I did a little research on inspiratory muscle training today. I found several articles suggesting that the “threshold” type is the best type.
A Primer on Inspiratory Muscle Trainers
The Threshold brand of threshold type trainer is sold online in individual units (versus the 10-packs in the medical supply catalogs the speech therapist had). Here is one place
Today was a more productive visit to the speech therapist. Monkey went in with a better attitude after I pointed out that going to 4-8 speech therapy visits and working on the things he learned there might be enough to make the problem go away forever.
She worked with him more on diaphragmatic breathing and progressive relaxation exercises. She even got him on a treadmill and had him work a bit on his running posture and breathing while jogging. He’s going to work on the breathing exercises at home, and also try running short sprints while thinking about his posture/tension. He needs to relax his shoulders and fists when running, which is not natural for him.
If he has an attack, he’s to try the relaxation and breathing methods.
She also suggested that he might want to try inspiratory muscle training. She said there were some preliminary studies suggeting that it can help, and it looks like it might be something worth doing. I found a reference to this here:
Inspiratory stridor – How do you deal with ‘asthma’ when the drugs don’t work? and
Inspiratory Muscle Training in Exercise-Induced Paradoxical Vocal Fold Motion
Inspiratory Muscle Training in Three Athletes with Exercise-Induced PVFM
She is looking into helping us buy one or obtain a sample via a couple of medical supply catalogs, but they are sold in sets of 10, so if we can’t get a sample, I may look to purchase one online. They sell IMT devices for athletes which look be simliar, and one of them is the actual device used by the authors of the first article linked above.
We’ll go back in a week.
We get to pay for this out of pocket even though it’s for a medical diagnosis. Our insurance doesn’t cover speech therapy except under very specific situations, which this doesn’t fit under. Oh well, in the long run we may save more than this on asthma meds he may be taking in vain.
I spoke to the nurse in pediatric pulmonary today. She said that while the spiriva doesn’t build up in the blood stream, it has a longer-term impact on the lungs, and should be used daily. I’m still unclear on how a medication that acts on the lungs impacts VCD.
We decided to give the Spiriva (tiotropium bromide) a try. I did find a few references to using it or other related medications in kids/teens for VCD or for exercise-induced asthma. Spiriva belongs to the class of drugs called anticholinergics. It is a once per day medication and it apparently lasts for 24 hours, but it is not a “build up in the bloodstream” kind of thing. So I’m planning to call back the pulmonologist and ask about Monkey only taking it on days when he has soccer. Due to a number of other conflicts, I don’t think Monkey will be going to any soccer practices or games until his away game this Sunday. He’s going away on a school trip for a few days next week, and I think I’d rather not have him on an unfamiliar medication at that time, so I probably won’t have him start on it until he gets back.
Here is the prescribing information for Spiriva.
I called the pulmonologist to relate the events of yesterday’s soccer game. He does not want Monkey using the albuterol inhaler that frequently. He is now saying only once every 3 hours, which is a reversal of his prior instruction: to use it as much as needed, but to report in if he needs it too frequently. If he is having attacks every 15 minutes, the albuterol is not really working, anyhow, but Monkey feels that it is the only thing that gets him past the accute “can’t breathe” stage.
He believes it is VCD. He prescribed Spiriva, which he says is a medication that works for VCD, and is very safe. But it is intended/tested for COPD, and not tested at all in children. So I’m not sure about that. He says the most important thing is to follow up with the speech therapist and do more practice with the relaxation and breathing exercises.
I think the most important thing is to get Monkey to buy into the possibility that this is VCD and that he needs to master these exercises to deal with it. We may need to see a different speech therapist too, because this one didn’t seem to be teaching exercises for him to practice, or relaxation exercises, but just giving him a few strategies to try when he has an attack. I also think we may need to find an athletic trainer to teach Monkey how to run properly. The speech therapist said that running with tight shoulders and clenched fists could trigger an attack, but Monkey doesn’t know how to run any other way, and doesn’t seem to be able to fix that on his own. I don’t think just thinking about it during soccer will be enough, since there is so much else to think about during soccer. He may need to do some work on running separate from anything else.
Not a good game for Monkey. It was a hot and humid evening. Our team was missing several players, so they had no subs. They had a not-too-vigorous half-hour practice before the game.
Monkey played the first 20 minutes or so of the game, then had an attack and left the field. He tried the VCD techniques with no luck, then used his inhaler (2 puffs). He went back in after about 5 minutes. He was back out 15 minutes later. Tried the VCD techniques again, then used his inhaler again. He took a total of 3 puffs at that time. By the time he was feeling better it was halftime.
He was able to start playing again after the halftime break. But about 15 minutes later he was out again. He was pretty freaked out. I went over to the players’ side of the field at that point. He had already tried the VCD stuff and taken 1 puff of his inhaler. He was crying. He said in addition to the breathing issues, he had a headache, felt like he was dehydrated, but also had a stomach ache from drinking so much (about a quart of gatorade by that point). He needed 2 more puffs of his inhaler (total of 3) to start feeling better. I got him some ibuprofen for his headache. He felt dizzy and light-headed, and then got jittery from the inhaler. He felt another attack coming on even though he had just been sitting there. He tried humming and panting, and then just relaxing, and it backed down. About 20 minutes later he did feel better, and went in and played the last 5 minutes or so of the game.
At this point Monkey doesn’t believe it is VCD because none of the things he’s been taught to do for VCD work, and the albuterol does, at least somewhat. But it doesn’t make sense to me, and he was clearly pointing toward his throat when the attack came on while he was sitting down. I am starting to think that we are going to need a definitive diagnosis before Monkey will be able to psychologically “let” the VCD techniques work, if it even is VCD. That will involve triggering an attack, so they can see what his vocal cords are doing, but he’s not going to like that, and I’m not sure how easy it will be to trigger an attack, even on a treadmill!
About 1.25 hours into the practice, he had an attack. He felt it coming on and tried the things the speech therapist had suggested: relaxed shoulders, abdominal breathing, throat clearing, coughing, humming, etc. These did not help. He felt that the thing I had showed him with saying “sssss” on exhalation helped a bit, but not enough. The attack worsened, so he used his albuterol. This helped and he was fine for the remaining half hour of practice.
He reflected later that he did in fact run with his shoulders hunched/tight and his fists clenched. He said that he tried to unclench his fists and found himself unable to run quickly that way.
Monkey met with speech therapist who did some evaluations and gave him some things to think about for preventing attacks and some strategies to try to reverse an attack once it begins.
For prevention, she instructed him to try to run with good posture, relaxed shoulders, and unclenched fists. Monkey thought that he already did run this way, but agreed to pay special attention to it during his practice that evening.
For attacks, she instructed him to try to clear his throat, cough, or hum to trick his vocal cords out of the attack. She also instructed him to try to use abdominal breathing.
I had read that it was good to use abdominal breathing plus making a “ffffff” or “sssss” sound while exhaling, but she was not familiar with that approach.
Monkey managed to play a good chunk of the game with no attacks. This ended up being a shorter-than-usual game.
I called the pulmonologist to relate the clues I listed in another post. He agrees that we should re-consider a diagnosis of VCD. We set up an appointment for next month. In the meantime he is sending us information about VCD and speech therapists who might be able to help Monkey.
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