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Asthma can be a difficult malady to diagnose. Symptoms for some are intermittent and lung function tests can be normal if they are performed between episodes. The typical complaints of asthma are cough, wheezing and shortness of breath. Asthma is caused by reversible narrowing of the airways that are about one millimeter in diameter. A reduction in the size of the airways creates a one-way valve that obstructs the flow of air when trying to breathe out or exhale,  The force needed to  breathe out against the obstruction creates a high pitched whistle called a wheeze.  Many effective medicines are available to treat this once feared disease, which has drastically reduced the death rate from asthma. When asthma is not responding to the usual or high doses of medications, the diagnosis needs to be reconsidered.
A common imitator of asthma is vocal cord dysfunction (VCD). In this disorder, the vocal cords are the site of airway obstruction. Instead of moving apart when inhaling or exhaling, the vocal cords move together, generating a wheezing sound that is present during both phases of breathing. A simple office spirometry test may detect restricted airflow breathing in and out. Occasionally, spirometry must be performed after exercise to observe the abnormal airflow. Cold air and exercise can trigger vocal cord dysfunction, and it is not unusual in well trained athletes. The diagnosis can also be confirmed  in the office by observing the voice box with a laryngoscope during  an asthma attack. At that time,the  vocal cords will be seen moving in the wrong or “paradoxical” direction. Occasionally, vocal cord dysfunction will exist with asthma. In this setting, there will be both upper and lower airway obstruction.
The cause of VCD is not certain. Most people seem to have irritability of the voice box from underlying inflammation. Evidence of inflammation may be changes in the voice or a foreign body sensation in the throat. In others a psychogenic cause is suspected, possibly related to panic or anxiety attacks. Airway irritation and inflammation may result from allergies, smoking, poor air quality and acid reflux