Speaker's Highlight

• Don Sin University of British Columbia, St. Paul Hospital (Canada)
  Kenneth R. Chapman Toronto General Hospital Research Institute (Canada)
• Parameswaran Nair McMaster University (Canada)
  Carolyn Calfee UCSF (U.S.A.)
• Gregory P. Downey University of Colorado School of Medicine (U.S.A.)
  David A. Schwartz University of Colorado School of Medicine (U.S.A.)
• Neil Schluger Tuberculosis Control Branch, California Department of Public Health (U.S.A.)
  Nick Kim Critical Care & Sleep Medicine, University of California San Diego (U.S.A.)
• Nicola Hananiah Baylor College of Medicine (U.S.A.)
  Jae-Joon Yim Seoul National University College of Medicine (Republic of Korea)
• Koichiro Asano Tokai University School of Medicine (Japan)
  Diahn-Warng Perng Taipei Veterans General Hospital (Taiwan)
• Konstantinos Kostikas University of Ioannina (Greece)
  Karin Klooster University Medical Center Groningen (Kingdom of the Netherlands)

• Vocal Cord Dysfunction Mimicking Asthma

  Vocal cord dysfunction is a common description for abnormal vocal fold movement that narrows the upper airway during breathing. Clinicians increasingly use the term inducible laryngeal obstruction (ILO), especially when symptoms are triggered by exercise, irritants, stress, or sudden changes in breathing demand.

  Because the episodes can produce breathlessness, wheezing, chest tightness, and anxiety, they are often mistaken for bronchial asthma. The distinction matters: asthma affects the lower airways, while ILO develops at the level of the larynx. Some patients have both conditions, making careful assessment essential.

  Respiratory physicians, primary care teams, emergency clinicians, and allied healthcare professionals benefit from recognizing this pattern early. Correct identification can reduce unnecessary corticosteroid exposure, repeated emergency visits, and frustration when standard asthma treatment provides little relief.

  Recognizing The Upper-Airway Pattern

  An episode of inducible laryngeal obstruction often begins suddenly and reaches maximum intensity within minutes. The patient may describe difficulty breathing in, a tight throat, choking, voice change, or noisy inhalation called stridor. The sound is usually loudest over the neck rather than across the chest.

  Asthma more commonly causes expiratory wheeze, prolonged exhalation, cough, and chest tightness. In vocal cord dysfunction, oxygen saturation is frequently normal, and symptoms may resolve quickly when the trigger stops. A patient who repeatedly reports severe attacks with normal examinations between episodes deserves evaluation beyond routine asthma escalation.

  Why It Is Mistaken For Asthma

  Both disorders can cause shortness of breath and audible breathing, and they may occur in the same person. Exercise-induced laryngeal obstruction can appear during intense activity, while exercise-induced bronchoconstriction may develop later or persist after exertion. Timing, breathing phase, and response to medication provide useful clues.

  Common triggers include cold or dry air, strong odors, cleaning chemicals, smoke, vocal strain, emotional stress, reflux, and upper respiratory infection. A history of frequent “asthma” attacks with poor bronchodilator response, repeated normal spirometry, or abrupt recovery should prompt consideration of laryngeal obstruction.

  Patients should not be advised to stop prescribed asthma medicines without clinical guidance. When both asthma and ILO are present, each condition requires its own treatment plan, and objective testing helps prevent one diagnosis from obscuring the other.

  Confirming The Diagnosis

  Initial assessment includes a detailed symptom history, physical examination, oxygen saturation, and pulmonary function testing. Spirometry may show a flattened inspiratory limb on the flow-volume loop, suggesting variable extrathoracic airway obstruction. This finding can be absent when the patient is symptom-free, so a normal test does not exclude the condition.

  Flexible laryngoscopy performed while symptoms are present remains central to diagnosis. Exercise or other controlled provocation may be used when exertion is the main trigger. The examination can demonstrate inappropriate narrowing of the vocal folds during inspiration and help distinguish ILO from structural lesions, vocal fold paralysis, or other upper-airway disorders.

  For clinicians and researchers sharing respiratory findings, clear case definitions and objective evidence strengthen educational and scientific communication. Relevant presenters can review the abstract submission guidelines when preparing work related to asthma misdiagnosis, laryngeal obstruction, or multidisciplinary respiratory care.

  Distinguishing Clinical Features

  Feature	Inducible Laryngeal Obstruction	Bronchial Asthma
  Main difficulty	Breathing in	Breathing out
  Sound	Inspiratory stridor or throat noise	Expiratory wheeze
  Location of tightness	Throat or upper chest	Chest
  Onset	Sudden, often during a trigger	Variable, often progressive
  Episode duration	Frequently brief	May persist for hours
  Bronchodilator response	Limited or absent	Usually beneficial
  Key test	Laryngoscopy during symptoms	Spirometry with bronchodilator testing
  Common treatment	Breathing retraining and trigger control	Inhaled anti-inflammatory therapy

  This comparison is a guide rather than a substitute for assessment. Breath sounds can be difficult to characterize during distress, and patients may use the word “wheeze” for any noisy breathing. Recording the timing of symptoms in relation to exercise, exposure, and medication can make the diagnostic pattern clearer.

  Treatment And Self-Management

  The primary treatment for ILO is usually respiratory retraining led by a speech-language pathologist or another clinician experienced in laryngeal breathing disorders. Techniques may include relaxed throat breathing, nasal inhalation, controlled exhalation, posture adjustment, and strategies for interrupting an episode early.

  Management also addresses individual triggers. Treatment of rhinitis, reflux, chronic cough, or irritant exposure may reduce laryngeal sensitivity. Athletes may benefit from sport-specific breathing practice, while performers may need guidance on vocal load and technique. Psychological support can help with fear and panic during attacks, without implying that the symptoms are imaginary or purely emotional.

  A written action plan should explain the patient’s typical warning signs and the breathing techniques that have worked in training. Asthma medication remains appropriate when coexisting asthma is objectively supported, but repeated increases in inhaler therapy should be reconsidered when the clinical pattern points toward ILO.

  Urgent Assessment And Follow-Up

  Severe breathing difficulty, blue or gray lips, fainting, confusion, inability to speak, or persistent symptoms require urgent medical evaluation. Upper-airway obstruction can occasionally be serious, and clinicians must consider anaphylaxis, foreign body aspiration, infection, edema, or structural disease when the presentation is new or unusually severe.

  After an episode, follow-up should review test results, triggers, medication use, and the patient’s understanding of the diagnosis. Coordinated care between respiratory medicine, otolaryngology, speech therapy, allergy services, and primary care is valuable when symptoms are persistent or mixed.

  Useful recommendations for clinical practice include:

  • Listen for inspiratory noise over the neck and ask whether inhalation or exhalation feels harder.
  • Document the timing of symptoms during and after exercise or exposure.
  • Arrange laryngoscopy during provoked symptoms when ILO is suspected.
  • Assess for coexisting asthma rather than assuming one diagnosis excludes the other.
  • Teach individualized breathing retraining and provide a clear episode-management plan.

  Recognizing laryngeal obstruction can transform a confusing respiratory history into a manageable clinical pattern. Sharing well-documented cases and multidisciplinary approaches through respiratory medicine congresses can further improve diagnosis, treatment, and patient education.

  Richard Russell Nuffield Department of Clinical Medicine, University of Oxford (United Kingdom)
• Mona Bafadhel King’s College London (United Kingdom)
  David Jackson Guy’s and St Thomas’ Hospital, King’s College London (United Kingdom)
• James Chalmers University of Dundee (United Kingdom)
  David Price University of Aberdeen (United Kingdom)