Development and validation of the Exercise-Induced Laryngeal Obstruction Dyspnea Index (EILODI)

Credibility of Minimal Clinically Important Differences for Otolaryngology Patient-Reported Outcome Measurements: A Scoping Review

OBJECTIVE

Anchor-based approaches for determining a minimal clinically important difference (MCID) for patient-reported outcome measures (PROMs) are critical for detecting meaningful changes in clinical status. However, the methodologies for MCID determination vary across the literature and have been found to be inconsistent. Our objective is to evaluate the credibility of anchor-based MCIDs in otolaryngology.

DATA SOURCES

PubMed, Embase, and Web of Science.

REVIEW METHODS

Studies identifying novel anchor-based MCIDs for PROMs in otolaryngology from inception to November 2, 2021, in a previous review were included. A systematic search of PubMed, Embase, and Web of Science was conducted for original articles on the same topic from November 3, 2021, to January 4, 2024. The credibility of MCIDs was assessed using a previously developed instrument with five main criteria, including anchor interpretability and relevance to patients, correlation between the anchor and the patient-reported outcome, sample size, and determination if the selected anchor threshold is small and meaningful.

RESULTS

In total, 43 studies reported anchor-based MCIDs in otolaryngology. A total of 74 MCIDs were identified across subspecialties, most commonly in rhinology (38%) and otology (26%). Only 25% (18/74) were deemed credible, whereas 48% (35/74) had low credibility. In 34% (24/74) of cases, correlations between the anchor and PROMs were not reported. Most MCIDs (70%) were calculated using differences in their anchors that were considered sufficiently small and clinically relevant to patients. All MCIDs were calculated using at least an anchor-based method, with 50 (58%) relying on the mean change anchor-based method.

CONCLUSION

A small subset of MCIDs for PROMs in otolaryngology were found to be credible. These findings highlight the need for more rigorous methods and standardized guidelines for defining MCIDs, ensuring that criteria, such as sufficient sample size and appropriate anchor thresholds, are met.

Practice Patterns in Speech-Language Pathologist Treatment of Induced Laryngeal Obstruction

PURPOSE

The goal of this study was to examine current speech-language pathologist (SLP) practice patterns in the diagnosis and treatment of induced laryngeal obstruction (ILO; both exercise- and irritant-induced variants: exercise-induced laryngeal obstruction [EILO]/ILO).

METHOD

One hundred ninety-one SLPs from throughout the United States were surveyed regarding practice patterns for diagnosing and treating EILO/ILO. SLPs were queried regarding diagnostic procedures, treatment practices, outcome measures, rescue breathing strategies utilized, and discharge criteria employed within their clinical practice. SLPs rated their confidence in treating EILO/ILO using a visual analog scale. Clinician confidence was compared across SLPs working in different settings, with different populations, and with varying access to diagnostic equipment/collaborators. Median income of facility neighborhood and clinician experience were also considered.

RESULTS

Most SLPs reported that patients with EILO/ILO were diagnosed using laryngoscopy (with or without videostroboscopy) either at rest or following exercise. Only 4.7% of respondents indicated that their patients had access to continuous laryngoscopy during exercise (CLE) for diagnosing EILO. The Dyspnea Index was the most common patient-reported outcome measure for both EILO and ILO. SLPs reported high confidence levels in rescue breathing techniques, and informal patient report was the most common method of tracking therapeutic progress. Forty-one percent of SLPs voiced the need for increased access to diagnostic equipment (CLE or laryngoscopy), and 51.8% expressed the need for exercise facilities (i.e., treadmills or places to have patients run). Clinicians reported significantly higher levels of confidence treating EILO as opposed to ILO (p < .001). Collaborating with a laryngologist (p < .001), more years of experience (p = .025), and wealthier median income of practice setting (p = .014) predicted increased confidence in treating EILO/ILO.

CONCLUSIONS

SLPs may have limited access to the most effective facilities and diagnostic equipment designed to identify EILO/ILO. Continuing research is needed to provide SLPs with evidence-based diagnostic procedures, treatment strategies, and outcome measures to enhance EILO/ILO intervention for all patients.

Treatment and Outcome Metrics for Speech-Language Pathology Treatment of Upper Airway Disorders: A Systematic Review

OBJECTIVE

Clinical treatment strategies and progress metrics for patients with inducible laryngeal obstruction (ILO) and exercise-induced laryngeal obstruction (EILO) have not been systematically applied across clinics. The goals of this review were to identify the intervention strategies used to treat upper airway disorders and determine the clinical metrics by which improvement or resolution of ILO/EILO is determined in clinical studies of speech-language pathology intervention.

METHOD

A systematic review was conducted using the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Systematic Reviews Checklist. English language, full-text publications were identified through MEDLINE (Ovid), APA PsycINFO, and Web of Science for publications that described clinical outcomes following behavioral treatment for ILO provided by a speech-language pathologist (SLP).

RESULTS

A total of 238 sources were retrieved, of which 75 were duplicates. Titles and abstracts of 163 were screened, with 22 sources included for full-text review. Citation review yielded nine additional resources. Thirty-one sources were included for data extraction. Most sources described use of respiratory/laryngeal retraining. There was a lack of consistency for clinical and standardized metrics used to evaluate improvement or resolution of upper airway symptoms.

CONCLUSIONS

Behavioral and standardized outcome metrics for evaluating therapy outcomes from SLP behavioral intervention of ILO/EILO are not consistently applied. Clinical metrics standards for clinicians are needed to provide a means to evaluate graded improvement in treatment and changes in health care utilization as well as for training less-experienced clinicians.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.27172683.

Competitive Swim Breathing: A Survey-Informed Tutorial for Speech-Language Pathologists Who Treat EILO

PURPOSE

Swimmers present a unique challenge for the clinician when presenting with a diagnosis of exercise-induced laryngeal obstruction (EILO). The purpose of this tutorial was to query competitive swimmers about commonly used breathing strategies and then use that information as a basis from which to provide speech-language pathologists who treat EILO in swimmers with a clinical perspective for treatment planning and implementation.

METHODS

A survey of competitive female and male swimmers aged 18 and over was conducted to inquire about swim breathing techniques used in the context of swim distance(s), training versus competition, bilateral versus unilateral head turn, and stroke-to-breath ratio. Questions regarding experience with EILO and asthma were also included.

RESULTS

Following receipt of consent, 62 competitive swimmers completed the survey. The survey results indicated a preference for trickle breathing; however, many volunteers described different breathing strategies for training versus competition. Breath-to-stroke ratios differed widely, often based on swim distance as a means to have competitive advantage. Thirteen volunteers reported difficulty inhaling while swimming, two of whom reported a diagnosis of EILO and one who reported a diagnosis of asthma.

CONCLUSIONS

Swimmers with EILO present with unique challenges for clinicians, given the various breathing techniques used and the idiosyncratic nature of breathing strategies for each swimmer. A one-size-fits-all approach is insufficient for this population and clinicians interested in treating swimmers with EILO will need to employ optimal critical thinking skills for intervention success-a true merger of art and deep understanding of respiratory and laryngeal physiology.

Effects of Exercise-Induced Laryngeal Obstruction in Adolescents: A Qualitative Study

PURPOSE

The purpose of this study was to examine the influence of exercise-induced laryngeal obstruction (EILO) on adolescents.

METHOD

Twenty patients (< 17 years) diagnosed with EILO participated in this study. Patients completed semistructured interviews examining their experience with the health care system, treatment, and the effects of EILO symptoms on quality of life. Interviews were analyzed using a combination of directed and conventional content analyses. Researchers identified seven overarching themes either prior to or during analysis, and 24 subthemes were inductively identified from patient interviews using open, axial, and selective coding.

RESULTS

On average, patients went 1.9 years between symptom onset and EILO diagnosis. Patients described symptom onset as frightening and confusing. Even after initially reporting symptoms to a medical provider, patients went an average of 10.5 months before diagnosis. Patients perceived that delays in diagnosis prevented efficient management and allowed symptoms to escalate. Patients reported that EILO detrimentally influenced athletic performance, forcing them to pace themselves or cease participation altogether. Social and academic effects of EILO included missed classes, difficulty in physical education courses, and resentment from teammates if athletic performance declined. Both athletes and nonathletes indicated that EILO elicited feelings of fear, frustration, dread, guilt, and embarrassment. Patients reported that therapy with a speech-language pathologist (SLP) effectively addressed symptoms; however, employing rescue breathing techniques was often more difficult than anticipated.

CONCLUSIONS

Physical and emotional sequelae associated with EILO may have widespread influence on patient quality of life. Therapy with an SLP reportedly ameliorated EILO symptoms; however, patients indicated that delayed diagnosis allowed negative effects to intensify prior to treatment.

Long-Term Outcomes of Respiratory Retraining Therapy for Exercise-Induced Laryngeal Obstruction

OBJECTIVE

To assess the long-term outcomes and efficacy of respiratory retraining therapy in patients with exercise-induced laryngeal obstruction (EILO).

METHODS

A retrospective chart review and prospective questionnaire-based survey were conducted on 88 patients who received respiratory retraining therapy for EILO at our institution over the past 5 years RESULTS: Thirty-four patients were included in the final analysis, with a mean age at symptom onset and age at initial evaluation of 13.67 ± 2.96 and 15.12 ± 3.48, respectively. We found a statistically significant difference in the pretreatment and post-treatment Dyspnea indices following respiratory retraining therapy, with a mean difference of 12.03 ± 7.18 (P < 0.001). When asked about the effectiveness of respiratory retraining therapy, the majority of patients (n = 28) reported improvement (13.3% "a little," 13.3% "somewhat better," 53.3% ("a lot better," and 13.3% complete resolution of symptoms. Only two patients (6.7%) responded that their breathing "did not get better." The most effective therapy techniques cited by patients were abdominal breathing (n = 10), ratio breathing (n = 5), and pursed lips or "straw" breathing (n = 5).

CONCLUSIONS

Respiratory retraining therapy represents an effective technique in both the short-term and long-term management of EILO. This therapy remains the first line in the management of EILO due to its ease of administration, non-invasive nature, and durable effect on breathing function.

Growing up with allergies: Transitioning from adolescence to adulthood

Allergic disease management for adolescents and young adults requires consideration of unique psychosocial challenges and opportunities. Erik Erikson's model for the Stages of Psychosocial Development is a useful lens through which we can understand adolescent and young adult experiences with allergic and immunologic disease, particularly with regard to identity and relationship development. It is important to provide anticipatory guidance for patients who are transitioning environments (eg, home to college), with attention to the anxiety-provoking demands for increased responsibility on top of new stressors such as academic and vocational demands. It is critical that health care professionals use an empathetic, shared decision-making approach regarding the emotional impact of allergy on a patient's social engagement. A patient's ability to develop positive lifelong habits is also shaped by their environment's "culture of wellness," and clinicians can encourage habits to promote healthy choices and effective disease management. Social media provides opportunities and challenges as a conduit for both social connection and possible misinformation. Overall, allergic disease management in adolescents and young adults is a "high-risk, high-reward" period of time-and with awareness, anticipation, and proactive action, health care professionals can better serve patients by leveraging this transitional period to promote positive approaches to management of allergies and asthma, trusting relationships, and personal responsibility.

Therapy Outcomes for Teenage Athletes With Exercise-Induced Laryngeal Obstruction

PURPOSE

This study examined treatment outcomes of speech-language pathology intervention addressing exercise-induced laryngeal obstruction (EILO) symptoms in teenage athletes.

METHOD

A prospective cohort design was utilized; teenagers diagnosed with EILO completed questionnaires during initial EILO evaluations, posttherapy, 3-month posttherapy, and 6-month posttherapy. Questionnaires examined the frequency of breathing problems, the use of the techniques taught in therapy, and the use of inhaler. Patients completed the Pediatric Quality of Life (PedsQL) inventory at all time points.

RESULTS

Fifty-nine patients completed baseline questionnaires. Of these, 38 were surveyed posttherapy, 32 at 3-month posttherapy, and 27 at 6-month posttherapy. Patients reported more frequent and complete activity participation immediately posttherapy (p = .017) as well as reduced inhaler use (p = .036). Patients also reported a significant reduction in the frequency of breathing problems 6-month posttherapy (p = .015). Baseline PedsQL physical and psychosocial scores were below normative range and were not impacted by therapy. Baseline physical PedsQL score significantly predicted frequency of breathing difficulty 6-month posttherapy (p = .04), as better baseline scores were associated with fewer residual symptoms.

CONCLUSIONS

Therapy with a speech-language pathologist for EILO allowed for more frequent physical activity following therapy completion and decreased dyspnea symptoms 6-month posttherapy. Therapy was associated with a decrease in inhaler use. PedsQL scores indicated mildly poor health-related quality of life even after EILO symptoms improved. Findings support therapy as an effective treatment for EILO in teenage athletes and suggest that dyspnea symptoms may continue to improve following discharge as patients continue using therapy techniques.

Vocal cord dysfunction/inducible laryngeal obstruction-2022 Melbourne Roundtable Report

Vocal cord dysfunction/inducible laryngeal obstruction (VCD/ILO), is a common condition characterized by breathlessness associated with inappropriate laryngeal narrowing. Important questions remain unresolved, and to improve collaboration and harmonization in the field, we convened an international Roundtable conference on VCD/ILO in Melbourne, Australia. The aims were to delineate a consistent approach to VCD/ILO diagnosis, appraise disease pathogenesis, outline current management and model(s) of care and identify key research questions. This report summarizes discussions, frames key questions and details recommendations. Participants discussed clinical, research and conceptual advances in the context of recent evidence. The condition presents in a heterogenous manner, and diagnosis is often delayed. Definitive diagnosis of VCD/ILO conventionally utilizes laryngoscopy demonstrating inspiratory vocal fold narrowing >50%. Computed tomography of the larynx is a new technology with potential for swift diagnosis that requires validation in clinical pathways. Disease pathogenesis and multimorbidity interactions are complex reflecting a multi-factorial, complex condition, with no single overarching disease mechanism. Currently there is no evidence-based standard of care since randomized trials for treatment are non-existent. Recent multidisciplinary models of care need to be clearly articulated and prospectively investigated. Patient impact and healthcare utilization can be formidable but have largely escaped inquiry and patient perspectives have not been explored. Roundtable participants expressed optimism as collective understanding of this complex condition evolves. The Melbourne VCD/ILO Roundtable 2022 identified clear priorities and future directions for this impactful condition.

Exercise induced laryngeal obstruction (EILO) in children and young people: Approaches to assessment and management

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.

Vocal cord dysfunction/inducible laryngeal obstruction: novel diagnostics and therapeutics

INTRODUCTION

Vocal cord dysfunction/inducible laryngeal obstruction (VCD/ILO) is an important medical condition but understanding of the condition is imperfect. It occurs in healthy people but often co-exists with asthma. Models of VCD/ILO pathophysiology highlight predisposing factors rather than specific mechanisms and disease expression varies between people, which is seldom appreciated. Diagnosis is often delayed, and the treatment is not evidence based.

AREAS COVERED

A unified pathophysiological model and disease phenotypes have been proposed. Diagnosis is conventionally made by laryngoscopy during inspiration with vocal cord narrowing >50% Recently, dynamic CT larynx was shown to have high specificity (>80%) with potential as a noninvasive, swift, and quantifiable diagnostic modality. Treatment entails laryngeal retraining with speech pathology intervention and experimental therapies such as botulinum toxin injection. Multidisciplinary team (MDT) clinics are a novel innovation with demonstrated benefits including accurate diagnosis, selection of appropriate treatment, and reductions in oral corticosteroid exposure.

EXPERT OPINION

Delayed diagnosis of VCD/ILO is pervasive, often leading to detrimental treatments. Phenotypes require validation and CT larynx can reduce the necessity for laryngoscopy, thereby fast-tracking diagnosis. MDT clinics can optimize management. Randomized controlled trials are essential to validate speech pathology intervention and other treatment modalities and to establish international standards of care.

Diagnosis and management of allergy and respiratory disorders in sport: An EAACI task force position paper

Allergy and respiratory disorders are common in young athletic individuals. In the context of elite sport, it is essential to secure an accurate diagnosis in order to optimize health and performance. It is also important, however, to consider the potential impact or consequences of these disorders, in recreationally active individuals engaging in structured exercise and/or physical activity to maintain health and well-being across the lifespan. This EAACI Task Force was therefore established, to develop an up-to-date, research-informed position paper, detailing the optimal approach to the diagnosis and management of common exercise-related allergic and respiratory conditions. The recommendations are informed by a multidisciplinary panel of experts including allergists, pulmonologists, physiologists and sports physicians. The report is structured as a concise, practically focussed document, incorporating diagnostic and treatment algorithms, to provide a source of reference to aid clinical decision-making. Throughout, we signpost relevant learning resources to consolidate knowledge and understanding and conclude by highlighting future research priorities and unmet needs.

Exercise-induced laryngeal obstruction (EILO) in athletes: a narrative review by a subgroup of the IOC Consensus on 'acute respiratory illness in the athlete'

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.