Is insufficient pulmonary air support the cause of dysphonia in chronic obstructive pulmonary disease?

Immediate and Late Effects of a Single, Low-Intensity Inspiratory Muscle Intervention on Voice and Breathing in Chronic Obstructive Pulmonary Disease

INTRODUCTION

Chronic obstructive pulmonary disease (COPD) is characterized by progressive airflow limitation, exacerbations, and systemic inflammatory effects that can impair functional capacity and respiratory muscle strength, potentially affecting voice production.

OBJECTIVE

To examine the immediate and late effects of a single low-intensity inspiratory muscle training (IMT) intervention on voice and airflow limitation parameters in subjects with COPD.

METHODS

Randomized clinical trial with seventeen subjects (40 to 80 years old, both genders) randomly divided into two groups: IMT and simulated inspiratory muscle training (SIMT). The following outcomes were assessed before, immediately after, and 30 days post intervention: Vocal Symptom Scale, maximum phonation time (MPT), and numerical count time (MPTC); numerical count (CN); inspiratory muscle strength; peak expiratory flow; and dyspnea sensation.

RESULTS

There were no significant differences between the groups immediately after intervention. The MPT/e/ increased significantly in the IMT group, and the perception of vocal symptoms was significantly reduced in the SIMT group immediately after intervention. At follow-up, according to the analysis of variance, these effects were not maintained.

CONCLUSION

Low-intensity IMT in people with COPD showed immediate positive results on MPT/e/, but these were not sustained after 30 days. There was no immediate effect on measures of airflow limitation, suggesting that the continuation of low-intensity IMT for long periods would provide benefits to subjects with COPD.

Association of Dysphonia in Patients With Dysphagia in the United States: A National Database Study

OBJECTIVE

Limited research exists on the prevalence and comorbidity of dysphagia and dysphonia, though prior studies highlight their co-existence in multiple disease cohorts. This study investigates the prevalence of dysphonia in U.S. adults with dysphagia.

METHODS

A cross-sectional study was conducted using the NIH's All of Us Research Program controlled tier dataset (version 7). Multivariate logistic regression and marginal effects (ME) examined the association of dysphonia in U.S. adults with dysphagia.

RESULTS

Among 266,612 adults, 24,198 had dysphagia (median age, 67 years; 63% female), and 242,414 did not (median age, 58 years; 61% female). Dysphonia was significantly more prevalent in patients with dysphagia (14% vs. 1.9%, p < 0.001). Multivariate analysis showed a 6.78-fold increase in odds of dysphonia with dysphagia (95% CI 6.47-7.11; ME 9.82%). Dysphagia was significantly associated with dysphonia in patients with head and neck cancer (aOR 2.93; ME 13.51%), stroke (aOR 3.71; ME 14.56%), neurodegenerative conditions (aOR 4.34; ME 13.16%), COPD (aOR 4.33; ME 13.35%), ACDF (aOR 5.24; ME 18.90%), and vocal fold abnormalities (aOR 1.40; ME 7.71%).

CONCLUSION

Patients with dysphagia had a 6.78-fold increase in odds of having a diagnosis of dysphonia. Otolaryngologists and speech-language pathologists should consider dysphonia assessment in their patients presenting with dysphagia.

LEVEL OF EVIDENCE: 3

Impact of Pulmonary Function on Voice Outcomes After Injection Laryngoplasty for Unilateral Vocal Fold Paralysis

OBJECTIVES

Pulmonary function is closely associated with voice quality especially in patients with voice disorder including unilateral vocal fold paralysis (UVFP). Injection laryngoplasty (IL) is the standard treatment for patients with UVFP. We investigated the subjective and objective voice outcomes according to pulmonary function test (PFT) before IL in patients with UVFP.

METHOD

We retrospectively analyzed the patients who underwent IL for UVFP between 2004 and 2021 (N = 1201), and finally investigated 261 patients with PFT results before IL. The patients were classified into three groups according to results of PFT: normal (n = 189, 72%), mild (n = 40, 15%), and moderate (n = 32, 13%) obstructive pattern. Aspiration symptoms and subjective and objective voice parameters of voice handicap index (VHI), GRBAS score, maximal phonation time (MPT), Jitter, Shimmer, and noise to harmonic ratio (NHR) were compared between normal and abnormal (mild or moderate obstructive pattern) PFT groups.

RESULTS

Age (68.0 ± 9.1 and 61.2 ± 12.6, respectively) was significantly higher and males were more common (84.7% and 57.7%, respectively) in abnormal PFT than in normal PFT. Aspiration showed significant improvement in all groups. The subjective and objective voice parameters significantly improved after IL in normal and mild obstruction groups, but MPT, Shimmer, and VHI did not significantly improve in the moderate obstruction group. The improvement in VHI-30 after IL was significantly higher in the normal group (20.0 ± 29.5) than in the mild (10.3 ± 32.8) or moderate (9.9 ± 33.2) obstruction group (P = 0.035). Improved amounts of MPT, Jitter, Shimmer, and NHR were not significantly different among the groups, but improvement of VHI was smallest in the moderate obstructive pattern group.

CONCLUSION

Voice parameters showed significant improvement after IL in both normal and mild obstructive pattern groups, but MPT and VHI did not significantly improve in the moderate obstructive pattern group. In addition, patients with normal pulmonary function had marked improvement of subjective symptoms after IL in comparison with patients with abnormal pulmonary function.

Can We Use the Maximum Phonation Time as a Screening of Pulmonary Forced Vital Capacity in Post-COVID-19 Syndrome Patients?

OBJECTIVE

To verify the accuracy of the maximum phonation time of the vowel /a/ (MPT/a/), fricative /s/ (MPT/s/), number counting (MPTC), and number reached in this count (CN) to estimate forced vital capacity (FVC) in patients with post-COVID-19 syndrome.

METHOD

Cross-sectional study involving adult patients, who were admitted to the intensive care unit and referred to the Post-COVID-19 Rehabilitation Outpatient Clinic. Voice function was assessed using a Vocal Handicap Index (VHI) self-assessment questionnaire and MPT tests. To perform the phonatory tests, the patients remained in a standing posture and were instructed to inhale as much air as possible and, during a single exhalation, at usual pitch and loudness, sustain the emission of /a/ and /s/; and in another breath, to perform the ascending numerical count, starting from the number one up to the highest number they could reach. Pulmonary function was assessed by spirometry. The receiver operating characteristic (ROC) curve was plotted, and FVC values lower than the normal limit by Z-score (fifth percentile) were classified as impaired lung function. The predictive values and likelihood ratios were calculated.

RESULTS

A total of 70 patients participated, with 20-30% having a high VHI. Approximately 24% had an FVC impairment and significantly low values of MPT/a/, MPT/s/, MPTC, and CN. The test results showed overall accuracy of 70% and the cutoff points of 9.69, 6.78, 10.60, and 13, respectively, with high sensitivity, predictive negative value and low specificity, predictive positive value, and positive likelihood ratio.

CONCLUSIONS

Our results suggest that the MPT has moderate discriminatory power for FVC impairment, indicating that it is not a reliable indicator of pulmonary function in the population studied. Therefore, in patients with an MPT of less than 10.60 seconds, or a CN lower than 13, other criteria should be added to improve the diagnostic accuracy and support the decision to perform more complex investigations.

Maximum Phonation Times as Biomarkers of Lung Function

PURPOSE

To verify whether measurements of maximal phonation times are biomarkers of forced vital capacity in patients with chronic obstructive pulmonary disease, and to characterize the vocal aspects of these patients, taking into account variables, such as age, body mass index, use of bronchodilators, presence of symptoms, and quality of life related to voice.

METHODS

Complete records of 25 subjects with chronic obstructive pulmonary disease, both sexes, aged 31 to 85 years, evaluated by forced vital capacity, maximum phonation times of /a/, and numerical count and number reached at this count, Vocal Symptom Scale, Voice Quality of Life. Data were presented descriptively and statistically analyzed using Student's t test for independent samples and Mann-Whitney U test. A significance level of 5% was accepted. The receiver operating characteristic curve was plotted and the standardized value of forced vital capacity <80% was considered as an indicator of pulmonary dysfunction.

RESULTS

Patients exhibited reduced maximum phonation times for /a/, numeric counting, and reached digits in counting; discrepancies in Vocal Signs and Symptoms and Voice Quality of Life Scale scores. Numeric counting times of up to 12.5 seconds indicated that forced vital capacity may be impaired.

CONCLUSION

The patients with chronic obstructive pulmonary disease examined in this study exhibited vocal deviations as evidenced by reduced maximum phonation times of /a/, numeric counting, and the digit reached during counting, as well as deviations in vocal self-assessment. Maximum phonation time in numerical counting was considered a biomarker of pulmonary function impairment.

The correlation between six-minute walking distance and maximum phonation time in healthy adults

Objectives

This study aimed to determine the association between six-minute walking distance (6MWD) and maximum phonation time (MPT) in healthy adults.

Patients and methods

The cross-sectional study was conducted with 50 sedentary nonsingers (32 females, 18 males; mean age: 33.5±8.3 years; range, 18 to 50 years) between February 2021 and April 2021. Subjects with a history of smoking, respiratory symptoms in the last two weeks, and heart, lung, musculoskeletal, and balance problems were excluded. The measurements of MPT and 6MWD were carried out by two different assessors blinded to each other.

Results

The mean MPT was higher in male subjects (27.4±7.4 sec vs. 20.6±5.1 sec, p<0.001). In the bivariate analysis, there was a significant correlation between MPT and 6MWD (r=0.621, p<0.001), as well as body height (r=0.421, p=0.002) and the mean fundamental frequency (r=-0.429, p=0.002); however, no association was found with age, body weight, and the mean sound pressure level. After multiple regression, 6MWD was the only factor associated with MPT (p=0.002).

Conclusion

There is a significant association between 6MWD and MPT in healthy adults, and the results suggest that aerobic capacity might have a role in improving the ability to sustain phonation.

Effect of Pompage on Vocal and Respiratory Measurements from Female Teachers: A Randomized Clinical Trial

INTRODUCTION

Teachers stand out among occupational groups due to their contribution to modern societies, and their voice is the main form of interaction.

OBJECTIVE

The aim of the study was to verify the changes in vocal and respiratory measurements from teachers with vocal and musculoskeletal complaints and with normal larynx after applying a musculoskeletal manipulation protocol of myofascial release using pompage.

METHODS

Controlled and randomized clinical trial with 56 participants: 28 teachers in the study group and 28 teachers in the control group. Anamnesis, videolaryngoscopy, hearing screening, sound pressure and maximum phonation time measurements, and manovacuometry were performed. The musculoskeletal manipulation protocol of myofascial release using pompage consisted of a total of 24 sessions, 40 min for each session, three times a week, for 8 weeks.

RESULTS

There was a significant improvement in the maximum respiratory pressure in the study group after the intervention. The sound pressure level and the maximum phonation time did not change significantly.

DISCUSSION AND CONCLUSION

Musculoskeletal manipulation protocol of myofascial release using pompage had a direct effect on the respiratory measurements from female teachers, significantly increasing the maximum respiratory pressure but without affecting sound pressure level and the /a/ maximum phonation time.

Effects of Respiratory Muscle Strength Training on Respiratory-Related Impairments of Parkinson's Disease

In addition to typical motor dysfunction, Parkinson's disease is also characterized by respiratory-related dysfunction. As a means of rehabilitation, respiratory muscle strength training (RMST) has been applied to restore Parkinson's disease (PD) functions. However, the current clinical value of RMST in the application for PD has not been widely established. This article aims to review the research progress of the application of RMST in PD rehabilitation to provide new sight into respiratory-related impairments management in people with PD.

Comparison of respiratory function, physical function, and activities of daily living among community-dwelling patients with respiratory and non-respiratory disease

[Purpose] The purpose of this study was to investigate the differences in respiratory function, physical function, and Activities of Daily Living (ADL) between respiratory and non-respiratory patients using community-based home rehabilitation. [Participations and Methods] Maximum Phonation Time (MPT), upper and lower limb muscle strength, and ADL were compared in two groups: a respiratory disease group including respiratory patients and those with respiratory comorbidities, and a non-respiratory disease group. Cutoff values were determined for items that showed significant differences between groups. [Results] There were no significant differences between the two groups in assessments other than MPT. MPT was significantly lower in the respiratory disease group, with an MPT cutoff value of 10.1 sec and an area under the curve of 0.74. [Conclusion] Use of the MPT cutoff value may help to determine whether respiratory function is impaired in patients with respiratory disease.

The physiology of singing and implications for 'Singing for Lung Health' as a therapy for individuals with chronic obstructive pulmonary disease

Singing is an increasingly popular activity for people with chronic obstructive pulmonary disease (COPD). Research to date suggests that ‘Singing for Lung Health’ may improve various health measures, including health-related quality-of-life. Singing and breathing are closely linked processes affecting one another. In this narrative review, we explore the physiological rationale for ‘Singing for Lung Health’ as an intervention, focusing on the abnormalities of pulmonary mechanics seen in COPD and how these might be impacted by singing. The potential beneficial physiological mechanisms outlined here require further in-depth evaluation.

Post-extubation dysphagia and dysphonia amongst adults with COVID-19 in the Republic of Ireland: A prospective multi-site observational cohort study

Objectives

This study aims to (i) investigate post‐extubation dysphagia and dysphonia amongst adults intubated with SARS‐COV‐2 (COVID‐19) and referred to speech and language therapy (SLT) in acute hospitals across the Republic of Ireland (ROI) between March and June 2020; (ii) identify variables predictive of post‐extubation oral intake status and dysphonia and (iii) establish SLT rehabilitation needs and services provided to this cohort.

Design

A multi‐site prospective observational cohort study.

Participants

One hundred adults with confirmed COVID‐19 who were intubated across eleven acute hospital sites in ROI and who were referred to SLT services between March and June 2020 inclusive.

Main Outcome Measures

Oral intake status, level of diet modification and perceptual voice quality.

Results

Based on initial SLT assessment, 90% required altered oral intake and 59% required tube feeding with 36% not allowed oral intake. Age (OR 1.064; 95% CI 1.018–1.112), proning (OR 3.671; 95% CI 1.128–11.943) and pre‐existing respiratory disease (OR 5.863; 95% CI 1.521–11.599) were predictors of oral intake status post‐extubation. Two‐thirds (66%) presented with dysphonia post‐extubation. Intubation injury (OR 10.471; 95% CI 1.060–103.466) and pre‐existing respiratory disease (OR 24.196; 95% CI 1.609–363.78) were predictors of post‐extubation voice quality. Thirty‐seven per cent required dysphagia intervention post‐extubation, whereas 20% needed intervention for voice. Dysphagia and dysphonia persisted in 27% and 37% cases, respectively, at hospital discharge.

Discussion

Post‐extubation dysphagia and dysphonia were prevalent amongst adults with COVID‐19 across the ROI. Predictors included iatrogenic factors and underlying respiratory disease. Prompt evaluation and intervention is needed to minimise complications and inform rehabilitation planning.

Self-Perceived Handicap Associated With Dysphonia and Health-Related Quality of Life of Asthma and Chronic Obstructive Pulmonary Disease Patients: A Case-Control Study

Purpose The association between voice alterations, health-related quality of life (HRQL), and chronic respiratory diseases, such as asthma and chronic obstructive pulmonary disease (COPD), has previously been reported. The aim of this study was to test the hypothesis that HRQL and dysphonia-associated handicap of patients diagnosed with asthma or COPD are worse than healthy controls. Method A case-control study in which participants were recruited by a consecutive sampling method from a single institution was conducted. Three groups were created: (a) asthma (51 patients), (b) COPD (52 patients), and (c) 50 healthy controls. Self-reported handicap associated with dysphonia was assessed using the 30-item Voice Handicap Index (VHI-30); meanwhile, HRQL was tested via the European Quality of Life (EQ) Questionnaire and the EQ-visual analog scale. Also, aerodynamic assessment applied to phonation was assessed, and maximum phonation time and s/e index were registered. Results VHI scores were higher for asthma and COPD (7.19 ± 8.31 and 11.80 ± 15.18, respectively) than in the control group (3.72 ± 6.78). The EQ index was lower in asthma and COPD patients than in controls. The EQ-visual analog scale showed lower scores in asthma and COPD than in the controls. Conclusions HRQL was worse in COPD patients than in asthma patients. Even though the patient groups showed worse VHI and HRQL scores than the healthy controls, the scores fell within the normal variation range. No significant variations in the maximum phonation time index between groups were noted.

The Impact of Respiratory Function on Voice in Patients with Presbyphonia

BACKGROUND AND OBJECTIVE

Presbyphonia is an age-related voice disorder characterized by vocal fold atrophy and incomplete glottal closure during phonation. The extent to which the effects of presbyphonia may be compounded by age-related declines in the respiratory system and further impact communication and quality of life remains unknown. Therefore, the objective of this study was to determine how variations in respiratory function impacts voice measures in a sample of participants with presbyphonia.

METHODS

In this pilot study, 21 participants with presbyphonia underwent respiratory assessments (spirometry and respiratory muscle strength testing) and voice assessments (videostroboscopy, acoustic analysis, auditory-perceptual ratings, aerodynamic assessment, and self-assessments). Factor and cluster analyses were conducted to extract voice and respiratory constructs and to identify groups of participants with similar profiles. Correlations and regression analyses were conducted to better describe the relationships between voice and respiratory function.

RESULTS

Respiratory function was found to impact voice via two main pathways: through its physiological effect on voice and through its impact on general health and impairment. A lower respiratory function was associated with a lower vocal fold pliability and regularity of vibration and with an elevated aerodynamic resistance accompanied by laryngeal hyperfunction. Standardized measures of respiratory function were associated with perceived voice-related handicap. Respiratory function did not associate with voice quality, which was mostly influenced by the severity of vocal fold atrophy.

CONCLUSION

Poor respiratory health exacerbates the burden of vocal fold atrophy and, therefore, implementation of respiratory screening prior to starting voice therapy may significantly affect the treatment plan and consequently the outcomes of voice therapy in this patient population.

The Effects of Respiratory Muscle Training on Phonatory Measures in Individuals with Parkinson's Disease

INTRODUCTION

In individuals with Parkinson's disease (PD), respiratory muscle weakness and rigidity, bradykinesia of abdominal muscles and stiffness of the chest wall, affect the respiratory component of voice intensity due to reduced pulmonary capacity and airflow needed to vibrate the vocal folds. It may be possible to improve voice production by strengthening respiratory muscles. The purpose of this study was to evaluate the effects of inspiratory and expiratory muscle training on voice production outcomes in individuals with PD.

METHOD

Thirty-one participants with PD were randomly allocated to three study groups (control group n = 10, inspiratory training group, n = 11, and expiratory training group, n = 11). The inspiratory and expiratory group performed a home-based inspiratory and expiratory muscle training program, respectively (five sets of five repetitions). Both groups trained six times a week for 2 months using a progressively increased resistance. The control group performed expiratory muscle training using the same protocol and a fixed resistance. Phonatory measures, maximum inspiratory/expiratory pressure, and spirometric indexes were assessed before and at 2 months after training.

RESULTS

Differences in peak subglottic pressure were moderate (d = 0.59) between expiratory and inspiratory groups, large between inspiratory and control groups (d = 1.32), and large between expiratory and control groups (d = 1.96). Differences in maximum phonation time were large (d = 1.26) between inspiratory and control groups, moderate (negative) between expiratory and inspiratory groups (d = -0.60), and moderate between expiratory and control groups (d = 0.72). Differences in peak sound pressure level were large (d = 1.27) between inspiratory and control groups, trivial between expiratory and inspiratory groups (d = -0.18), and large between expiratory and control groups (d = 1.10).

CONCLUSIONS

Inspiratory muscle training is effective in improving maximum phonation time, and expiratory muscle training is more effective for improving peak subglottic pressure, and peak sound pressure level in individuals with PD.

Association Between Subglottic Pressure and Pulmonary Function in Individuals With Parkinson's Disease

INTRODUCTION

In individuals with Parkinson's disease (PD), pulmonary complication such as weakness and rigidity of respiratory muscles and reduced cough airflow may be associated with reduced voice production due to limited pulmonary capacity and reduced airflow needed to vibrate the vocal folds. It is not clear, however, which pulmonary function parameter is determinant in the association with peak subglottic pressure (SGP). Therefore, the purpose of this study was to determine the association between peak SGP and pulmonary function parameters in individuals with PD.

METHODS

Forty-two individuals with diagnosis of idiopathic PD of both genders were recruited in the study. Mean and peak SGP, spirometric indices, maximum inspiratory pressure, maximum expiratory pressure (MEP), and peak cough flow (PCF) during reflex and voluntary cough were measured on all participants.

RESULTS

The analysis revealed that peak SGP had a moderate but significant linear association with MEP (r = 0.38; P = 0.013), voluntary (r = 0.31; P = 0.051), and reflex PCF (r = 0.40; P = 0.012), but not with maximum inspiratory pressure (r = 0.23; P = 0.145). Higher values in peak SGP were associated with higher values in MEP, voluntary PCF, and reflex PCF. No linear association was detected between peak SGP and spirometric indices.

CONCLUSIONS

Peak SGP has a direct association with voluntary and reflex PCF, and expiratory muscle strength, but not with inspiratory muscle strength. The association with peak SGP is higher for reflex PCF than for voluntary PCF.

COPD and Singing for Lung Health: A Patient and Clinician Perspective

This article, co-authored by a patient living with chronic obstructive pulmonary disease (COPD) and a respiratory physiotherapist, discusses the patient’s experience of COPD and singing as a form of therapy. The clinician then discusses his experience of Singing for Lung Health in the context of the patient, and how more research is needed in this area.