All that wheezes is not asthma. Paradoxical vocal cord movement presenting as severe acute asthma requiring ventilatory support.

A 23-year-old female presented with an acute exacerbation of her asthma, for which she required ventilatory support. Her wheeze disappeared immediately following tracheal intubation and ventilatory support was achieved with low airway pressures. We believe that the diagnosis of status asthmaticus was incorrect and that the patient was suffering from vocal cord dysfunction. We review reports of this condition and suggest that, in asthma, the expiratory flow limitation due to paradoxical vocal cord movement may be an appropriate physiological response to improve overall airflow. However, this glottic narrowing may cause respiratory distress of its own accord. Our observations suggest a simple approach to the diagnosis and management of patients whose respiratory distress may be caused by paradoxical vocal cord movement. Immediate relief of 'bronchospasm' in an asthmatic following tracheal intubation may establish the correct diagnosis. This has important implications for the management of these patients in the intensive care unit.