And now for something completely different. It’s: Laryngospasm

  • Laryngospasm

Laryngospasm & You: Enquiring Minds & Inspiring Throats Want to Know

So…as most of my Facebook buddies know…I recently had what I perceived to be a near-death experience due to something called laryngospasm (don’t bother Googling, I’ll explain all in a minute or two) caused by a combination of a bad upper respiratory infection and GERD (gastroesophageal reflux disease…no worries, I’ll touch on that too).

As it turns out, I had little chance of dying at that moment, but try convincing ME at the time! When your airway is pretty sealed shut there’s this natural tendency to think the worst of the situation and that your next raspy breath might be your last. This tendency extends even to those with a medical background and can lead to profound panic.

Panic=bad. So this Public Service Announcement should hopefully serve to quell the panic and give you, dear reader, handy tools to eject yourself from the vortex of fear and transport magically to a peaceful meadow where you will breathe deeply of my fragrant floral bouquet of tranquility, mixed metaphors and run-on sentences. Let’s begin.

Ahem. I’d like you all to join me in a little demonstration. It’ll be very instructive and not the least bit painful…and as all of us on the other side of 40 know, most of life’s significant lessons come with some measure of pain…so this is a bonus.

First, purse your lips up like you are about to give a smooshie kiss to a pudgy baby. Next, take your favorite index finger (preferably one on your hand, but any index finger will work I suppose) and gently place it against your lips. If you are sitting in a Starbucks or other public place while doing this, no worries: just raise your eyebrows up (if Botoxed, use your other hand to raise them) and people will just think that you are reading something especially fascinating…which of course you are!

Anyway, with finger gently placed on pursed lips, try to take in a deep breath. A bit of air should be trickling past but not much. After a few seconds there’ll be this natural urge to want to breathe in faster. Don’t resist…but what you will instantly find is that extra effort only makes breathing in that much more difficult. Keep doing that for a few more seconds until it feels annoying enough for you to want to end this nonsense and go back to breathing normally. Public readers, at this point remove finger from lips, tap it against your cheek and loudly whisper “how insightful!”…I’m pretty sure onlookers will see you as an uninhibited intellectual, not a pursed-lip meshugannah.

The feel of laryngospasm is kinda like that. Except the finger is on your vocal cords and you feel powerless to ever remove it. Imagine waterboarding without the water…and half the fun.

So…What is Laryngospasm? Why does it happen? Who gets it? What can be done to prevent it? Can the effects be lessened? Is there a cure?

My, my…so many questions from someone who, pre-finger-experiment, was just reading this to either be polite or procrastinate. No matter, the answers are coming up [cue ominous kettledrumroll]
Nowadays whenever doctors want to get some quick answers, we go straight to our favorite medical textbook…and by medical textbook I mean we Google it like the rest of y’all…but we do so before you did. Add white coat, slow condescending tone in lower vocal range, $200,000 in tuition debt and presto: Doctor. I kid, but try this one: ask your doctor a particularly tough question. If they hurriedly excuse themselves from the room and return a few minutes later with a well-articulated answer they either had to pee or had to Google. Maybe sometimes both. TMI.

Let’s tackle the questions one at a time.

1. What is Laryngospasm?
Laryngospasm is an involuntary contraction of the muscles that serve to close up your vocal cords. Think of one of those awful cramps that suddenly makes your toes seize up and painfully curl towards the sky when you least expect it. Ordinarily the vocal cords need to tighten and loosen so we can speak or sing or shriek horrifically at our two-year-old not to write on her face with a red Sharpie marker.

Here’s a few demonstrations of vocal cords in action:

or freakier still: (turn the volume down a bit before clicking or the estimation of you in your fellow Starbucks’ patrons heads will rapidly shift back toward “meshugginah”)

Now here’s a quick demonstration of laryngospasm:

 

Notice how there’s minimal space between the vocal cords. That desperate, raspy sound you hear is called “stridor”. You may have heard it when your little kid had croup in between their barking coughs… or when you try to breathe in after laughing too hard and too long. That sound you hear is turbulent flow past vocal cords. Turbulence, anywhere it happens, always spells a choppy ride’s ahead. Like on a plane, these episodes of turbulence can last a few seconds to a minute or more…and can rarely follow one after another. But during laryngospasm those are the longest seconds of your life. Trust me.

2. Why does laryngospasm happen?

Whether your question stems from wanting to know the physiologic mechanism behind it…or you’re one of those beret-wearing bohemians yearning for some teleological rationalization for what useful purpose we were built with a reflex that makes us feel like we’re choking to death…no worries, science has an answer for both!

Teleology first…the reflux makes sense for the sole purpose of a situation where we are about to drown and we’d be better off not breathing at all for some short while instead of breathing in water and rapidly flooding our lungs. Understanding that it’s just a temporary reflex goes a long way to reducing the panic during episodes. More on that later.

As for the mechanism of why it happens…and speaking of airplanes and turbulence…lets talk about Bernoulli’s Principle. Daniel Bernoulli was a mathematician from the 1700’s who figured out that the faster the flow in an area, the lower the pressure. This is awesome for airplanes as it’s what keeps the wings lifted up in the air…providing the planes actually leave the tarmac where you’ve been sitting for an hour waiting for take-off…smelling other people’s unshod feet and listening to the drunk douche in front of you talking loudly on his phone.

It is NOT awesome for the vocal cords during laryngospasm. “Curse you Daniel Bernoulli!” you’d say if you were capable of phonating anything other than a pitiful guttural “skweek!”. With your vocal cords held close together, creating faster air movement flowing past them by desperately trying to take in rapid breaths only serves to increase the speed of flow moving past…this faster flow drops the pressure between the cords and literally sucks them even closer together. Sucks indeed, my friend. Sucks indeed.

3. Who gets laryngospasm?

Now that we know that it’s a reflex, it’s just a matter of thinking of things that can trigger the reflex to occur. Sometimes it’s simply inhaling some water while drinking. Other times irritants (inhaled from the environment or refluxed up from the stomach) can trigger it. In many patients, previous injuries to the vocal cords and the nerves that get the muscles to contract can lead to an “itchy trigger finger” of sorts…and make the patient more apt to go into spasms.

Rarely you hear about something like this in the news…too ghastly for me to put on paper, click link at your own peril:

http://www.gossipextra.com/2012/10/09/man-dies-eat-cockroaches-florida-1899/

Moral of story: it’s just like that crazy homeless dude wearing 12 layers of clothes in the summertime who stood outside the convenience store used to say: “If you’re going to eat the cockroaches, chew thoroughly and slowly”. Moving along…

4. Can laryngospasm be prevented?

If you figure out the triggers that lead to the spasm, you can try to avoid them. Drink slowly, keep away from environmental irritants, don’t eat a lot of cucarachas, etc.

One trigger that can be mitigated is gastroesphageal reflux disease (or GERD). This is a disorder where instead of your esophagus being a one-way conduit of food and fluid down to your stomach, stuff backs up the wrong way (reflux). Ordinarily the esophagus has sphincters [pause to allow 12-year-olds, and my older brother Rob, to giggle at the word “sphincter”] that serve as one-way valves to check the wrong way flow. The lower esophageal sphincter is susceptible to becoming relaxed at inappropriate times, thus allowing acidic stomach contents to jet back up into the esophagus and potentially get to the airway and reach the vocal cords. That’s when you start to lose control of other sphincters. TMI.

So…limiting the things that lead to GERD can in turn limit the triggering of laryngospasm. This means giving up certain behaviors that patients have a tough time parting with. We’re talking things like caffeine, alcohol, chocolate, mints, citrus, fried foods, smoking. Ouch, right?

Aside from that buzz-kill…literally….there are other things we can do to decrease GERD from happening such as not eating past the early evening. Also, sleeping with the head elevated, weight loss, using medications that reduce stomach acid production are all things that have been shown to help. They aren’t sexy, but they work.

Let’s turn back to my case for a moment. I have GERD and, like many physicians, I am not always as adherent to my medication regimen and lifestyle adjustments as I should be [pauses to sip his coffee]. I do take a certain medication called a proton-pump-inhibitor that serves to decrease the production of stomach acid thereby decreasing the side effects of GERD and allowing the stomach ulcer I developed during my years in Emergency Medicine to heal. Do I take it EVERY day? I’d like to say yes. I’d especially like to say that I took it regularly in the weeks leading up to my episode…but I can’t exactly say that. If you couple that with the wicked upper respiratory infection I picked up from little Mia (of Sharpie face-painting fame)…and the airway inflammation that I typically get with such infections…I was a recipe for disaster.

How it played out was awaking coughing with some post-nasal drip only to realize that my throat wouldn’t clear and I could hardly move air past my vocal cords. Having experienced something similar previously that lasted about 5 seconds each time, I tried to work through it in a rational, calm way. After about 20 seconds anxiety crept in. And by “crept” I mean thundered to the forefront of my consciousness like giant megaOrcs out of Mordor that aimed trebuchets loaded with flaming balls of sh*% at the deepest animal-fear-centers of my brain.

What I DID do:

In the end, I did not panic too much. Rather, I thought about what quick things I could do that might decrease inflammation and move air. Fortunately, and I say that with a LOT of irony…it’s ridiculously cold in Chicagoland now. I opened the door and sat in the cold air and tried to breathe. The cold seemed to help a bit, much as it might for a croupy kid. But it wasn’t breaking the spasm. I croaked to my wife to get Mia’s nebulizer machine and tried some misty albuterol/saline. This seemed to help a bit more…but likely not for the reason I thought (more about this below). Finally after it relaxed enough for me to think a bit more, I tried adding corticosteroids…or powerful anti-inflammatory medication. Again, it was slowly getting better…hard to say if it made much difference acutely.

What I COULDA did:

Interestingly enough…very credible sources that I could find in my “medical textbook” suggested that…even when these episodes last a minute or so…they typically just break on their own. The key is less about managing spasm and more about managing panic. It means grabbing a mental Gandalf staff and telling those Orcs “YOU SHALL NOT PASS!”… albeit with a soothing, calm voice.

Easier said than done. Whenever just about ANYTHING in life is “easier said than done”, it usually means that you have to practice doing that particular thing many many many-many times until its about as natural to do it as it is to say it.

In the case of laryngospasm I found a wonderful video by Dr. Robert Bastian, MD of Loyola Medical Center’s Bastian Voice Institute. In it, he describes a very easy to learn technique called “Straw Breathing” where patients develop a pattern of slow, steady breathing by sipping breaths through a coffee straw…thus reducing the speed of flow past the cords and thereby keeping the opening between the cords as wide as possible until the episode of spasm eases. I think that was really what I was accomplishing by sipping on the nebulizer tube slowly versus trying to gasp in big fast, useless breaths. If you practice the technique enough, you can automatically shift to “Straw Breathing Mode” when an episode of spasm occurs.

Here’s the link to Dr. Bastian’s videos about laryngospasm and I recommend them highly:

There are other treatments that have been described…certain medications that try to target the spasm directly rather than the causal factors such as GERD. I’m not going to mention those here for the mere fact that I don’t know much about their efficacy/risks. And, I’m completely serious about this one…the single most important phrase for a doctor to know is “I don’t know” (IDK for short). IDK helps doctors adhere to the primary dictum in medicine: First Do No Harm (primum non nocere). IDK has a cousin: I DID know it at some point in my career, but like muscles, memory is a use-it-or-lose it type of deal and now I better look it up!

And THAT is what this endeavor was about. It’s about re-educating myself to be able to educate others to ultimately somehow make a difference. You may have watched that previous link I posted with a video about the Butterfly Effect. I’m just trying to flap my wings a bit…make some lemonade out of the lemons I got the other night.

I truly hope that this has been as fun and informative for to you to read as it was for me to research and write.

Have more questions about laryngospasm and all things throaty? Ask Dr. Bastian. I will be asking plenty during the appointment I made with him. I’m happy to share my experience with you when it’s over.

Have any questions about varicose veins and spider veins or chronic lower extremity discomfort?

THAT I can help you with! Feel free to check out the website Rosen Vein Care –
Vein Treatment Clinic in Illinois
, email me at drosen@RosenVeinCare.com or call to schedule a consulation appointment at 847-272-8346
.

Happiness, Good Health and Peace to all…and of course easy breathing!

-David Rosen,MD