Why Can’t I Breathe? Vocal Cord Dysfunction In Swimmers

Courtesy of Dr. Erin Cameron

I gasp for air. But my lungs don’t expand. The air gets caught in my throat like a punch being blocked in a fight. Instead of quiet breathing, I hear the all too familiar sound of my high-pitched, gainless attempt to inhale the precious air that my body needs.

And then again I hear the countdown, 3-2-1 GO. I push off the wall for another 25 underwater.

The reality of a swimmer with vocal cord dysfunction (VCD).

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I want to share my story with you because I have seen swimmers diagnosed with vocal cord dysfunction lose their love of the sport; they struggle to find ways to manage their physical and emotional symptoms, as I did too at times.

It is important for these swimmers who have VCD to know that they are not alone; there are strategies they can use to continue to train, perform and enjoy the sport of swimming.

I also want to share with you from a medical perspective how to recognize signs of vocal cord dysfunction and give you the appropriate vocabulary to describe your symptoms. My hope is that this information will help swimmers with undiagnosed VCD seek help from the appropriate medical professional as soon as possible and assist them in determining the appropriate diagnosis.

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My Story

It was always my goal to swim for the University of Michigan. When I first stepped on the deck at Canham Natatorium my freshman year, I felt like I was living a dream. I had amazing coaches and teammates and was swimming faster than I ever had before.

Prior to my sophomore year of college, I had never experienced breathing difficulties. My symptoms came on suddenly, without warning or just cause. My throat would tighten, I felt like I could not get air into my lungs and a high-pitched, terrifying sound occurred every time I tried to breathe in. At first, this would only occur once, maybe twice per week, during very challenging sets. But then it became more frequent, occurring during almost every main set.

The next year was full of countless doctor’s appointments spent trying to deduce what was causing my symptoms. Various treatments, including an albuterol inhaler and a high dose of the corticosteroid, Advair, were used to help decrease what appeared to be exercise-induced asthma: but nothing helped.

My practices and races suffered. My mental health suffered. As positive as I tried to remain, I couldn’t help but think, why is this happening? Why has nothing helped? Why is, whatever this is, trying to suck the joy out of the sport that I love so much?

Not only were my symptoms frightening for me, but my condition soon became an area of concern for my coaches and teammates. No one was sure how to move forward; on one occasion the potential of transferring to a volunteer assistant role for the following season was mentioned.

I was crushed.

I was in my junior year, with aspirations of captainship the following year and excitement to compete in my last year in the sport that I love so much. Suddenly, there was more on the line. I sought out additional guidance from my athletic trainer. He referred me to a pulmonologist that had experience working with elite swimmers.

With the help of my mom, a nurse, we finally determined the proper word to describe the high-pitched sound that I was making when trying to breath: stridor. This was the information the pulmonologist needed to change direction, to no longer believe that what I was experiencing was solely exercise-induced asthma. I was scheduled for a treadmill stress test, a scope was placed down my nasal passage and suddenly I could see on a video screen the answer to why I was not able to breathe.

My vocal cords were spasming shut while I was trying to breathe in; those stubborn little flaps were doing the exact opposite of what they should have been doing.

I was thrilled to have a diagnosis but frustrated to know there was no cure. There were, however, strategies that I could use to decrease the impact of these symptoms on my performance. These I gathered through a speech-language pathologist and an athletic counselor at my university. These people, as well as my own stubbornness to continue to train and compete, allowed me to complete my collegiate career. My last year of collegiate swimming was by far the most challenging, yet fulfilling of my career.

I cursed my vocal cords many times throughout my swimming career: especially during the last 100 of my 400 IM. In fact, I still curse them sometimes to this day. But I have found ways to decrease my symptoms and continue to swim, as well as perform other endurance sports regularly to this day.

Since the time that I was diagnosed, I have researched the condition extensively in an effort to better understand the causes and treatments for VCD. My hope is that by sharing this information, individuals who are experiencing VCD will have a better understanding of how to describe their symptoms and when to seek medical help.

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What is Vocal Cord Dysfunction?

“Unintentional paradoxical adduction of the vocal cords.”

Let’s break this down:

Unintentional = not done on purpose

Paradoxical = seemingly absurd or self-contradictory

Adduction = to move closer to the center of the body

Vocal Cords = two flaps of tissue that span the larynx (part of the respiratory system that air must flow through to enter or exit the body)

So “Unintentional paradoxical adduction of the vocal cords” = The closing of the flaps that usually open to allow air to flow to the lungs. It is not done on purpose and makes no sense.

As you can see, the vocal cords in the picture must be open to breathe. However, in individuals with vocal cord dysfunction, the vocal cords intermittently spasm shut and block the flow of air to the lungs. This blockage can occur during inhaling or exhaling, but most commonly occurs during inhaling. Generally, these spasms appear suddenly and resolve quickly – usually in less than 2 minutes.

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Why Does this Happen?

An overactive laryngeal reflex may be to blame. This reflex is used to protect the airway by closing the vocal cords to block passage to the airway on the other side.

But why is this reflex occurring when it should not be? The short answer is, we do not know for sure. The one thing that is clear, however, is that there are many factors that can contribute to VCD and that these factors vary from person to person.

Potential Contributing Factors

Determining the factors that provoke VCD is a complex process. Generally, there are multiple contributors at play. The guidance of a trained, medical professional will be imperative in helping to decipher the puzzle of factors that are provoking symptoms.

Below is a list of factors that may contribute to VCD.

1. Gender: Females are more likely to experience VCD
2. Airborne irritants
3. Strong odors
4. “Mold(s) Exposure”; Occupancy in Water Damaged Building
5. Swimming Pool Environment
6. High Levels of Dust
7. Acid reflux
8. Respiratory infections, post nasal drip
9. Certain foods (limited research on this)
10. Physical exertion
11. Emotional stressors/psychological conditions including anxiety, stress, depression

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How do I Recognize Vocal Cord Dysfunction?

Everyone with VCD uses different words to describe what they are experiencing. I have heard people describe their symptoms as “choking” or “feeling like air is getting stuck in their throat.” A second commonality is patients describing a high pitched noise that usually occurs when they are breathing in; this sound is also described as stridor.

A healthcare provider may use a list of questions such as the Vocal Cord Dysfunction Questionnaire (http://clok.uclan.ac.uk/12036/1/The%20VCDQ.pdf) to help determine if your symptoms are caused by VCD or some other condition. Specific breathing tests may also be performed. The gold standard of diagnosing VCD is using a small video camera to see the vocal cords.

As mentioned previously, I went a long time before I was able to properly describe my symptoms to my physician. The initially treated course of albuterol and corticosteroid inhalers was not working, yet I was reassured that what I was experiencing was exercise-induced asthma and that my symptoms should improve with increased medication dose.

In retrospect, exercise-induced asthma made sense, at least for part of what I was experiencing. I did not know enough about the disorder at the time to better explain my symptoms, so for over a year, I was improperly treated for my condition.

Being able to describe symptoms in a clear, systematic manner is crucial to help medical professionals determine the proper diagnosis. If you or someone you know is experiencing symptoms consistent with VCD, I hope that this section gives you the language you need transfer what you are experiencing into words.

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What You Can Do

If these symptoms sound like what you or someone you know are experiencing, seek medical attention. Knowing the correct terms and words to describe your symptoms will assist your physician in making a diagnosis. The correct diagnosis will help you receive the most beneficial treatment.

The most successful treatment approach will likely involve a multidisciplinary team that may include a physician, a speech and language therapist and a sports psychologist.

Since the triggers for VCD are different for everyone, treatment will vary from person to person. Keeping a log of your symptoms can help you determine which factors are contributing the most.

For example, do you only experience your symptoms at big meets or high-pressure situations? Maybe stress and anxiety are contributors. Do you only experience symptoms when you train indoors? Maybe air irritants are at play. Are you more challenged when you have acid reflux/heartburn? Maybe meal choice and timing are factors.

For me, the breathing strategies that I learned during speech therapy were too challenging to replicate while swimming. However, the visualization techniques that my speech therapist taught me were beneficial. It sounds absurd, but I would picture my airway relaxing, becoming as wide as a tennis ball. I would visualize this during my underwaters, deliberately relaxing the muscles of my neck before breaking out onto the surface of the water.

I found that using this relaxation strategy while on the wall during sets was also helpful, especially when combined with slow, deep, diaphragmatic breathing. Relaxing my throat, visualizing an open airway while coming into the wall would help decrease the difficulty of my first breath, which in turn would calm me enough to allow relatively normal breathing within the next 10-20 seconds.

My athletic counselor helped me determine strategies to calm myself before races and during tough sets. Through these sessions, I learned that I could manage at least some of my symptoms by changing my mindset.

I began to find comfort in not letting my symptoms “surprise me,” but rather accepting that they were going to occur and working to manage the parts that I had control over. I remember thinking over and over: I had made it through tough races and practices before, and I will this time as well.

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Final Thoughts

Swimming with VCD is not easy. I will admit that I often look back at my swimming career and wonder, “What if?” What if I never had these challenges? How much faster could I have been?

I find comfort, however, in knowing that this question is regarding how much better my performances could have been, rather than second-guessing a decision to quit the sport that I have loved since I was a child.

While I found that continuing to train and compete was the best option for me, this may not be the correct answer for everyone. After being diagnosed with VCD, some individuals find that dedicating themselves to other activities outside of swimming leads to a happier and more fulfilling life. This is a painfully challenging decision to make, but it is an imperative one.

I hope that you found the information in this article helpful. If you have questions or comments you can reach out to me via email at [email protected].

1. Brooks SM (2017) Vocal Cord Dysfunction after an Inhalation Exposure. J Allergy Ther 8: 261. doi:10.4172/2155-6121.1000261
2. K. Kenn, R. Balkissoon. Vocal cord dysfunction: what do we know?European Respiratory Journal 2011 37: 194-200; DOI: 10.1183/09031936.00192809
3. Roberts, Claire-Marie and Faull, Andrea (2016) An Interdisciplinary Approach to the Management of Vocal Cord Dysfunction in an Elite Female Swimmer: a Case Study. In: The Association for Applied Sport Psychology 31st Annual Conference, 28th September – 1st October 2016, Phoenix, Arizona.
4. Varney V, Parnell H, Evans J, Cooke N, Lloyd J, Bolton J. The successful treatment of vocal cord dysfunction with low-dose amitriptyline – including literature review. Journal of Asthma and Allergy. 2009;2:105-110.
5. Weinberger M, Doshi D. Vocal cord dysfunction: a functional cause of respiratory distress. Breathe. 2017;13(1):15-21. doi:10.1183/20734735.019316.
6. https://my.clevelandclinic.org/health/diseases/17623-vocal-cord-dysfunction.
   

Bio

In 4th grade, when asked what she wanted to be when she grew up Dr. Erin Cameron, DPT replied “physical therapist,” a rather unconventional response for a child that age. She was a young swimmer with shoulder pain, desperate to return the to sport that she loved so dearly. The dedication of her physical therapist allowed her to pursue her passion and eventually go on to compete at the collegiate level.

While swimming at the University of Michigan she studied to obtain a Bachelor of Science in Movement Science from the School of Kinesiology. During her collegiate swimming career, she earned the following accolades: two-time CSCAA Honorable Mention Scholar All-American, three-time Big Ten Distinguished Scholar, team captain and the Michigan Leadership Academy Leader of Distinction award.

Erin has dedicated much of her life to the sport of swimming. In addition to competing in the sport for 15 years, she has coached at various elite swim camps and clinics growing her expertise in stroke technique and video critique. She has also served as a volunteer staff member for Division I, II and III swim programs aiding in both coaching and developing exercise programs/educational sessions for upper extremity injury prevention.

Erin received her Doctorate in Physical Therapy from Northwestern University’s Feinberg School of Medicine. During her time in physical therapy school, she developed a special interest in treating patients with a broad range of orthopedic injuries and promoting general health and wellness. She currently works at COR Physical Therapy (hyperlink: https://www.trainingcor.com) in Santa Clara, California where she specializes in treating youth athletes and adults with orthopedic conditions and is a contributor to Swimming Science Website (hyperlink: www.swimmingscience.net).