Jemma Haines

The VCDQ – a Questionnaire for symptom monitoring in vocal cord dysfunction

Vocal cord dysfunction (VCD) typically involves abnormal adduction of the vocal cords during inspiration, mimics the symptoms of asthma and leads to the prescription of ineffective medications.

M15 Patient satisfaction in a tertiary cough service

Introduction Patient satisfaction surveys (PSS) can help identify ways of improving practice and facilitate better quality care. Patient opinion in health services research is integral but data from chronic cough populations is unknown. Aim To identify patient satisfaction in our tertiary cough service. Methods We devised a PSS containing 19 structured questions. Patients attending review consultations in two consecutive clinics were asked to consider completing the anonymous PSS. Results Fifty-two PSS were completed; an 84% response rate. Of those 43 had full responses for analysis [79% female, 58%≥55 years in age]. Patient satisfaction was extremely high (figure 1); 70% thought the care received was excellent and 95% were likely to recommend the service to friends and family. Improvement suggestions related to parking and appointment management. However 44% felt clinic locality was inconvenient, but the majority (63%) of those were not interested in Skype review consultations; response was unrelated to age. Conclusion To our knowledge, this is the first reported patient satisfaction data in chronic cough patients. Despite the refractory nature of the condition, patient satisfaction is extremely high. As a quarter of our service’s patients travel ≥25 miles, the inconvenience of clinic accessibility is not surprising. Nonetheless, patients appear to value face to face consultations and further patient consultation is required before utilising tele-health. Abstract M15 Figure 1

M11 The impact of respiratory speech and language therapy on patients’ cough related symptoms

Introduction Unexplained chronic cough may persist despite systematic evaluation and medical treatment of relevant comorbidities. Currently there are no effective, acceptable anti-tussive agents for the treatment of such patients and significant physical, social and psychological morbidity is described. The role of non-pharmacological treatment approaches and specifically speech and language therapy have been reported to be effective. In our specialist tertiary airways service, all patients with unexplained chronic cough greater than 8 weeks in duration, remaining unexplained after investigation and supervised therapeutic trials, are referred for respiratory speech and language therapy (rSLT). Aims To determine the effect of rSLT on the Leicester Cough Questionnaire (LCQ) and establish specifically whether the impact occurs across each of the described domains: physical, psychological and social. Methods We included retrospective data from all patients with unexplained chronic cough who completed rSLT between January and June 2016, and who had LCQ data available before and after treatment. Results Sixteeen full data sets [69% female; median (range) age 58 (35–73) years] were available for analysis; rSLT median = 4, (range = 3–6) sessions. There was overall improvement in LCQ from median (range) 13.0 (7.0–18.0) pre to 17.4 (8.0–21.0) post rSLT [minimal important difference (MID) 1.3; Wilcoxon’s signed rank p < 0.001]. Each domain improved post rSLT: physical from 4.7 (3.0–7.0) pre to 6.0 (2.0–7.0) post (MID 0.2; p = 0.004); psychological: from 4.0 (1.0–6.0) to 6.1 (3.0–7.0) (MID 0.8; p = 0.001); and social from 4.0 (2.0–7.0) to 5.7 (3.0–7.0) post (MID 0.2, p = 0.001). Individual answers to 10 of the 19 LCQ questions showed statistically significant improvements. Conclusion These preliminary data indicate that rSLT improves cough related symptoms similarly cross all domains. Further investigation is needed to inform which aspects of patients’ cough-related symptoms do/do not improve with therapy to guide treatment refinement. Specifically, closer investigation of response to individual LCQ questions may lead to improvements in therapeutic strategies.

M10 The development of a Vocal Cord Dysfunction Laryngoscopic Appearance Scale

Introduction Vocal cord dysfunction (VCD) typically involves abnormal vocal cord movement during inspiration. The recognised gold standard for diagnosis is fibreoptic laryngoscopy (FOL) during a symptomatic attack. Despite this there are no reported VCD FOL assessment scales to facilitate agreement in presentation, disease severity and treatment monitoring. Our VCD tertiary airways clinic receives over 300 referrals a year. We run a weekly diagnostic FOL list and identified the need for a VCD FOL classification for optimal care. Aims To gain consensus for a VCD FOL appearance scale and identify its interrater reliability. Methods An expert consensus group was convened comprising two respiratory consultant physicians and two respiratory speech and language therapists (SLTs). All have significant experience in VCD FOL interpretation. The group met, discussed and agreed on the VCD FOL appearance scale (Table 1). Two assessment teams were identified, each comprising a respiratory physician and a respiratory SLT. Each team rated patients, referred for FOL with a clinical suspicion of VCD, in three consecutive diagnostic FOL lists. All procedures were recorded and then blindly re-rated during playback by the other assessment team.Abstract M10 Table 1 Vocal cord dysfunction laryngoscopic appearance scale Scale Classification 0 Normal vocal cord movements observed during respiration throughout assessment 1 Transient abnormal vocal cord movements observed during inspiration, with large proportions of normal vocal cord movements during respiration 2 Mild abnormal vocal cord movements observed during respiration (up to 50% vocal cord closure during inspiration) 3 Moderate abnormal vocal cord movements observed during inspiration (50% or more, but not total closure, i.e. gap still visible between the cords) 4 Total apposition of the vocal cords (i.e. 100% closure) observed during respiration Results Eighteen patients received ratings; the mean (range) age was 51(19–80) and 78% were female. The assessing teams agreed on the rating for seven patients. For nine patients there was disagreement but adjacent classifications. Interrater agreement was performed using a weighted kappa (1 = complete agreement in classification; 0.5 = disagreement but adjacent classifications; 0 = disagreement and non-adjacent classifications). There was moderate agreement between the teams; 0.44 with a 95% confidence interval of 0.18–0.70. There was no bias between the assessment teams, as each had mean ratings for all patients of 2.4. Conclusions The VCD FOL appearance scale is a promising clinical assessment tool for the VCD population. We expected further interrater agreement; interestingly the majority of disagreement would not have changed management as classification still yielded a positive diagnosis. The differential maybe attributed to whether ratings were performed live or in playback, and this should be investigated. With further development, standardisation of application and robust validation it will be a useful assessment to direct appropriate management and facilitate accurate and consistent diagnosis.

M3 Anxiety and Depression in Patients with Breathing Pattern Disorders or Chronic Respiratory Disease

Background Patients that have chronic respiratory disease (CRD) and breathing pattern disorders (BPD) have a higher prevalence of anxiety and depression than the general population. These patients have worse respiratory health outcomes and in addition, their psychological problems are often left undiagnosed and untreated. Little is known about how anxiety and depression varies between CRD and BPD. Methods This prospective study involved screening patients attending secondary and tertiary respiratory clinics over an eight-week period. Patients were asked to complete the Hospital Anxiety and Depression Scale (HADS), Short Form-12 (SF-12) and St. George’s Respiratory Questionnaire (SGRQ). Demographical data and spirometry were also collected. Our primary outcome measure was the difference in these scores between patients with CRD (asthma, bronchiectasis and chronic obstructive pulmonary disease) compared to BPD (vocal cord dysfunction and dysfunctional breathing). Results 43 patients (21 with CRD and 22 with BPD) completed questionnaires; mean (SD) age 55 (17) yrs, 32 female. The overall prevalence of borderline anxiety was 17% and clinically significant anxiety 37%. The overall prevalence of borderline depression was 15% and clinically significant depression 29%. Of the patients with CRD, 29% had anxiety and 29% depression. In the BPD cohort, anxiety and depression were found in 45% and 30% of patients respectively. The difference between these groups was not statistically significant (anx: P = 0 .42; dep P = 0 .19). Independent predictors for anxiety and depression were higher SGRQ (anx: P = 0 .001; dep: P < 0 .0001), lower SF-12 Mental (anx: P < 0 .0001; dep: P < 0 .0001) and Physical (anx: P = 0 .042; dep: P = 0 .0027) Health Composite Scores, and lower FEV1% predicted (anx: P = 0 .0043; dep: P = 0 .016). Conclusions Anxiety and depression are present in a significant numbers of individuals in both CRD and BPD, with no difference between these groups, so efforts should be made to screen for psychological problems in patients with both CRD and BPD. Worse respiratory function and more symptoms are important contributing factors to patients’ risk of anxiety and depression.

P227 Development of a preliminary questionnaire for the identification of vocal cord dysfunction

Background Vocal cord dysfunction (VCD) is a debilitating condition characterised by paroxysmal episodes of dyspnoea, typically resulting from abnormal adduction of the vocal cords during breathing. Diagnosis is complicated by its self-limiting nature and significant overlap in symptoms with other respiratory conditions such as asthma, and referral for further investigation therefore requires a high index of suspicion from non-specialist physicians. Our aim is to design a questionnaire with a high positive predictive value for VCD, which would hopefully lead to earlier identification and treatment and also reduce the levels of iatrogenic morbidity associated with misdiagnosis. Methods 15 subjects with a confirmed diagnosis of VCD were recruited from the outpatient respiratory department. Semi-structured interviews in four focus groups were conducted to capture each sufferers subjective experience. Concurrently, two focus groups were held with nine healthcare professionals with specialist and non-specialist interest to gather professional opinion on VCD symptoms. The collated data were used to generate a preliminary questionnaire that was tested for face validity in ten patients and healthcare professionals. Results (1) Item generation: symptom profiles varied markedly, however certain characteristics did emerge with commonalities between most of the subjects or within a specific subset of individuals. These were grouped into the following themes—location, onset, sensations, breathing/voice changes, triggers, exacerbating factors and psychosocial impact. 17 items were generated for the preliminary questionnaire and expressed as positive or negative statements. (2) Face validity: general response was positive towards the comprehensibility of the statements and relevance to each subject. Based on user comments the number of items was reduced to twelve, all items were modified to positive statements to improve comprehensibility and a 5-point analogue scale will be used for scoring responses. Conclusions A preliminary diagnostic tool has been generated and tested for face validity in patients with VCD. Initial feedback indicates a high relevance of the questionnaire items to the subject. At this stage, modifications have been made to eliminate ambiguity and repetition. We will now test concurrent validity, specificity and test-retest variability of the questionnaire in healthy volunteers, and respiratory patients with and without VCD.

P206 Psychological comorbidity in vocal cord dysfunction

Background Vocal Cord Dysfunction (VCD) is typically reported to affect young females and has been associated with a psychiatric history. We run a multidisciplinary-based service for VCD patients with input from specialist speech and language therapy, physiotherapy and psychology. We investigated the demographics of our patient cohort with VCD, its association with anxiety and depression and whether this affected treatment response. Methods All patients referred for specialist speech and language therapy at the Royal Preston Hospital Airways Clinic between June 2006 and May 2011 with VCD confirmed by endoscopy were included. During routine clinical care data were collected including demographic details and comorbidities. Patients were also asked to complete the Hospital Anxiety and Depression (HAD) questionnaire. Subjective symptomatic improvement was recorded at patient follow-up visits. Results A total of 95 patients were eligible for study inclusion: 73.7% were female with a median age of 53 (17–83) years while men were older at 59 (37–80) years. Medical comorbidities included asthma (56.8%), reflux (47.4%), chronic cough (17.9%), nasal disease (16.8%) and neurological disease (12.6%). A history of confirmed psychiatric disease was noted in 38.9%. In 43 patients who completed HAD scores, moderate or severe anxiety was found in 41.8% and depression in 23.3%. Response to treatment was excellent (67% showing clinical improvement) and this was independent of medical or psychological comorbidity. Conclusions Our data suggest that VCD affects a wide range of patients, in terms of age, gender, comorbidities and HAD scores which do not impact on treatment response, as a result of the multidisciplinary approach and this success is comparable to most asthma therapies when patient compliance and education are accounted for. It challenges many previously held concepts and supports a multidisciplinary approach to treating VCD.