诱导喉梗阻/声带功能障碍及其在难治性哮喘中起作用的作用

Jorge Villalpando，Jay I Peters *和Sandra G Adams

UT Health San Antonio and the South Texas Veterans Health Care System, San Antonio, TX, USA

*通讯地址：Jay I Peters，UT Health San Antonio和South Texas退伍军人医疗保健系统，圣安东尼奥，德克萨斯州，美国电子邮件：Peters@uthscsa.edu

日期：提交：2017年8月1日;得到正式认可的：22 August 2017;Published:23 August 2017

如何引用本文：Villalpando J，Peters Ji，Adams SG。诱导喉梗阻/声带功能障碍及其在难治性哮喘中起作用的作用。拱哮喘过敏免疫素。2017年;1：036-039。DOI：10.29328/journal.haard.1001005

版权许可证：©2017 Villalpando J，et al。这是在Creative必威体育西汉姆联 Commons归因许可下分发的开放式访问文章，其允许在任何介质中不受限制使用，分发和再现，只要原始工作被正确引用。

慢性哮喘占大量of unscheduled office and emergency department (ED) visits. According to the latest World Health Organization statistics, asthma worldwide affects 300 million individuals and creates a substantial health burden by restricting the patient’s lifetime activities. Data estimate that asthma causes a loss of disability-adjusted life years over 150,000/year [1]. While most individuals with asthma can be controlled with current therapies, 5-10% of patients have difficult-to-control/refractory asthma. Severe or refractory asthma places a significant burden on the patient and often requires treatment with systemic glucocorticoids, which have significant side effects. The American Thoracic Society and the European Respiratory Society define refractory asthma as asthma that requires treatment with high-dose inhaled corticosteroids (ICS) plus a second controller and/or systemic corticosteroids to prevent it from becoming ‘‘uncontrolled’’ or asthma that remains ‘‘uncontrolled’’ despite this aggressive therapy. To fully meet this definition the diagnosis of asthma needs to be confirmed and comorbidities addressed as well. The above are considered major criteria for severe asthma and only one needs to be present for considering the diagnosis of refractory asthma [2]. For these reasons, clinicians must learn to identify and formulate additional diagnoses of “asthma imitators” [3]. One of the more common disorders associated with difficult-to-control asthma is vocal cord dysfunction (VCD) [4]. This disorder is known by many names, but current nomenclature endorsed by European and American societies correctly refers it as “Inducible Laryngeal Obstruction” (ILO) [5]. The following case demonstrates the importance of recognizing the clinical and spirometric features of ILO when asthma remains “refractory” to multiple therapies.

历史

29岁的女性医师被社区肺病学到了我们的医疗中心“难以控制的哮喘”。她过去的病史包括在8-10岁之间的儿童哮喘，由于呼吸困难导致夜间觉醒。在她的月经前一周，她描述了19岁的19岁岁，她在一周内描述了发作的“支气管炎和喘息”。在评估时，患者最近有一次参观（单个月前），以获得“严重的哮喘加剧”。她经常发生喘息，呼吸短促以及胸部紧绷长达2小时。在过去的八个月里，她的症状一直在变得更糟。她已知的触发器是冷空气，香水，灰尘和环境烟草烟雾（ETS）。患者是大学的竞技运动员，但由于深刻的呼吸困难，现在无法走一路楼梯。她是一生的非吸烟者，对Sulfa，阿司匹林和布洛芬过敏。她目前在适当的哮喘控制器吸入器和白三烯改性剂上进行了优化，并被认为具有难治性哮喘。

考试和调查

在体检时，她的生命体征和肺和心脏检查是不起眼的。她的前勤包括（1）一种心脏超声心动图，具有正常的左心室功能和正常的肺动脉收缩压，（2）是完全正常的负心应激试验和（3）肺功能试验（PFT）：FEV1 3.04L（98％），FEV1 / FVC 91％和DLCO 102％。基本实验室研究都是正常的：包括完整的血统计数，脑利钠肽（BNP），D-二聚体，总嗜酸性粒细胞计数和IG-E水平。胸部射线照片和高分辨率胸部CT扫描是正常的，没有明显的胸膜或实体疾病的迹象。因为她的症状显着加剧并且在施加期间严重严重，然后我们之前进行了肺活量测定了（图1）和运动后（图2）。她的练习术流量回路是正常的（图1），但后运动，她的吸气和呼气流量环是明显扁平的（图2），与严重的矛盾声带运动（PVFM）一致。患者接受了支气管镜检查，这在灵感和呼气期间持续收缩了她的声带和后部“Chink”（占她的非典型流量循环）。她的支气管肺泡灌洗（BAL）揭示了4％的嗜酸性粒细胞，她的支气管活组织检查显示了底层膜的温和增厚。

管理

The patient was referred to a speech therapist and trained to control her breathing and relax her airways. She reported marked improvement in symptoms and disease burden requiring fewer medications to control her symptoms and had no ED visits over the next 18 months.

具有难治性哮喘的患者的常见方法包括配制较广泛的差异，并评估患者的遵守药物，其环境及其吸入技术[6]。需要筛选患者的胃食管反流，鼻窦炎，鼻炎和某种加剧药物（例如，阿司匹林，非甾体抗炎药，β-阻滞剂等）进行筛选的因素[7,8]。

对哮喘的差异诊断包括阻塞性支气管炎，气道肿瘤，气管狭窄，超敏肺炎，结术，肺部栓塞和诱导喉梗阻/声带功能障碍（ILO / VCD）。ILO通常被误诊为涉及呼吸道的哮喘或过敏反应。这种误诊通常导致具有全身类固醇的不适当的疾病管理，频繁的诊所访问和患者生活质量的总体损害。ILO也可能被误诊为运动诱导的哮喘，并且可能在暴露于运动诱导的吸气刺激物后出现，并且通常与胃食管反流疾病（GERD）相关[9]。对某些临床医生可能令人惊讶的是，劳工组织可能与哮喘共存，高达32％的患者，进一步复杂化管理[10]。ILO的特征在于通常在吸气期间（85％）发生的声带的前2/3的矛盾的内膜，但也可以在到期期间，如我们患者的患者。这种声带的矛盾运动阻碍了气流，产生喘息，咳嗽，呼吸急促，以及典型的临床介绍的胸闷核算。因为ILO与吸气期间的潜在意识内容有关，因为在睡眠期间矛盾的运动很少发生。ILO患者通常抱怨喉咙紧张，语音变化，难度“空气进入”而不是空气。与不受控制的哮喘相比，攻击往往具有昼夜模式而不是夜间模式。 Episodes are often preceded by cough and fail to respond to bronchodilators [9]. On physical examination, inspiratory wheezing may be heard during the acute episode and tends not to worsen with cough. Symptoms fail to improve or even worsen rather than improve with inhalers in a subset of patients with isolated ILO, without concomitant asthma component.

Performing pre and post exercise PFTs may be helpful in diagnosing ILO showing a FEV₁out of proportion to airway resistance or an abnormal flow-volume loop. These findings support the diagnosis; however, the gold standard for diagnosing ILO is direct laryngoscopy of the vocal cords while the patient is actively symptomatic [11]. Speech therapy is the definitive long-term treatment for ILO and has been reviewed in detail [12]. It focuses on breathing exercises that train the patient to avoid or reduce paradoxical vocal cord adduction.

令人难以控制的哮喘患者应考虑诱导喉梗阻作为替代或伴随的诊断。条件可用的有效治疗，但准确的诊断是重要的，因为管理选择的不同基于患者是否具有ILO，哮喘或两者。

Learning points:

1。Severe refractory asthma can mimic a wide spectrum of respiratory diseases.

2.与难以控制的哮喘相关的常见疾病之一是诱导喉梗阻。

3.当呈现既定诊断的“哮喘”进行必要的确认试验（直接喉镜检查或支气管镜检查）。

4. In the patient has concomitant asthma, remove environmental triggers, confirm compliance, maximize anti-inflammatory therapy.

5. Consider an alternative diagnosis and directed therapy when the patient remains symptomatic despite appropriate therapy.