abstract "Breathlessness is a cardinal respiratory symptom for which a clear cause can often not be easily identified.1 One important aetiology is vocal cord dysfunction/inducible laryngeal obstruction (VCD/ILO) that has been increasingly acknowledged as a cardinal but under-recognized disorder.2 Notable innovations in the field of VCD/ILO have recently occurred that include advances in diagnostic routines and multidisciplinary management and consequently traditional diagnostic and treatment pathways are currently being redefined. In this Commentary, we outline some of the key developments. Recognition of VCD/ILO phenotypes has been a key insight.3 It has made it possible for the first time to reconcile wide-ranging and often disparate descriptions of the condition by using an overall framework able to embrace variations in clinical presentation and disease characteristics. To date, four major phenotypes have been proposed3 and the platform now requires validation in large cohorts as well as studies to examine basic pathophysiology, diagnostic characteristics, and treatment responses in the individual phenotypes. A major problem that has dogged VCD/ILO has been a lack of rapid and accurate diagnostic modalities. Conventional diagnosis employs endoscopy (laryngoscopy) that has limited availability globally in health services and that requires expensive and bulky processing equipment. A recent novel approach has been to apply modern mobile phone technologies to capture laryngoscopy images directly, process images and combine high-fidelity recording that can be viewed in a clinic on a computer screen.4 Using this innovation access to laryngoscopy can potentially be greatly expanded if combined with new low-cost ‘disposable’ endoscopy equipment that is becoming increasingly available. In this context, an international Delphi study has made a key contribution to gain consensus on standardized diagnostic criteria for VCD/ILO.5 In many areas of medicine advances in diagnostic imaging have been astounding. Computerized tomography (CT) has evolved from slow acquisition of anatomical-type images to ultra-fast methods capturing movement and function, also in respiratory medicine as summarized in the Respirology Review Series on ‘Imaging’.6 Our research group has applied these developments to VCD/ILO to capture and quantify abnormal laryngeal movement that characterizes the disorder.7 Recent studies have provided more information and validated CT larynx against laryngoscopy (Figure 1) demonstrating moderate sensitivity and high specificity (>90%).8 Importantly, radiation exposure has been kept low (<1 milli Sievert) and the test can be done in any imaging facility where cardiac CT is done. This novel and exciting diagnostic advance is now ready for application in everyday clinical settings and requires investigation of its utility to streamline diagnostic and downstream management pathways as outlined below. VCD/ILO is a complex condition. It occurs intermittently and is often accompanied by other multimorbidities.9 Clinical presentations are highly variable reflecting the putative phenotypes3 and management is conducted by a variety of health professionals including respiratory physicians, ENT surgeons, speech pathologists, respiratory therapists and others. In this disease context evaluation, diagnosis and management can be optimized by the implementation of multi-disciplinary team (MDT) strategies.10, 11 Our research has demonstrated the benefits of a VCD/ILO MDT clinic in several ways. Firstly, the clinic brought together health professionals involved in patient care and demonstrated the benefits of combined face-to-face and telehealth approaches for effective triage and management during the recent pandemic.4 Secondly, the MDT provided a unified point of care for patients with suspected VCD/ILO thereby enabling comparative studies of new diagnostic modalities (CT larynx) and established methodologies (laryngoscopy).8 Finally, current treatment strategies could be tested by conducting a randomized controlled trial (RCT) in people with verified VCD/ILO of speech pathology intervention. The RCT had to be terminated prematurely but valuable lessons were learnt that will inform future trial design and implementation.12 How do these developments in VCD/ILO impact current clinical practice, is it possible to make the diagnosis more swiftly and can effective management be offered to more patients? Early use of CT larynx can yield significant improvements (Figure 2). Placing this diagnostic modality early in management pathways will enable early specific diagnosis and can potentially avert laryngoscopy in up to half of patients in whom VCD/ILO is strongly suspected. Speech pathology intervention can be offered early and leave greater capacity for health services to conduct further in-depth investigation in the remaining people. Future investigations should examine practical implementation of these streamlined pathways to verify their benefits and to examine applicability of the pathways in diverse health care settings, and in low-resource environments. In summary, our thinking about VCD/ILO is changing. The condition is not rare, it is heterogeneous in its clinical expression, diagnostic testing is advancing and management is increasingly multidisciplinary. Enhancements in our understanding and capabilities can facilitate more optimal care for patients and improved outcomes. Important research priorities have been identified and will continue to emerge as we unravel this enigmatic disorder.5 Philip Bardin is co-Editor in Chief of Respirology. There are no competing interests to disclose for the other authors." @default.
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• W4386086822 date "2023-08-23" @default.
• W4386086822 modified "2023-09-26" @default.
• W4386086822 title "A new paradigm for vocal cord dysfunction/inducible laryngeal obstruction: Swift diagnosis and streamlined management pathways" @default.
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• W4386086822 doi "https://doi.org/10.1111/resp.14574" @default.
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