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Khan J, Moran B, McCarthy C, Butler MW, Franciosi AN. Management of comorbidities in difficult and severe asthma. Breathe (Sheff) 2023; 19:230133. [PMID: 38020342 PMCID: PMC10644109 DOI: 10.1183/20734735.0133-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 10/03/2023] [Indexed: 12/01/2023] Open
Abstract
Difficult-to-treat and severe asthma are challenging clinical entities. In the face of suboptimal asthma control, the temptation for clinicians is to reflexively escalate asthma-directed therapy, including increasing exposure to corticosteroids and commencement of costly but potent biologic therapies. However, asthma control is objectively and subjectively assessed based on measurable parameters (such as exacerbations or variability in pulmonary physiology), symptoms and patient histories. Crucially, these features can be confounded by common untreated comorbidities, affecting clinicians' assessment of asthma treatment efficacy.
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Affiliation(s)
- Jehangir Khan
- University College Dublin, Dublin, Ireland
- St Vincent's University Hospital, Dublin, Ireland
- Shared first authorship
| | - Barry Moran
- St Vincent's University Hospital, Dublin, Ireland
- Shared first authorship
| | - Cormac McCarthy
- University College Dublin, Dublin, Ireland
- St Vincent's University Hospital, Dublin, Ireland
| | - Marcus W. Butler
- University College Dublin, Dublin, Ireland
- St Vincent's University Hospital, Dublin, Ireland
- Shared senior authorship
| | - Alessandro N. Franciosi
- University College Dublin, Dublin, Ireland
- St Vincent's University Hospital, Dublin, Ireland
- Shared senior authorship
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2
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Wells C, Makariou I, Barker N, Thevasagayam R, Sonnappa S. Exercise induced laryngeal obstruction (EILO) in children and young people: Approaches to assessment and management. Paediatr Respir Rev 2023:S1526-0542(23)00018-0. [PMID: 37210300 DOI: 10.1016/j.prrv.2023.04.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 04/11/2023] [Indexed: 05/22/2023]
Abstract
Exercise Induced Laryngeal Obstruction (EILO) is characterised by breathlessness, cough and/or noisy breathing particularly during high intensity exercise. EILO is a subcategory of inducible laryngeal obstruction where exercise is the trigger that provokes inappropriate transient glottic or supraglottic narrowing. It is a common condition affecting 5.7-7.5% of the general population and is a key differential diagnosis for young athletes presenting with exercise related dyspnoea where prevalence rates go as high as 34%. Although the condition has been recognised for a long time, little attention, and awareness of the condition results in many young people dropping out of sporting participation due to troublesome symptoms. With evolving understanding of the condition, diagnostic tests and interventions, this review looks to present the current available evidence and best practice when managing young people with EILO.
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Affiliation(s)
- Charlotte Wells
- Department of Respiratory Paediatrics, The Royal Brompton Hospital Part of Guy's and ST Thomas's NHS Foundation Trust, London, UK; University of East Anglia, Health Sciences, Norwich Research Park, Norwich, UK
| | - Ioannis Makariou
- Department of Respiratory Paediatrics, The Royal Brompton Hospital Part of Guy's and ST Thomas's NHS Foundation Trust, London, UK
| | - Nicki Barker
- Department of Respiratory Medicine, Sheffield Children's NHS Foundation Trust, Sheffield, UK
| | - Ravi Thevasagayam
- Department of Respiratory Medicine, Sheffield Children's NHS Foundation Trust, Sheffield, UK
| | - Samatha Sonnappa
- Department of Respiratory Paediatrics, The Royal Brompton Hospital Part of Guy's and ST Thomas's NHS Foundation Trust, London, UK.
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3
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Clemm HH, Olin JT, McIntosh C, Schwellnus M, Sewry N, Hull JH, Halvorsen T. Exercise-induced laryngeal obstruction (EILO) in athletes: a narrative review by a subgroup of the IOC Consensus on 'acute respiratory illness in the athlete'. Br J Sports Med 2022; 56:622-629. [PMID: 35193856 PMCID: PMC9120388 DOI: 10.1136/bjsports-2021-104704] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/02/2022] [Indexed: 02/06/2023]
Abstract
Exercise-induced laryngeal obstruction (EILO) is caused by paradoxical inspiratory adduction of laryngeal structures during exercise. EILO is an important cause of upper airway dysfunction in young individuals and athletes, can impair exercise performance and mimic lower airway dysfunction, such as asthma and/or exercise-induced bronchoconstriction. Over the past two decades, there has been considerable progress in the recognition and assessment of EILO in sports medicine. EILO is a highly prevalent cause of unexplained dyspnoea and wheeze in athletes. The preferred diagnostic approach is continuous visualisation of the larynx (via laryngoscopy) during high-intensity exercise. Recent data suggest that EILO consists of different subtypes, possibly caused via different mechanisms. Several therapeutic interventions for EILO are now in widespread use, but to date, no randomised clinical trials have been performed to assess their efficacy or inform robust management strategies. The aim of this review is to provide a state-of-the-art overview of EILO and guidance for clinicians evaluating and treating suspected cases of EILO in athletes. Specifically, this review examines the pathophysiology of EILO, outlines a diagnostic approach and presents current therapeutic algorithms. The key unmet needs and future priorities for research in this area are also covered.
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Affiliation(s)
- Hege Havstad Clemm
- Department of Pediatric and Adolescent Medicine, Haukeland Universityhospital, Bergen, Norway .,Faculty of Medicine and Dentistry, Department of Clinical Science, University of Bergen, Bergen, Norway
| | - J Tod Olin
- Department of Pediatrics and Medicine, National Jewish Health, Denver, Colorado, USA
| | | | - Martin Schwellnus
- Sport, Exercise Medicine and Lifestyle Institute (SEMLI), Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa.,IOC Research Centre, South Africa
| | - Nicola Sewry
- Sport, Exercise Medicine and Lifestyle Institute (SEMLI), Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa.,IOC Research Centre, South Africa
| | - James H Hull
- Department of Respiratory Medicine, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Thomas Halvorsen
- Department of Pediatric and Adolescent Medicine, Haukeland Universityhospital, Bergen, Norway.,Faculty of Medicine and Dentistry, Department of Clinical Science, University of Bergen, Bergen, Norway.,Norwegian School of Sports Sciences, Oslo, Norway
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4
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Temte B, Wells J, Clark C, Lauw J, Mastronarde J. The feasibility of eucapnic voluntary hyperpnoea for the diagnosis of exercise-induced bronchoconstriction in a community pulmonary practice. J Asthma 2020; 59:145-151. [PMID: 32962464 DOI: 10.1080/02770903.2020.1827423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Exercise-induced bronchoconstriction (EIB) is a common condition and is typically treated empirically based on symptoms alone. However, symptoms of EIB are typically nonspecific. Objective testing with eucapnic voluntary hyperpnea (EVH) is a sensitive and specific method to diagnose EIB and may suggest alternative etiologies such as exercise-induced laryngeal obstruction (EILO). To this point, EVH has been primarily utilized in large academic centers and in elite athletes. We intend to discuss the feasibility and clinical application of utilizing EVH to diagnose EIB in a community-based pulmonary practice. METHODS Retrospective analysis of 62 patients who completed EVH at The Oregon Clinic Pulmonary Clinic. Patients with inspiratory flow volume loop flattening or clinical symptoms were assessed by otolaryngology for evidence of EILO. RESULTS 61 of 62 patients were included in the final analysis. 52 of 61 patients (85%) achieved an interpretable test with a maximum voluntary ventilation (MVV) >60%. There was no difference in baseline spirometry or patient characteristics between those who were able to reach an MVV >60% and those who did not. 14 (23%) patients were diagnosed with EIB, 18 (30%) with EILO, and 4 (7%) were diagnosed with both EIB and EILO. Only 1 patient had a non-diagnostic evaluation with MVV <60% and negative for EIB and EILO. CONCLUSIONS EVH is a feasible diagnostic modality to evaluate for EIB in a community pulmonary practice and may suggest alternative conditions such as EILO. Accurate diagnosis is paramount to prescribing proper therapy, decreasing inappropriate medication use, and relieving exercise-induced symptoms.
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Affiliation(s)
- Brandon Temte
- Internal Medicine, Providence Portland Medical Center, Portland, OR, USA
| | - Jason Wells
- The Oregon Clinic, Pulmonary and Critical Care, Portland, OR, USA
| | - Crystal Clark
- Pulmonary Medicine, The Oregon Clinic, Portland, OR, USA
| | - Jordan Lauw
- Pulmonary Medicine, The Oregon Clinic, Portland, OR, USA
| | - John Mastronarde
- Pulmonary and Critical Care, Portland VA Medical Center, Portland, OR, USA
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5
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Burman J, Elenius V, Lukkarinen H, Kuusela T, Mäkelä MJ, Kesti O, Väätäinen K, Maunula M, Remes S, Jartti T. Cut-off values to evaluate exercise-induced asthma in eucapnic voluntary hyperventilation test for children. Clin Physiol Funct Imaging 2020; 40:343-350. [PMID: 32491255 PMCID: PMC7496314 DOI: 10.1111/cpf.12647] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 03/25/2020] [Accepted: 05/25/2020] [Indexed: 01/06/2023]
Abstract
BACKGROUND AND AIM The eucapnic voluntary hyperventilation (EVH) testing is a diagnostic tool for diagnostics of exercise-induced bronchoconstriction; while the testing has become more common among children, data on the test's feasibility among children remain limited. Our aim was to investigate EVH testing feasibility among children, diagnostic testing cut-off values, and which factors affect testing outcomes. METHODS We recruited 134 patients aged 10-16 years with a history of exercise-induced dyspnoea and 100 healthy control children to undergo 6-min EVH testing. Testing feasibility was assessed by the children's ability to achieve ≥70% of the target minute ventilation of 30 times forced expiratory volume in 1 s (FEV1). Bronchoconstriction was assessed as a minimum of 8%, 10%, 12%, 15% or 20% fall in FEV1. Patient characteristics were correlated with EVH outcomes. RESULTS Overall, 98% of the children reached ≥70%, 88% reached ≥80%, 79% reached ≥90% and 62% reached ≥100% of target ventilation in EVH testing; of children with a history of exercise-induced dyspnoea, the decline percentages were as follows: 24% (≥8% fall), 17% (≥10% fall), 10% (≥12% fall), 6% (≥15% fall) and 5% (≥20% fall) in FEV1, compared to 11%, 4%, 3%, 1% and 0% among the healthy controls, respectively. Healthy controls and boys performed testing at higher ventilation rates (p < .05). CONCLUSION Eucapnic voluntary hyperventilation testing is feasible among children aged 10-16 years and has diagnostic value in evaluating exercise-induced dyspnoea among children. A minimum 10% fall in FEV1 is a good diagnostic cut-off value. Disease status appears to be important covariates.
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Affiliation(s)
- Janne Burman
- Skin and Allergy HospitalHelsinki University Hospital and University of HelsinkiHelsinkiFinland
| | - Varpu Elenius
- Department of Pediatrics and Adolescent MedicineTurku University Hospital and University of TurkuTurkuFinland
| | - Heikki Lukkarinen
- Department of Pediatrics and Adolescent MedicineTurku University Hospital and University of TurkuTurkuFinland
| | - Tom Kuusela
- Department of Physics and AstronomyUniversity of TurkuTurkuFinland
| | - Mika J. Mäkelä
- Skin and Allergy HospitalHelsinki University Hospital and University of HelsinkiHelsinkiFinland
| | - Olli Kesti
- Department of Pediatrics and Adolescent MedicineTurku University Hospital and University of TurkuTurkuFinland
| | - Katri Väätäinen
- Department of Pediatrics and Adolescent MedicineTurku University Hospital and University of TurkuTurkuFinland
| | - Maria Maunula
- Department of Pediatrics and Adolescent MedicineTurku University Hospital and University of TurkuTurkuFinland
| | - Sami Remes
- Department of PediatricsKuopio University HospitalKuopioFinland
| | - Tuomas Jartti
- Department of Pediatrics and Adolescent MedicineTurku University Hospital and University of TurkuTurkuFinland
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6
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Hull JH, Godbout K, Boulet LP. Exercise-Associated Dyspnea and Stridor: Thinking Beyond Asthma. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:2202-2208. [PMID: 32061900 DOI: 10.1016/j.jaip.2020.01.057] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 01/21/2020] [Accepted: 01/21/2020] [Indexed: 12/26/2022]
Abstract
Breathlessness during sport can be caused by various cardiorespiratory conditions, but when associated with stridor, usually arises from an upper airway etiology. The term exercise-induced laryngeal obstruction (EILO) is now used to describe the phenomenon of transient glottic closure occurring in association with physical activity. Exercise-related laryngeal closure is most commonly encountered in athletic individuals and likely affects between 5% and 7% of all young adults and adolescents. The diagnosis of EILO is not always straightforward because features can overlap with exercise-induced asthma/exercise-induced bronchoconstriction. EILO can therefore remain misdiagnosed for years, and most patients receive inappropriate asthma therapy. In contrast with asthma, EILO symptoms are usually most prominent at maximal exercise intensity and resolve quickly on exercise cessation. It is important to recognize that EILO and asthma can coexist in a proportion of athletes. The criterion standard test for diagnosing EILO is continuous laryngoscopy during exercise testing, although eucapnic voluntary hyperpnea testing has also been used. Various surgical or pharmacological interventions can be used to treat EILO, but first-line treatment is breathing technique work. Further research is needed to establish the optimal treatment algorithm, and more work is needed to increase awareness of this important clinical entity.
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Affiliation(s)
- James H Hull
- Department of Respiratory Medicine, Royal Brompton Hospital, London, United Kingdom
| | - Krystelle Godbout
- Institut universitaire de cardiologie et de pneumologie de Québec - Université Laval, Québec, Québec, Canada
| | - Louis-Philippe Boulet
- Institut universitaire de cardiologie et de pneumologie de Québec - Université Laval, Québec, Québec, Canada.
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7
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Boulet LP, Turmel J. Cough in exercise and athletes. Pulm Pharmacol Ther 2019; 55:67-74. [PMID: 30771475 DOI: 10.1016/j.pupt.2019.02.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Revised: 01/31/2019] [Accepted: 02/09/2019] [Indexed: 02/06/2023]
Abstract
In the general population, particularly in individuals with asthma, cough is a common symptom, often reported after exertion, although regular exercise may be associated with a reduction in the prevalence of cough. In athletes, exercise-induced cough is also a particularly frequent symptom. The main etiologies of cough in athletes are somewhat similar to non-athletes, including asthma/airway hyperresponsiveness, upper airways disorders such as allergic or non-allergic rhinitis, and exercise-induced laryngeal obstruction, although these conditions are more frequently observed in athletes. In these last, this symptom can also be related to the high ventilation and heat exchange experienced during exercise, particularly during exposure to cold/dry air or pollutants. However, gastroesophageal reflux, a common cause of cough in the general population, despite being highly prevalent in athletes, has not been reported as a main cause of cough in athletes. Cough may impair quality of life, sleep and exercise performance in the general population and probably also in athletes, although there are few data on this. The causes of cough should be documented through a systematic evaluation, the treatment adapted according to identified or most probable cough etiology and pattern of presentation, while respecting sports anti-doping regulations. More research is needed on exercise-induced persistent cough in the athlete to determine its pathophysiology, optimal management and consequences.
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Affiliation(s)
- Louis-Philippe Boulet
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Canada.
| | - Julie Turmel
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Canada
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8
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Connett GJ, Thomas M. Dysfunctional Breathing in Children and Adults With Asthma. Front Pediatr 2018; 6:406. [PMID: 30627527 PMCID: PMC6306426 DOI: 10.3389/fped.2018.00406] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Accepted: 12/07/2018] [Indexed: 12/01/2022] Open
Abstract
Asthma occurs across the life course. Its optimal treatment includes the use of personalized management plans that recognize the importance of co-morbidities including so-called "dysfunctional breathing." Such symptoms can arise as a result of induced laryngeal obstruction (ILO) or alterations in the mechanics of normal breathing called breathing pattern disorders. Whilst these two types of breathing abnormalities might be related, studies tend to focus on only one of them and do not consider their relationship. Evidence for these problems amongst childhood asthmatics is largely anecdotal. They seem rare in early childhood. Both types are more frequently recognized in the second decade of life and girls are affected more often. These observations tantalizingly parallel epidemiological studies characterizing the increasing prevalence and severity of asthma that also occurs amongst females after puberty. Exercise ILO is more common amongst adolescents and young adults. It should be properly delineated as it might be causally related to specific treatable factors. More severe ILO occurring at rest and breathing pattern disorders are more likely to be occurring within a psychological paradigm. Dysfunctional breathing is associated with asthma morbidity through a number of potential mechanisms. These include anxiety induced breathing pattern disorders and the enhanced perception of subsequent symptoms, cooling and drying of the airways from hyperventilation induced hyperresponsiveness and a direct effect of emotional stimuli on airways constriction via cholinergic pathways. Hyperventilation is the most common breathing pattern disorder amongst adults. Although not validated for use in asthma, the Nijmegen questionnaire has been used to characterize this problem. Studies show higher scores amongst women, those with poorly controlled asthma and those with psychiatric problems. Evidence that treatment with breathing retraining techniques is effective in a primary care population including all types of asthmatics suggests the problem might be more ubiquitous than just these high-risk groups. Future challenges include the need for studies characterizing all types of dysfunctional breathing in pediatric and adult patient cohorts and clearly defined, age appropriate, interventional studies. Clinicians caring for asthmatics in all age groups need to be aware of these co-morbidities and routinely ask about symptoms that suggest these problems.
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Affiliation(s)
- Gary J. Connett
- University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
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9
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Clinical presentation, assessment, and management of inducible laryngeal obstruction. Curr Opin Otolaryngol Head Neck Surg 2018. [DOI: 10.1097/moo.0000000000000452] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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10
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Walsted ES, Hull JH, Hvedstrup J, Maat RC, Backer V. Validity and reliability of grade scoring in the diagnosis of exercise-induced laryngeal obstruction. ERJ Open Res 2017; 3:00070-2017. [PMID: 28765826 PMCID: PMC5532755 DOI: 10.1183/23120541.00070-2017] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Accepted: 06/12/2017] [Indexed: 11/05/2022] Open
Abstract
The current gold-standard method for diagnosing exercise-induced laryngeal obstruction (EILO) is continuous laryngoscopy during exercise (CLE), with severity classified by a visual grade scoring system. We evaluated the precision of this approach, by evaluating test-retest reliability of CLE and both inter- and intra-rater variability. In this prospective case-control study, subjects completed four consecutive treadmill CLE tests under identical conditions. Laryngoscopic video recordings were anonymised and graded by three expert raters. 2 months following initial scoring, videos were re-randomised and rating repeated to assess intra-rater agreement. 20 subjects (16 cases and four controls) completed four CLE tests. The time to exhaustion increased by 30 s (95% CI 0.02-57.8, p<0.05) in the second CLE compared with the first test, but remained identical in the subsequent tests. Only one-third of subjects retained their initial diagnosis in the subsequent three tests. Inter-rater agreement on grade scores (weighted Cohen's ϰ) was 0.16-0.45, while intra-rater agreement ranged from 0.30 to 0.67. The CLE test is key in the diagnostic assessment of patients with EILO. However, the widely adopted visual grade scoring system does not appear to be a robust means for reliably classifying severity of EILO.
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Affiliation(s)
- Emil Schwarz Walsted
- Respiratory Research Unit, Dept of Respiratory Medicine, Bispebjerg University Hospital, Copenhagen, Denmark.,Dept of Respiratory Medicine, Royal Brompton Hospital, London, UK
| | - James H Hull
- Dept of Respiratory Medicine, Royal Brompton Hospital, London, UK
| | - Jeppe Hvedstrup
- Respiratory Research Unit, Dept of Respiratory Medicine, Bispebjerg University Hospital, Copenhagen, Denmark
| | | | - Vibeke Backer
- Respiratory Research Unit, Dept of Respiratory Medicine, Bispebjerg University Hospital, Copenhagen, Denmark
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11
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Walsted ES, Hull JH. Breathless and young-In need of inspiration? Pediatr Pulmonol 2016; 51:1105-1107. [PMID: 27362642 DOI: 10.1002/ppul.23517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Revised: 06/15/2016] [Accepted: 06/16/2016] [Indexed: 11/09/2022]
Affiliation(s)
- Emil S Walsted
- Department of Respiratory Medicine, Royal Brompton Hospital, Fulham Road, London, SW3 6HP, UK.,Respiratory Research Unit, Bispebjerg University Hospital, Copenhagen, Denmark
| | - James H Hull
- Department of Respiratory Medicine, Royal Brompton Hospital, Fulham Road, London, SW3 6HP, UK.
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12
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Liyanagedera S, McLeod R, Elhassan HA. Exercise induced laryngeal obstruction: a review of diagnosis and management. Eur Arch Otorhinolaryngol 2016; 274:1781-1789. [PMID: 27730324 PMCID: PMC5340851 DOI: 10.1007/s00405-016-4338-1] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2016] [Accepted: 10/04/2016] [Indexed: 11/30/2022]
Abstract
Exercise induced laryngeal obstruction (EILO) is a condition where inappropriate vocal cord or glottic closure occurs during exercise. This review of the literature provides an overview of the current understanding of the definition, epidemiology, diagnosis and management of EILO. Using The Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines the Cochrane, Embase, Ovid MEDLINE and PubMed databases were searched. Four search domains “exercise”, “induced”, “laryngeal” and “obstruction” were used. Primary searching found 469 records, 308 were excluded following screening of titles and citation. 100 were duplicates, a further 47 studies were excluded after applying inclusion and exclusion criteria. Two studies were identified following cross-referencing. A total of 15 studies were included. The last search date was 6/06/15. Average prevalence in the general adolescent population and athletes was 7.1 and 35.2 %, respectively. Dyspnoea was reported in 96.5, 99 and 100 % of three EILO patient cohorts. Two studies (n = 107) reported continuous laryngoscopy during exercise (CLE) testing could differentiate between patients and controls. In two studies (n = 33) the visual analogue scale (VAS) showed a beneficial effect of endoscopic supraglottoplasty (ES). Thirty-eight out of 43 patients who received two or more laryngeal control therapy sessions (LCT) had improvement or resolution of EILO symptoms. Exercise induced dyspnoea is the most common EILO symptom. EILO has a high occurrence in adolescents and athletes. The CLE test is the current gold standard for EILO diagnostics. Management of EILO includes both surgical and non-surgical interventions.
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13
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Walsted ES, Hull JH, Sverrild A, Porsbjerg C, Backer V. Bronchial provocation testing does not detect exercise-induced laryngeal obstruction. J Asthma 2016; 54:77-83. [PMID: 27285291 DOI: 10.1080/02770903.2016.1195843] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Exercise-induced laryngeal obstruction (EILO) is a key differential diagnosis for asthma in the presence of exertional respiratory symptoms. Continuous laryngoscopy during exercise (CLE), the current gold standard diagnostic test for EILO, has practical limitations. We aimed to establish if inspiratory flow data obtained during standard bronchoprovocation testing, to establish the presence of extra-thoracic hyper-responsiveness, may prove diagnostic for EILO and thus preclude requirement for CLE testing. METHODS We consecutively evaluated 37 adult subjects with exertional dyspnea and possible asthma referred over 6 months. All subjects received comprehensive assessment including a detailed clinical evaluation; pulmonary function testing, indirect and direct bronchial provocation testing, and CLE testing. RESULTS Out of 37 subjects, moderate or severe EILO was diagnosed in 8 subjects (22%, all female) while 5 (14%) had both asthma and EILO. There was no correlation between degree of EILO during CLE and mean decrease in forced inspiratory flow (%FIF50) obtained during neither the Methacholine (r = -0.15; p = 0.38) nor Mannitol (r = 0.04; p = 0.84) provocation tests. CONCLUSION Inspiratory flow parameters obtained during bronchoprovocation tests did not reliably detect EILO. It remains that CLE is an important and key investigation modality in establishing a secure diagnosis of EILO.
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Affiliation(s)
- Emil Schwarz Walsted
- a Respiratory Research Unit, Department of Respiratory Medicine , Bispebjerg University Hospital , Copenhagen , Denmark
| | - James H Hull
- b Department of Respiratory Medicine , Royal Brompton Hospital , London , United Kingdom
| | - Asger Sverrild
- a Respiratory Research Unit, Department of Respiratory Medicine , Bispebjerg University Hospital , Copenhagen , Denmark
| | - Celeste Porsbjerg
- a Respiratory Research Unit, Department of Respiratory Medicine , Bispebjerg University Hospital , Copenhagen , Denmark
| | - Vibeke Backer
- a Respiratory Research Unit, Department of Respiratory Medicine , Bispebjerg University Hospital , Copenhagen , Denmark
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14
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Heffler E, Bonini M, Brussino L, Solidoro P, Guida G, Boita M, Nicolosi G, Bucca C. Vitamin D deficiency and exercise-induced laryngospasm in young competitive rowers. Appl Physiol Nutr Metab 2016; 41:735-40. [PMID: 27218140 DOI: 10.1139/apnm-2015-0517] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Exercise-induced dyspnea is common among adolescents and young adults and often originates from exercise-induced bronchoconstriction (EIB). Sometimes, dyspnea corresponds to exercise-induced laryngospasm (EILO), which is a paradoxical decrease in supraglottic/glottic area. Vitamin D deficiency, which occurs frequently at northern latitudes, might favor laryngospasm by impairing calcium transport and slowing striate muscle relaxation. The aim of this study was to evaluate whether vitamin D status has an influence on bronchial and laryngeal responses to exercise in young, healthy athletes. EIB and EILO were investigated during winter in 37 healthy competitive rowers (24 males; age range 13-25 years), using the eucapnic voluntary hyperventilation test (EVH). EIB was diagnosed when forced expiratory volume in the first second decreased by 10%, EILO when maximum mid-inspiratory flow (MIF50) decreased by 20%. Most athletes (86.5%) had vitamin D deficiency (below 30 ng/mL), 29 mild-moderate (78.4%) and 3 severe (8.1%). EVH showed EIB in 10 subjects (27%), EILO in 16 (43.2%), and combined EIB and EILO in 6 (16.2%). Athletes with EILO had lower vitamin D (19.1 ng/mL vs. 27.0 ng/mL, p < 0.001) and higher parathyroid hormone (30.5 pg/mL vs. 19.2 pg/mL, p = 0.006) levels. The degree of laryngoconstriction (post-EVH MIF50 as a percentage of pre-EVH MIF50) was related directly with vitamin D levels (r = 0.51; p = 0.001) and inversely with parathyroid hormone levels (r = -0.53; p = 0.001). We conclude that vitamin D deficiency is common during winter in young athletes living above the 40th parallel north and favors laryngospasm during exercise, probably by disturbing calcium homeostasis. This effect may negatively influence athletic performance.
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Affiliation(s)
- Enrico Heffler
- a Respiratory Medicine and Allergy, AOU "Policlinico-Vittorio Emanuele", Department of Clinical and Experimental Medicine, University of Catania, Via Santa Sofia 78, 95123 Catania, Italy
| | - Matteo Bonini
- b Department of Public Health and Infectious Diseases, "Sapienza" University of Rome, Piazzale Aldo Moro 5, 00185 Roma, Italy
| | - Luisa Brussino
- c Department of Medical Sciences, University of Torino, Via Genova 3, 10126 Torino, Italy
| | - Paolo Solidoro
- d Department of Pneumology, Città della Salute e della Scienza, Via Genova 3, 10126 Torino, Italy
| | - Giuseppe Guida
- c Department of Medical Sciences, University of Torino, Via Genova 3, 10126 Torino, Italy
| | - Monica Boita
- c Department of Medical Sciences, University of Torino, Via Genova 3, 10126 Torino, Italy
| | - Giuliana Nicolosi
- a Respiratory Medicine and Allergy, AOU "Policlinico-Vittorio Emanuele", Department of Clinical and Experimental Medicine, University of Catania, Via Santa Sofia 78, 95123 Catania, Italy
| | - Caterina Bucca
- c Department of Medical Sciences, University of Torino, Via Genova 3, 10126 Torino, Italy.,d Department of Pneumology, Città della Salute e della Scienza, Via Genova 3, 10126 Torino, Italy
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