Breathing techniques for Parodoxical Vocal Cord Motion 1) As soon as one feels an attack coming, SLOWLY breath in through the NOSE. DO NOT BREATH IN THROUGH THE MOUTH! Sometimes deliberately holding breath for 5 seconds prior to nasal inhalation helps. 2) More quickly exhale out the mouth with pursed lips. 3) Continue slow nasal inhalation, and quick mouth exhalation with pursed lips until the episode passes. The workup I do which the majority of the times picks up something abnormal when addressed that helps dramatically includes (trying to find the triggers…): – EGD (rarely I have found ulcerations in the cervical esophagus which I hypothesize irritates the RLN) – Barium swallow (zenker’s, esophageal muscles spasms) – 24-Hour Multichannel Intraluminal Impedance (MII) and pH monitoring (acid and non-acid reflux) – Allergy testing – Pulmonary function test with methacholine challenge – Bronchoscopy with lavage cultures – CT chest (picked up a few lung cancers missed on CXR) Though botox does help reduce the severity, they still get the attacks so it is not the panacea (read last paragraph on some potential concerns with this method). Finally, if workup negative, consider elavil, nortriptyline, neurontin, lyrica, and/or ultram. For whatever reason, these drugs (titrated to effect) seems to help “calm” the sensory afferents of the larynx. If that fails, there’s always the trach (I would do botox at same time). I’ve aways been concerned about aspiration triggering even MORE severe attacks since there’s ALWAYS some number of days of side effects of dysphagia and aspiration after botox injection.