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Karkouli G, Douros K, Moriki D, Moutsatsou P, Giannopoulou I, Maratou E, Koumpagioti D. Dysfunctional Breathing in Children: A Literature Review. Children (Basel) 2024; 11:556. [PMID: 38790551 DOI: 10.3390/children11050556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/09/2024] [Revised: 04/22/2024] [Accepted: 05/03/2024] [Indexed: 05/26/2024]
Abstract
Dysfunctional breathing (DB) describes a respiratory condition that is mainly characterized by abnormal breathing patterns, affecting both children and adults, often leading to intermittent or chronic complaints and influencing physiological, psychological, and social aspects. Some symptoms include breathlessness; dizziness; palpitations; and anxiety, while its classification lies in breathing pattern disorders and upper airway involvement. Its prevalence among the pediatric population varies with a female overrepresentation, while the existence of comorbidities in DB, such as asthma, gastro-esophageal reflux, nasal diseases, and anxiety/depression, frequently leads to misdiagnosis or underdiagnosis and complicates therapeutic approaches. The basic diagnostic tools involve a detailed history, physical examination, and procedures such as structured light plethysmography, cardiopulmonary exercise testing, and laryngoscopy when a laryngeal obstruction is present. The management of DB presumes a multidimensional approach encompassing breathing retraining, disease-specific advice through speech and language therapy in the presence of laryngeal obstruction, psychotherapy for fostering self-efficacy, and surgical therapy in a structural abnormality. The current review was developed to provide a summary of classifications of DB and epidemiological data concerning the pediatric population, comorbidities, diagnostic tools, and therapeutic approaches to enhance the comprehension and management of DB in children.
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Affiliation(s)
- Georgia Karkouli
- Allergology and Pulmonology Unit, 3rd Pediatric Department, National and Kapodistrian University of Athens, 12462 Athens, Greece
| | - Konstantinos Douros
- Allergology and Pulmonology Unit, 3rd Pediatric Department, National and Kapodistrian University of Athens, 12462 Athens, Greece
| | - Dafni Moriki
- Allergology and Pulmonology Unit, 3rd Pediatric Department, National and Kapodistrian University of Athens, 12462 Athens, Greece
| | - Paraskevi Moutsatsou
- Department of Clinical Biochemistry, National and Kapodistrian University of Athens, 12462 Athens, Greece
| | - Ioanna Giannopoulou
- Department of Psychiatry, National and Kapodistrian University of Athens, 12462 Athens, Greece
| | - Eirini Maratou
- Department of Clinical Biochemistry, National and Kapodistrian University of Athens, 12462 Athens, Greece
| | - Despoina Koumpagioti
- Department of Nursing, National and Kapodistrian University of Athens, 11527 Athens, Greece
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Fujiki RB, Thibeault SL. Diagnostic utility of spirometry for children with induced laryngeal obstruction or chronic non-specific cough. Am J Otolaryngol 2024; 45:104316. [PMID: 38677150 DOI: 10.1016/j.amjoto.2024.104316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2024] [Accepted: 04/15/2024] [Indexed: 04/29/2024]
Abstract
PURPOSE To determine the diagnostic utility of spirometry in distinguishing children with Induced Laryngeal Obstruction (ILO) or chronic non-specific cough (a.k.a. tic cough) from those with mild or moderate to severe asthma. METHODS Retrospective cross sectional design. Children diagnosed with ILO (N = 70), chronic non-specific cough (N = 70), mild asthma (N = 60), or moderate to severe asthma (N = 60) were identified from the electronic medical record of a large children's hospital. Spirometry was completed before ILO, non-specific cough, or asthma diagnoses were made by pediatric laryngologists or pulmonologists. Spirometry was performed following American Thoracic Society guidelines and was interpreted by a pediatric pulmonologist. Forced Vital Capacity (FVC), Forced Expiratory Volume in 1 Second (FEV1), FEV1/FVC Ratio (FEV1/FVC), Forced Mid-Expiratory Flow 25--75 % (FEF25-75%), pulmonologist interpretation of flow volume loops, and overall exam findings were extracted from the medical record. RESULTS Ninety seven percent of children with ILO or chronic non-specific cough presented with spirometry values within normative range. Patients with ILO, non-specific cough, and mild asthma presented with FVC, FEV1, FEV1/FVC, and FEF25-75% values in statistically similar range. Children with moderate to severe asthma presented with significantly reduced FVC (p < .001), FEV1 (p < .001), FEV1/FVC (p < .001), and FEF25-75% (p < .001) values when compared with patients in the other groups. Flow volume loops were predominantly normal for children with ILO and non-specific cough. CONCLUSIONS Findings indicate that ILO and chronic non-specific cough can neither be diagnosed nor differentiated from mild asthma using spirometry alone. Spirometry should therefore be used judiciously with this population, bearing in mind the limitations of the procedure. Future research should determine the most effective and efficient ways of delineating ILO and non-specific cough from other respiratory conditions in children.
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Affiliation(s)
- Robert Brinton Fujiki
- Department of Surgery, University of Wisconsin - Madison, Madison, WI, United States of America
| | - Susan L Thibeault
- Department of Surgery, University of Wisconsin - Madison, Madison, WI, United States of America.
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Mills JF, Monaghan NP, Nguyen SA, O'Rourke AK, Halstead LA, Meyer TA. Adult Laryngomalacia: A Scoping Review. Otolaryngol Head Neck Surg 2024; 170:1020-1031. [PMID: 38219735 DOI: 10.1002/ohn.639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Revised: 12/14/2023] [Accepted: 12/17/2023] [Indexed: 01/16/2024]
Abstract
OBJECTIVE This review sought to determine the characteristics of adults diagnosed with new onset laryngomalacia including airway symptoms, laryngoscopic findings, treatments, and outcomes. Moreover, we wanted to highlight suspected limitations in the literature. DATA SOURCES Studies were identified through CINAHL, Cochrane Review, PubMed, and Scopus published between 1966 and 2023. REVIEW METHODS The search was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analysis Extension for Scoping Reviews checklist by 2 independent investigators. A meta-analysis of proportions and continuous measures was conducted. RESULTS Of the 1121 abstracts identified, 33 articles pertaining to laryngomalacia in the adult population were included. The most common presenting symptoms were stridor at rest (78.3%, 65.1-88.3) and dyspnea with exertion (83.8%, 64.8-96.3). The most suspected etiology was exercise-induced (86.0%, 69.4-95.5), and the most common description of laryngomalacia on visualization was collapse of supraglottic structures during exercise (93.3%, 79.0-99.1). Nonsurgical options were attempted in 87.0% (54.0-99.1), which included oral appliances, respiratory retraining, breathing techniques, and working with a speech pathologist. Surgical options were ultimately performed in 84.2% (75.0-91.0). Complete resolution of symptoms following therapy was seen in 61.9% (48.0-74.6). CONCLUSION Adult onset laryngomalacia is difficult to characterize. It typically presents in patients during exercise, with neurological injury, or idiopathically. Surgical management can lead to improvement or complete resolution of symptoms. The need for a universal nomenclature is highlighted in this review, as it is inconsistently classified.
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Affiliation(s)
- John F Mills
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
- Department of Otolaryngology-Head and Neck Surgery, Albany Medical College, Albany, New York, USA
| | - Neil P Monaghan
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Shaun A Nguyen
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Ashli K O'Rourke
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Lucinda A Halstead
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Ted A Meyer
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
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Weinberger M. Evaluation and management of exercise-induced dyspnea in otherwise healthy adolescents and young adults: A critical review. Paediatr Respir Rev 2024:S1526-0542(24)00025-3. [PMID: 38637185 DOI: 10.1016/j.prrv.2024.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Revised: 02/17/2024] [Accepted: 02/26/2024] [Indexed: 04/20/2024]
Abstract
Dyspnea on exertion in otherwise healthy adolescents and young adults is often brought to the attention of a pediatric pulmonologist when it interferes with an athletic activity. Assessment of the cause and management has been controversial. Skilled pediatric pulmonologists may suspect the cause from a careful history, but a more definite diagnosis is needed to provide the most appropriate management. Suspecting that laryngeal obstruction is the major cause, continuous laryngoscopy during exercise has been proposed. However, that method tends to over diagnose laryngeal obstruction and does not consider that the larynx is not the major cause of dyspnea on exertion (DOE). The cause of DOE can generally be best identified by a treadmill test using cardiopulmonary monitoring to determine the physiology associated with reproduced symptoms. Management of DOE requires a specific diagnosis and may involve medication, surgery, or education and training.
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Affiliation(s)
- Miles Weinberger
- Volunteer Clinical Professor, University of California SanDiego, Rady Children's Hospital, Professor Emeritus, University of Iowa, United States.
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Thougaard J, Pedersen L, Walsted E. Feasibility of Constant Work Rate Testing to Detect Exercise-Induced Laryngeal Obstruction. Med Sci Sports Exerc 2024; 56:427-434. [PMID: 38356163 DOI: 10.1249/mss.0000000000003319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2024]
Abstract
INTRODUCTION Exercise-induced laryngeal obstruction (EILO) is a condition in which laryngeal structures inappropriately obstruct the upper airway during exercise. The standard diagnostic test for EILO is the continuous laryngoscopy during exercise (CLE) test, usually performed with an incremental work rate protocol regardless of the nature of the triggering event. Typically, laryngeal obstruction occurs only briefly at the end of an incremental test, near peak work capacity. We aimed to investigate constant work rate (CWR) protocols for CLE testing to expand diagnostic test modalities and improve the understanding of EILO. METHODS In this prospective, self-controlled feasibility study, 10 patients with EILO performed both an incremental and a CWR CLE test at 70%, 80%, and 90% of maximal exercise capacity. Laryngoscopic video data were recorded and compared, and we evaluated the ability of CWR to reproduce the symptoms and laryngeal obstruction seen in incremental testing. RESULTS In 70%-90% of cases, CWR testing induced at least the same severity of obstruction as incremental testing and CLE scores remained comparable across test modalities. CWR at 70% allowed observation of laryngeal obstruction for a significantly longer duration than in incremental testing (158 s; 95% confidence interval, 25-291 s; P = 0.027). Dyspnea intensity appeared higher during CWR testing compared with incremental testing. CONCLUSIONS Submaximal CWR CLE testing is feasible and able to induce EILO equivalent to the standard incremental CLE test. This is the first step toward tailored CLE exercise protocols, and further studies are now needed to establish the utility of CWR in clinical and research settings.
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Affiliation(s)
- Jens Thougaard
- Department of Respiratory Medicine, Bispebjerg Hospital, Copenhagen, DENMARK
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Jeppesen K, Philipsen BB, Mehlum CS. Prevalence and characterisation of exercise-induced laryngeal obstruction in patients with exercise-induced dyspnoea. J Laryngol Otol 2024; 138:208-215. [PMID: 37646338 PMCID: PMC10849894 DOI: 10.1017/s0022215123001494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 07/03/2023] [Accepted: 07/18/2023] [Indexed: 09/01/2023]
Abstract
OBJECTIVE The prevalence of exercise-induced laryngeal obstruction is largely unknown. This study aimed to evaluate the prevalence of this condition in a selected study population of patients with exercise-induced dyspnoea. METHOD A retrospective analysis was conducted of demographic data, co-morbidities, medication, symptoms, performance level of sporting activities, continuous laryngoscopy exercise test results and subsequent treatment. RESULTS Data from 184 patients were analysed. The overall prevalence of exercise-induced laryngeal obstruction in the study population was 40 per cent, and the highest prevalence was among females aged under 18 years (61 per cent). However, a high prevalence among males aged under 18 years (50 per cent) and among adults regardless of gender (34 per cent) was also found. CONCLUSION The prevalence of exercise-induced laryngeal obstruction is clinically relevant regardless of age and gender. Clinicians are encouraged to consider exercise-induced laryngeal obstruction as a possible diagnosis in patients suffering from exercise-induced respiratory symptoms. No single characteristic that can distinguish exercise-induced laryngeal obstruction from other similar conditions was identified.
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Affiliation(s)
- Karin Jeppesen
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital of Southern Denmark, Sønderborg, Denmark
| | - Bahareh Bakhshaie Philipsen
- Department of Otorhinolaryngology, Head and Neck Surgery and Audiology, Odense University Hospital, Odense, Denmark
| | - Camilla Slot Mehlum
- Department of Otorhinolaryngology, Head and Neck Surgery and Audiology, Odense University Hospital, Odense, Denmark
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Dreßler M, Lassmann H, Eichhorn C, Trischler J, Hutter M, Zielen S, Schulze J. Are Questionnaires Helpful To Predict Exercise-Induced Bronchoconstriction (EIB) And Exercise-Induced Laryngeal Obstruction (EILO)? Klin Padiatr 2024; 236:139-144. [PMID: 38286408 DOI: 10.1055/a-2151-2269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2024]
Abstract
OBJECTIVE Exercise induced laryngeal obstruction (EILO) is an important differential diagnosis to exercise induced bronchoconstriction (EIB) and diagnosed via continuous laryngoscopy while exercising (CLE). However, availability of CLE is limited to specialized centres. And without CLE EILO is often misdiagnosed as EIB. Therefore it is essential to carefully preselect potential EILO candidates. Aim of this study was to investigate whether two short questionnaires -Asthma Control Test (ACT) and Dyspnea Index (DI) evaluating upper airway-related dyspnea- can differentiate between EIB and EILO. METHODS Patients with dyspnea while exercising were analysed with an exercise challenge in the cold chamber (ECC) to diagnose EIB in visit 1 (V1), as appropriate a CLE in visit 2 (V2, 4-6 weeks after V1) and ACT and DI in V1 and V2. EIB patients were treated with asthma medication after V1. RESULTS Complete dataset of 36 subjects were gathered. The ACT showed lower values in V2 in EILO compared to EIB patients. A lack of improvement in ACT in V2 after asthma medication of EIB patients is suspicious for additional EILO diagnosis. The DI showed higher values in V1 in EILO compared to EIB patients. A score≥30 can predict a positive CLE reaction. CONCLUSION ACT and DI are valuable tools in preselecting CLE candidates to assure timely diagnostic despite limited diagnostic capabilities.
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Affiliation(s)
- Melanie Dreßler
- Goethe-University Frankfurt, University Hospital, Department of Pediatrics, Pneumology, Allergology, Infectious Diseases, Gastroenterology, Germany
| | - Hannah Lassmann
- Goethe-University Frankfurt, University Hospital, Department of Pediatrics, Pneumology, Allergology, Infectious Diseases, Gastroenterology, Germany
| | - Celine Eichhorn
- Goethe-University Frankfurt, University Hospital, Department of Pediatrics, Pneumology, Allergology, Infectious Diseases, Gastroenterology, Germany
| | - Jordis Trischler
- Goethe-University Frankfurt, University Hospital, Department of Pediatrics, Pneumology, Allergology, Infectious Diseases, Gastroenterology, Germany
| | - Martin Hutter
- Goethe-University Frankfurt, University Hospital, Department of Pediatrics, Pneumology, Allergology, Infectious Diseases, Gastroenterology, Germany
| | - Stefan Zielen
- Goethe-University Frankfurt, University Hospital, Department of Pediatrics, Pneumology, Allergology, Infectious Diseases, Gastroenterology, Germany
| | - Johannes Schulze
- Goethe-University Frankfurt, University Hospital, Department of Pediatrics, Pneumology, Allergology, Infectious Diseases, Gastroenterology, Germany
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Kolnes LJ, Stensrud T, Andersen OK. A multidimensional strategy to managing dysfunctional breathing and exercise-induced laryngeal obstruction in adolescent athletes. BMC Sports Sci Med Rehabil 2024; 16:13. [PMID: 38212851 PMCID: PMC10782679 DOI: 10.1186/s13102-023-00804-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 12/28/2023] [Indexed: 01/13/2024]
Abstract
BACKGROUND Exercise induced laryngeal obstruction (EILO) causes inspiratory distress in the upper airway in many adolescent athletes. The nature of EILO is not fully understood, and effective management strategies are lacking. This study aimed to assess the effectiveness of a multidimensional individually tailored intervention, including Norwegian Psychomotor Physiotherapy (NPMP), elements of cognitive behavioural therapy and a rehabilitation plan, in reducing inspiratory distress and dysfunctional breathing in adolescent athletes with EILO. METHODS A mixed methods design, which combined qualitative and quantitative research, was used. Data, including subjective experiences of respiratory distress, findings from body examinations and objective measurements of lung function and aerobic capacity were gathered before and after a five month intervention involving 18 participants. RESULTS Following the intervention, the participants showed a reduction in respiratory distress and anxiousness associated with their breathing difficulties. Furthermore, the participants reported to be more in control of their breathing. The body assessments revealed a more functional breathing motion and improved posture, which imply that the breathing was less thoracic and more diaphragmatic in rest and exercise in all participants after the intervention. CONCLUSIONS Our results suggest that a multidimensional individually tailored intervention, including NPMP based physiotherapy, cognitive behavioural therapy elements, and a rehabilitation plan may reduce inspiratory distress and dysfunctional breathing in athletes with EILO. TRIAL REGISTRATION ClinicalTrials.gov Protocol Registration and Results system NCT06033755, date of registration: September12, 2023. Retrospectively registered.
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Affiliation(s)
- Liv-Jorunn Kolnes
- Faculty of Health, VID Specialized University, Diakonveien 12-18, 0370, Oslo, Norway.
| | - Trine Stensrud
- Department of Sports Medicine, Norwegian School of Sport Sciences, Oslo, Norway
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Ntoumenopoulos G, Andersen T, Hardingham NM. Upper airway assessment and its implications for interventions by respiratory physiotherapists. Physiother Theory Pract 2024; 40:184-189. [PMID: 35904123 DOI: 10.1080/09593985.2022.2106916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Accepted: 07/16/2022] [Indexed: 10/16/2022]
Abstract
BACKGROUND When noninvasive interventions such as chest physiotherapy fail, then more aggressive interventions for airway secretion clearance with nasotracheal airway suctioning may be required. Clinicians however have to insert the nasotracheal suction catheter "blindly" and the success of being able to trigger a cough and pass through the vocal folds with a suction catheter is low. CASE DESCRIPTION The patient, a 48-year-old male underwent a heart and lung transplant. Following extubation, the patient developed secretion retention with a weak ineffective cough and swallow and required physiotherapy interventions with frequent "blind" passes of nasotracheal suctioning. OUTCOMES The patient required nasotracheal suction with frequent multiple failed attempts before successful passage of the suction catheter to trigger a cough reflex and clear secretions. A combined physiotherapist and speech and language therapist intervention during fiberoptic endoscopic evaluation of swallow (FEES) was recorded to both evaluate swallow and passage of the suction catheter. The video illustrated the successful passage of a suctioning catheter through the vocal folds leading to an effective cough and airway clearance. DISCUSSION We present a case report demonstrating that it is feasible to visualize the upper airways during nasotracheal suctioning as an objective means to guide the more accurate successful insertion of the suction catheter past the vocal folds. Rather than "blind" placement of nasotracheal suction catheters visualization using transnasal laryngoscopy should be useful to increase chances of passing through the vocal folds.
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Affiliation(s)
| | - Tiina Andersen
- Norwegian Centre of Excellence for Home Mechanical Ventilation, Thoracic Department, Haukeland University Hospital, Bergen, Norway
| | - Nicola M Hardingham
- Speech Pathology Department, St Vincent's Hospital, Sydney, Australia
- School of Health and Rehabilitation Sciences, University of Queensland, St Lucia, Australia
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Leng T, Wiedermann J, Cofer S, Pillai S. The Clinical Utility of Continuous Laryngoscopy During Exercise: A Report of Two Cases. Cureus 2023; 15:e50572. [PMID: 38222221 PMCID: PMC10788043 DOI: 10.7759/cureus.50572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/14/2023] [Indexed: 01/16/2024] Open
Abstract
Exertional dyspnea is a common and disabling symptom in otherwise healthy children and adolescents, as well as in children with baseline airway abnormalities. It impairs the quality of life and may be associated with fatigue and underperformance in sports. Exertional dyspnea can be caused by a wide variety of structural and psychogenic causes. Exercise-induced laryngeal obstruction (EILO) is a relatively prevalent entity in young people that usually presents with exertional stridor, coughing, and dyspnea caused by transient closure of the larynx. In more complex cases where conventional tests such as pulmonary function tests (PFTs), chest imaging, ECG, and echocardiography are unrevealing, continuous laryngoscopy during exercise (CLE) tests may provide diagnostic utility. In addition to the baseline abnormalities visualized by conventional laryngoscopy, CLE can assess dynamic laryngeal responses during exercise. This article describes the clinical characteristics of two pediatric patients with various degrees of laryngeal dysfunction at baseline and the utility of CLE testing in tailoring management strategies.
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Affiliation(s)
- Tomas Leng
- Department of Pediatrics and Adolescent Medicine, Mayo Clinic, Rochester, USA
| | - Joshua Wiedermann
- Department of Pediatric Otorhinolaryngology, Mayo Clinic, Rochester, USA
| | - Shelagh Cofer
- Department of Pediatric Otorhinolaryngology, Mayo Clinic, Rochester, USA
| | - Sophia Pillai
- Department of Pediatric Pulmonary Medicine, Mayo Clinic, Rochester, USA
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Irewall T, Bäcklund C, Naumburg E, Ryding M, Stenfors N. A longitudinal follow-up of continuous laryngoscopy during exercise test scores in athletes irrespective of laryngeal obstruction, respiratory symptoms, and intervention. BMC Sports Sci Med Rehabil 2023; 15:87. [PMID: 37454093 DOI: 10.1186/s13102-023-00681-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 06/21/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND Exercise-induced laryngeal obstruction (EILO) is diagnosed by the continuous laryngoscopy during exercise (CLE) test. Whether or how much CLE test scores vary over time is unknown. This study aimed to compare CLE test scores in athletes over time, irrespective of respiratory symptoms and grade of laryngeal obstruction. METHODS Ninety-eight athletes previously screened for EILO were invited for a follow-up CLE test irrespective of CLE scores and respiratory symptoms. Twenty-nine athletes aged 16-27 did a follow-up CLE test 3-23 months after the baseline test. Laryngeal obstruction at the glottic and supraglottic levels was graded by the observer during exercise, at baseline and follow-up, using a visual grade score (0-3 points). RESULTS At baseline, 11 (38%) of the 29 athletes had moderate laryngeal obstruction and received advice on breathing technique; among them, 8 (73%) reported exercise-induced dyspnea during the last 12 months. At follow-up, 8 (73%) of the athletes receiving advice on breathing technique had an unchanged supraglottic score. Three (17%) of the 18 athletes with no or mild laryngeal obstruction at baseline had moderate supraglottic obstruction at follow-up, and none of the 3 reported exercise-induced dyspnea. CONCLUSIONS In athletes with repeated testing, CLE scores remain mostly stable over 3-24 months even with advice on breathing technique to those with EILO. However, there is some intraindividual variability in CLE scores over time. TRIAL REGISTRATION ISRCTN, ISRCTN60543467, 2020/08/23, retrospectively registered, ISRCTN - ISRCTN60543467: Investigating conditions causing breathlessness in athletes.
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Affiliation(s)
- Tommie Irewall
- Division of Medicine, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Catharina Bäcklund
- Unit of Physiotherapy, Östersund Hospital, Region Jämtland Härjedalen, Östersund, Sweden
| | - Estelle Naumburg
- Department of Clinical Sciences, Pediatrics, Umeå University, Umeå, Sweden
| | - Marie Ryding
- Unit of Otorhinolaryngology, Östersund Hospital, Region Jämtland Härjedalen, Östersund, Sweden
| | - Nikolai Stenfors
- Division of Medicine, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden.
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Fujiki RB, Olson-Greb B, Braden M, Thibeault SL. Therapy Outcomes for Teenage Athletes With Exercise-Induced Laryngeal Obstruction. Am J Speech Lang Pathol 2023; 32:1517-1531. [PMID: 37195781 PMCID: PMC10473392 DOI: 10.1044/2023_ajslp-22-00359] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 01/16/2023] [Accepted: 03/07/2023] [Indexed: 05/18/2023]
Abstract
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.
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Affiliation(s)
- Robert Brinton Fujiki
- Department of Surgery, University of Wisconsin-Madison
- Speech and Audiology Clinics, UW Health, Madison, WI
| | | | - Maia Braden
- Department of Communication Sciences and Disorders, University of Wisconsin-Madison
| | - Susan L Thibeault
- Department of Surgery, University of Wisconsin-Madison
- Department of Communication Sciences and Disorders, University of Wisconsin-Madison
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Rogde ÅJ, Lehmann S, Halvorsen T, Clemm HH, Røksund OD, Hufthammer KO, Kvidaland HK, Vollsæter M, Andersen TM. Prevalence and impact of exercise-induced laryngeal obstruction in asthma: a study protocol for a cross-sectional and longitudinal study. BMJ Open 2023; 13:e071159. [PMID: 37328176 PMCID: PMC10277068 DOI: 10.1136/bmjopen-2022-071159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 05/30/2023] [Indexed: 06/18/2023] Open
Abstract
INTRODUCTION Exercise-induced laryngeal obstruction (EILO) and exercise-induced asthma can cause troublesome respiratory symptoms that can be difficult to distinguish between. Further, there is now a growing appreciation that the two conditions may coexist, complicating the interpretation of symptoms. The primary aim of this study is to investigate the prevalence of EILO in patients with asthma. Secondary aims include evaluation of EILO treatment effects and investigation of comorbid conditions other than EILO in patients with asthma. METHODS AND ANALYSIS The study will be conducted at Haukeland University Hospital and Voss Hospital in Western Norway, and enrol 80-120 patients with asthma and a control group of 40 patients without asthma. Recruitment started in November 2020, and data sampling will continue until March 2024. Laryngeal function will be assessed at baseline and at a 1-year follow-up, using continuous laryngoscopy during high-intensity exercise (CLE). Immediately after the EILO diagnosis is verified, patients will be treated with standardised breathing advice guided by visual biofeedback from the laryngoscope video screen. The primary outcome will be the prevalence of EILO in patients with asthma and control participants. Secondary outcomes include changes in CLE scores, asthma-related quality of life, asthma control and number of the asthma exacerbations, as assessed between baseline and the 1-year follow-up. ETHICS AND DISSEMINATION Ethical approval has been obtained from the Regional Committee for Medical and Health Research Ethics, Western Norway, (ID number 97615). All participants will provide signed informed consent before enrolment. The results will be presented in international journals and conferences. TRIAL REGISTRATION NUMBER NCT04593394.
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Affiliation(s)
- Åse Johnsen Rogde
- Thoracic Department, Haukeland University Hospital, Bergen, Norway
- Faculty of Medicine, Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Sverre Lehmann
- Thoracic Department, Haukeland University Hospital, Bergen, Norway
- Faculty of Medicine, Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Thomas Halvorsen
- Faculty of Medicine, Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Department of Pediatrics, Haukeland University Hospital, Bergen, Norway
| | - Hege Havstad Clemm
- Faculty of Medicine, Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Department of Pediatrics, Haukeland University Hospital, Bergen, Norway
| | - Ola Drange Røksund
- Department of Pediatrics, Haukeland University Hospital, Bergen, Norway
- Department of Health and Function, Western Norway University of Applied Sciences, Bergen, Norway
| | | | - Haakon Kristian Kvidaland
- Department of Pediatrics, Haukeland University Hospital, Bergen, Norway
- Department of Health and Function, Western Norway University of Applied Sciences, Bergen, Norway
| | - Maria Vollsæter
- Faculty of Medicine, Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Department of Pediatrics, Haukeland University Hospital, Bergen, Norway
| | - Tiina Maarit Andersen
- Thoracic Department, Haukeland University Hospital, Bergen, Norway
- Department of Health and Function, Western Norway University of Applied Sciences, Bergen, Norway
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14
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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15
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Clemm HSH. Letter from Norway. Respirology 2023; 28:500-501. [PMID: 36882379 DOI: 10.1111/resp.14478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 02/15/2023] [Indexed: 03/09/2023]
Affiliation(s)
- Hege Synnøve Havstad Clemm
- Department of Pediatric and Adolescent Medicine, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Science, University of Bergen, Bergen, Norway
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16
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Giraud L, Destors M, Clin R, Fabre C, Doutreleau S, Atallah I. Diagnostic work-up of exercise-induced laryngeal obstruction. Eur Arch Otorhinolaryngol 2023; 280:1273-1281. [PMID: 36136148 DOI: 10.1007/s00405-022-07654-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 09/12/2022] [Indexed: 02/07/2023]
Abstract
PURPOSE Exercise-induced laryngeal obstruction (EILO) is suspected when dyspnea associated with upper airway symptoms is triggered by exercise. This condition affects mainly adolescent athletes. Visualization of the obstruction, while the patient is experiencing the symptoms during continuous laryngoscopy during exercise (CLE-test) is the gold standard for diagnosing EILO. Our study aims to evaluate the prevalence of EILO in a population presenting exercise-induced inspiratory symptoms (EIIS) or uncontrolled asthma with exertional symptoms. The second objective was to evaluate the diagnostic strength of laryngology consultation (LC) and pulmonary function tests (PFTs). METHODS All patients referred to our center for EIIS or uncontrolled asthma with exertional symptoms were included. EILO diagnosis was made if Maat score was > 2 for patients with CLE-test or if there were inspiratory anomalies on PFTs and LC. The sensitivity and specificity of LC and PFTs as diagnostic tools were calculated considering CLE-test as the gold standard. RESULTS Sixty two patients were referred to our center for EIIS or uncontrolled asthma with exertional symptoms. EILO was diagnosed in 28 patients (56%) with associated asthma in 9 patients (18%). The sensibility and specificity of LC for supraglottic anomalies were 75% and 60%, respectively. The sensibility and specificity of PFTs were 61% and 89%, respectively. CONCLUSIONS There was a high prevalence of EILO among patients with EIIS and uncontrolled asthma. Some clinical characteristics might guide the diagnosis. Nevertheless, CLE-test remained the gold standard for EILO diagnosis and identification of the dysfunctional upper airway site to provide specific management.
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Affiliation(s)
- Ludovic Giraud
- Otolaryngology-Head and Neck Surgery Department, Clinique Universitaire d'ORL et Chirurgie Cervico-Faciale, CHU Grenoble Alpes, Grenoble Alpes University Hospital, BP 217, 38043, Grenoble Cedex 09, France.,Faculté́ de Médecine, Université́ Grenoble Alpes, Domaine de la Merci, BP 170, 38042, Grenoble Cedex 9, France
| | - Marie Destors
- Clinique de Physiologie Sommeil et Exercice, CHU Grenoble Alpes, BP 217, 38043, Grenoble Cedex 09, France
| | - Rita Clin
- Clinique de Physiologie Sommeil et Exercice, CHU Grenoble Alpes, BP 217, 38043, Grenoble Cedex 09, France.,Inserm 1042, Laboratoire HP2, Université Grenoble-Alpes, 38000, Grenoble, France.,Pôle Thorax et Vaisseaux, Clinique de Physiologie Sommeil et Exercice, CHU de Grenoble-Alpes, 38000, Grenobl, France
| | - Christol Fabre
- Otolaryngology-Head and Neck Surgery Department, Clinique Universitaire d'ORL et Chirurgie Cervico-Faciale, CHU Grenoble Alpes, Grenoble Alpes University Hospital, BP 217, 38043, Grenoble Cedex 09, France.,Faculté́ de Médecine, Université́ Grenoble Alpes, Domaine de la Merci, BP 170, 38042, Grenoble Cedex 9, France
| | - Stéphane Doutreleau
- Médecine du Sport, CHU Grenoble Alpes, Hôpital Sud, 19 Avenue de Kimberley, 38130, Échirolles, France
| | - Ihab Atallah
- Otolaryngology-Head and Neck Surgery Department, Clinique Universitaire d'ORL et Chirurgie Cervico-Faciale, CHU Grenoble Alpes, Grenoble Alpes University Hospital, BP 217, 38043, Grenoble Cedex 09, France. .,Faculté́ de Médecine, Université́ Grenoble Alpes, Domaine de la Merci, BP 170, 38042, Grenoble Cedex 9, France.
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17
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Milstein CF, Patel RR, Laurash E, Kampert M. Identification of Breathing Pattern Disorder in Athletes With Exercise-Induced Laryngeal Obstruction: A Novel Assessment Tool. J Voice 2023:S0892-1997(23)00006-1. [PMID: 36710197 DOI: 10.1016/j.jvoice.2023.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 01/05/2023] [Accepted: 01/05/2023] [Indexed: 01/30/2023]
Abstract
OBJECTIVE To report the diagnostic utility of the novel, high-ventilatory task assessment tool called the Milstein Breathing Pattern Assessment Index (M-BPAI) for evaluation of Breathing Pattern Disorder (BPD) in athletes with and without breathing difficulty, and to evaluate the prevalence of BPD in athletes referred for Exercise Induced Laryngeal Obstruction (EILO). BPD is an abnormal respiratory biomechanical pattern caused from functional or structural factors. The presence of BPD in athletes with EILO is unknown. The current clinical evaluations of dysfunctional breathing patterns are limiting for evaluation of BPD in patients with EILO, as these only evaluate the patients in low ventilatory output tasks of rest breathing. STUDY DESIGN AND METHODS In this prospective study, a total of 77 athletes referred to the clinic for suspected EILO and 58 athletes without any respiratory difficulty underwent M-BPAI assessment. Data collection from the experimental group also included the Dyspnea Index, and laryngeal video endoscopic provocation test. RESULTS The M-BPAI score was significantly larger in the patient group compared to the control group. An overall M-BPAI score of ≥8 corresponds to the AUC of 0.87 (95% CI: 0.81-0.93) with a sensitivity of 0.862 and specificity of 0.792. A total of 60 (78%) patients had an overall M-BPAI score of ≥8. CONCLUSION The M-BPAI has the potential to be a valuable clinical diagnostic marker for identifying BPD in patients with suspected EILO with further research and validation.
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Affiliation(s)
| | - Rita R Patel
- Department of Otolaryngology Head & Neck Surgery, Indiana University School of Medicine, Indianapolis, Indiana.
| | - Emma Laurash
- Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio
| | - Matthew Kampert
- Department of Sports Medicine, Cleveland Clinic, Cleveland Ohio; Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, Ohio
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18
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Muralitharan P, Carlsen P, Hilland M, Delestre-Levai I, Vollsæter M, Hufthammer KO, Engan M, Røksund OD, Halvorsen T, Clemm HH. Use of inhaled ipratropium bromide to improve exercise-induced laryngeal obstruction cannot be recommended. ERJ Open Res 2023; 9:00308-2022. [PMID: 36699648 PMCID: PMC9868967 DOI: 10.1183/23120541.00308-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 10/18/2022] [Indexed: 11/18/2022] Open
Abstract
Introduction Exercise-induced laryngeal obstruction (EILO) is a common cause of exertional breathing problems in young adults. Current management generally consists of breathing advice, speech therapy, inspiratory muscle training or supraglottoplasty in highly motivated subjects with supraglottic collapse. Inhaled ipratropium bromide (IB) is a muscarinic receptor antagonist used to treat asthma that is suggested in a few reports to improve EILO symptoms. The aim of the present study was to investigate effects of inhaled IB in EILO diagnosed by continuous laryngoscopy exercise (CLE) test and classified by CLE scores. Methods A randomised crossover trial was conducted at Haukeland University Hospital, Bergen, Norway, enrolling participants diagnosed with EILO defined by characteristic symptoms and CLE score ≥3 (range 0-12). Two consecutive CLE tests were performed within 2 weeks, one test with and one test without prior administration of inhaled IB in a randomised order. Main outcomes were the CLE score, dyspnoea measured using a modified BORG scale (range 0-10) and cardiopulmonary exercise data provided by the CLE test. Results 20 participants (14 females) aged 12-25 years participated, and all ran to exhaustion on both tests. Mean CLE score, BORG score and peak oxygen consumption were similar in tests performed with and without IB; mean differences (95% confidence interval) were 0.08 (-0.28-0.43), 0.35 (-0.29-0.99) and -0.4 (-1.9-1.1) mL·kg-1·min-1, respectively. Conclusion Inhaled IB did not improve CLE score, dyspnoea or exercise capacity in subjects with EILO. The study does not support the use of inhaled IB to treat EILO.
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Affiliation(s)
- Praveen Muralitharan
- Department of Pediatric and Adolescent Medicine, Haukeland University Hospital, Bergen, Norway,Corresponding author: Praveen Muralitharan ()
| | - Petter Carlsen
- Department of Pediatric and Adolescent Medicine, Haukeland University Hospital, Bergen, Norway
| | - Magnus Hilland
- Department of Pediatric and Adolescent Medicine, Haukeland University Hospital, Bergen, Norway
| | - Irisz Delestre-Levai
- Department of Pediatric and Adolescent Medicine, Haukeland University Hospital, Bergen, Norway
| | - Maria Vollsæter
- Department of Pediatric and Adolescent Medicine, Haukeland University Hospital, Bergen, Norway,Department of Clinical Science, University of Bergen, Bergen, Norway
| | | | - Mette Engan
- Department of Pediatric and Adolescent Medicine, Haukeland University Hospital, Bergen, Norway
| | - Ola Drange Røksund
- Department of Pediatric and Adolescent Medicine, Haukeland University Hospital, Bergen, Norway,Faculty of Health and Social Sciences, Western Norway University of Applied Sciences, Bergen, Norway
| | - Thomas Halvorsen
- Department of Pediatric and Adolescent Medicine, Haukeland University Hospital, Bergen, Norway,Department of Clinical Science, University of Bergen, Bergen, Norway,Department of Sports Medicine, Norwegian School of Sport Sciences, Oslo, Norway
| | - Hege H. Clemm
- Department of Pediatric and Adolescent Medicine, Haukeland University Hospital, Bergen, Norway,Department of Clinical Science, University of Bergen, Bergen, Norway
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19
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Thomander T, Malmberg LP, Toppila-Salmi S, Aaltonen LM, Kauppi P. The continuous laryngoscopy exercise test in severe or in difficult-to-treat asthma in adults: a systematic review. J Asthma 2023; 60:1-10. [PMID: 35125054 DOI: 10.1080/02770903.2022.2029481] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE A systematic review was performed to determine if the continuous laryngoscopy exercise test (CLE) has been used in the diagnostics of exercise dyspnea in adults with asthma, and whether inducible laryngeal obstruction (ILO) is found in those with asthma or with severe or difficult-to-treat asthma. DATA SOURCES We used Scopus and PubMed databases. The articles published up to 13 August 2019 were considered. STUDY SELECTIONS We excluded manuscripts that did not contain information about adult patients with asthma. We included six studies from 59 search results in Scopus and none from the 17 search results in PubMed. RESULTS The articles included 455 study individuals. Of these, 229 (50.3%) had diagnosed asthma or were treated with asthma medication. Altogether 31/229 (13.5%) subjects with diagnosis of asthma or previous asthma treatment had exercise-induced laryngeal obstruction (EILO) as comorbidity. The CLE test was performed on 229 patients with asthma. The method was used only for differential diagnosis of exercise-induced dyspnea to confirm EILO. At least 10/455 (2.2%) out of the 455 subjects experienced adverse events. CONCLUSIONS This systematic review revealed that only a small proportion of patients with asthma had undergone the CLE test to assess exercise-induced dyspnea. None of the selected manuscripts reported severity of asthma. Whether CLE provides a valuable diagnostic tool for patients with severe or difficult-to-treat asthma cannot be determined according to this review.
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Affiliation(s)
- Tuuli Thomander
- Doctoral Programme in Clinical Research, University of Helsinki, Helsinki, Finland.,Department of Allergology, Skin and Allergy Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - L Pekka Malmberg
- Department of Clinical Physiology, Inflammation Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Sanna Toppila-Salmi
- Department of Allergology, Skin and Allergy Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Leena-Maija Aaltonen
- Department of Otorhinolaryngology, Head and Neck Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Paula Kauppi
- Pulmonary Department, Heart and Lung Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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20
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Koh J, Phyland D, Baxter M, Leong P, Bardin PG. Vocal cord dysfunction/inducible laryngeal obstruction: novel diagnostics and therapeutics. Expert Rev Respir Med 2023; 17:429-445. [PMID: 37194252 DOI: 10.1080/17476348.2023.2215434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Accepted: 05/15/2023] [Indexed: 05/18/2023]
Abstract
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.
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Affiliation(s)
- Joo Koh
- Monash Health Department of Otolaryngology, Head and Neck Surgery, Monash Hospital and University, Melbourne, Australia
- Monash Lung Sleep Allergy & Immunology, Monash Hospital and University, Melbourne, Australia
| | - Debra Phyland
- Monash Health Department of Otolaryngology, Head and Neck Surgery, Monash Hospital and University, Melbourne, Australia
- School of Clinical Sciences, Faculty of Medicine, Nursing & Health Sciences, Monash University, Melbourne, Australia
| | - Malcolm Baxter
- Monash Health Department of Otolaryngology, Head and Neck Surgery, Monash Hospital and University, Melbourne, Australia
- Monash Lung Sleep Allergy & Immunology, Monash Hospital and University, Melbourne, Australia
| | - Paul Leong
- Monash Lung Sleep Allergy & Immunology, Monash Hospital and University, Melbourne, Australia
- Hudson Institute, Monash Hospital and University, Melbourne, Australia
| | - Philip G Bardin
- Monash Lung Sleep Allergy & Immunology, Monash Hospital and University, Melbourne, Australia
- Hudson Institute, Monash Hospital and University, Melbourne, Australia
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21
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Price OJ, Walsted ES, Bonini M, Brannan JD, Bougault V, Carlsen K, Couto M, Kippelen P, Moreira A, Pite H, Rukhadze M, Hull JH. Diagnosis and management of allergy and respiratory disorders in sport: An EAACI task force position paper. Allergy 2022; 77:2909-2923. [PMID: 35809082 PMCID: PMC9796481 DOI: 10.1111/all.15431] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 07/02/2022] [Accepted: 07/06/2022] [Indexed: 01/27/2023]
Abstract
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.
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Affiliation(s)
- Oliver J. Price
- School of Biomedical SciencesFaculty of Biological Sciences, University of LeedsLeedsUK,Leeds Institute of Medical Research at St James'sUniversity of LeedsLeedsUK
| | - Emil S. Walsted
- Department of Respiratory MedicineRoyal Brompton HospitalLondonUK,Department of Respiratory MedicineBispebjerg HospitalCopenhagenDenmark
| | - Matteo Bonini
- Fondazione Policlinico Universitario A. Gemelli – IRCCSUniversità Cattolica del Sacro CuoreRomeItaly,National Heart and Lung Institute (NHLI)Imperial College LondonLondonUK
| | | | | | - Kai‐Håkon Carlsen
- Division of Paediatric and Adolescent MedicineOslo University HospitalOsloNorway,Faculty of Medicine, University of OsloInstitute of Clinical MedicineOsloNorway
| | - Mariana Couto
- Allergy CenterCUF Descobertas HospitalLisbonPortugal
| | - Pascale Kippelen
- Division of Sport, Health and Exercise SciencesCollege of Health, Medicine and Life Sciences, Brunel University LondonUK
| | - André Moreira
- Centro Hospitalar Universitário de São JoãoPortoPortugal,Epidemiology Unit (EPIUnit)Laboratory for Integrative and Translational Research in Population Health (ITR)Basic and Clinical Immunology, Department of Pathology, Faculty of MedicineUniversity of PortoPortoPortugal
| | - Helena Pite
- Allergy Center, CUF Descobertas Hospital and CUF Tejo HospitalCEDOC, NOVA University, Universidade NOVA de LisboaLisbonPortugal
| | | | - James H. Hull
- Department of Respiratory MedicineRoyal Brompton HospitalLondonUK,Institute of Sport, Exercise and Health (ISEH)Division of Surgery and Interventional Science, University College London (UCL)LondonUK
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22
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Brekka AK, Vollsæter M, Ntoumenopoulos G, Clemm HH, Halvorsen T, Røksund OD, Andersen TM. Adjustments of non-invasive ventilation and mechanically assisted cough by combining ultrasound imaging of the larynx with transnasal fibre-optic laryngoscopy: a protocol for an experimental study. BMJ Open 2022; 12:e059234. [PMID: 35613803 PMCID: PMC9134209 DOI: 10.1136/bmjopen-2021-059234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Application of non-invasive positive airway pressure may provoke laryngeal responses that obstruct the airways, especially in patients with disturbed laryngeal control. To control and adjust for this, transnasal fibre-optic laryngoscopy (TFL) is used to visualise laryngeal movements during therapeutic interventions. Being an invasive procedure, this may be unpleasant for patients. The aim of this study is to evaluate if ultrasound (US) imaging of the larynx may be used as an alternative less invasive diagnostic tool for evaluating the upper airway responses to non-invasive ventilation (NIV) and mechanical insufflation-exsufflation (MI-E). METHODS AND ANALYSIS This protocol presents an experimental cross-sectional study of a novel method to study laryngeal responses in adult healthy volunteers (n=30). The participants will be assessed with simultaneous TFL and laryngeal US imaging (anterior and lateral approaches) during NIV and MI-E therapy. Additionally, airflow and pressure signals will be registered during the procedures. The primary outcome is whether laryngeal US is a feasible method to study laryngeal responses and, if so, to compare the laryngeal responses visualised with TFL and US. The participants' perception of the examinations will be recorded. Secondary outcomes include airflow curve shapes and calculated ventilation volumes during the interventions. ETHICS AND DISSEMINATION The study has been approved by The Regional Committee for Medical Research Ethics in Norway, and registered in ClinicalTrials.gov. Results will be disseminated through peer-reviewed journals, presentation of scientific abstracts at international medical conventions and oral presentations in relevant medical conventions. TRIAL REGISTRATION NUMBER NCT04586855.
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Affiliation(s)
| | - Maria Vollsæter
- Norwegian Advisory Unit on Home Mechanical Ventilation, Haukeland University Hospital, Bergen, Norway
- Faculty of Medicine, Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - George Ntoumenopoulos
- Department of Physiotherapy, St Vincent's Hospital Sydney, Sydney, New South Wales, Australia
| | - Hege Havstad Clemm
- Faculty of Medicine, Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Department of Pediatrics, Haukeland University Hospital, Bergen, Norway
| | - Thomas Halvorsen
- Department of Pediatrics, Haukeland University Hospital, Bergen, Norway
| | - Ola Drange Røksund
- Department of Pediatrics, Haukeland University Hospital, Bergen, Norway
- The Faculty of Health and Social Sciences, Western Norway University of Applied Sciences, Bergen, Norway
| | - Tiina Maarit Andersen
- Norwegian Advisory Unit on Home Mechanical Ventilation, Haukeland University Hospital, Bergen, Norway
- The Faculty of Health and Social Sciences, Western Norway University of Applied Sciences, Bergen, Norway
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23
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Hull JH, Burns P, Carre J, Haines J, Hepworth C, Holmes S, Jones N, MacKenzie A, Paton JY, Ricketts WM, Howard LS. BTS clinical statement for the assessment and management of respiratory problems in athletic individuals. Thorax 2022; 77:540-551. [DOI: 10.1136/thoraxjnl-2021-217904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Fretheim-Kelly Z, Engan M, Clemm H, Andersen T, Heimdal JH, Strand E, Halvorsen T, Røksund O, Vollsæter M. Reliability of trans-laryngeal airway resistance measurements during maximal exercise. ERJ Open Res 2022; 8:00581-2021. [PMID: 35309036 PMCID: PMC8923134 DOI: 10.1183/23120541.00581-2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 01/11/2022] [Indexed: 11/05/2022] Open
Abstract
Objective: Exercised induced laryngeal obstruction (EILO) is an important cause of exertional dyspnea. The diagnosis rests on visual judgement of relative changes of the laryngeal inlet during continuous laryngoscopy exercise (CLE) tests, but we lack objective measures that reflect functional consequences. We aimed to investigate repeatability and normal values of trans-laryngeal airway resistance measured at maximal intensity exercise.Methods: Thirty-one healthy non-smokers without exercise related breathing problems were recruited. Participants performed two CLE tests enabling verified positioning of two pressure sensors, one at the tip of the epiglottis (supraglottic) and one by the fifth tracheal ring (subglottic). Airway pressure and flow data were continuously collected breath-by-breath and used to calculate trans-laryngeal resistance at peak exercise. Laryngeal obstruction was assessed according to a standardised CLE-score system.Results: Data from 26 participants (16 females) with two successful tests and equal CLE scores on both test-sessions were included in the trans-laryngeal resistance repeatability analyses. The coefficient of repeatability (CR) was 0.62 cmH2O·L−1·s−1, corresponding to a CR% of 21%. Mean (sd) trans-laryngeal airway resistance (cmH2O·L−1·s−1) in participants with no laryngeal obstruction (n=15) was 2.88 (0.50) in females and 2.18 (0.50) in males. Higher CLE scores correlated with higher trans-laryngeal resistance in females (r=0.81, p<0.001).Conclusions: This study establishes trans-laryngeal airway resistance obtained during exercise as a reliable parameter in respiratory medicine, opening the door for more informed treatment decisions and future research on the role of the larynx in health and disease.
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Hammer IJ, Halvorsen T, Vollsaeter M, Hilland M, Heimdal JH, Røksund OD, Clemm HH. Conundrums in the breathless athlete; exercise induced laryngeal obstruction or asthma? Scand J Med Sci Sports 2022; 32:1041-1049. [PMID: 35114031 PMCID: PMC9303344 DOI: 10.1111/sms.14137] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 01/30/2022] [Indexed: 12/01/2022]
Abstract
PURPOSE Exercise-induced bronchoconstriction (EIB) and exercise-induced laryngeal obstruction (EILO) are two disorders commonly considered when athletes complain of exertional dyspnea. They are highly different but often confused. We aimed to address this diagnostic challenge and its consequences in elite athletes. METHODS We included all athletes competing at national or international level, referred to our institution for workup for EILO during 2013-2016. We diagnosed EILO from video-recorded laryngoscopy performed during maximal cardiopulmonary treadmill exercise (CLE-test). Symptoms and previous diagnostic evaluations were obtained from referral letters and chart reviews. RESULTS EILO was diagnosed in 73/101 referred athletes, of whom 70/73 had moderate/severe supraglottic obstruction and 3/73 had primarily glottic obstruction with only minor supraglottic involvement. Of the 73 athletes with EILO, we were able to identify objective tests for asthma in 55 participants, of whom 22 had findings supporting asthma. However, 58/73 had used asthma therapy at some time previously, with current use in 28. Only three reported that asthma medication had improved their exercise related breathing problems, two of whom with tests confirming asthma. Treatment for EILO improved breathing problems in all but four. CONCLUSIONS Objective testing verified EILO in most of the referred athletes. EILO coexisting with asthma was common, and large proportions had used asthma medication; however, few reported effect on exercise related breathing problems. Unexplained persistent exertional dyspnoea must not lead to indiscriminate escalation of asthma treatment, but instead incite investigation for EILO, either as a co-morbidity or as a differential diagnosis.
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Affiliation(s)
- Ida Jansrud Hammer
- Department of Pediatric and Adolescent Medicine, Haukeland University Hospital, Bergen, Norway
| | - Thomas Halvorsen
- Norwegian School of Sports Sciences, Oslo, Norway.,Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Maria Vollsaeter
- Department of Pediatric and Adolescent Medicine, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Magnus Hilland
- Department of Otolaryngology/Head and Neck surgery, Haukeland University Hospital, Bergen, Norway
| | - John-Helge Heimdal
- Department of Otolaryngology/Head and Neck surgery, Haukeland University Hospital, Bergen, Norway.,Department of Surgery, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Ola Drange Røksund
- Department of Pediatric and Adolescent Medicine, Haukeland University Hospital, Bergen, Norway.,Department of Otolaryngology/Head and Neck surgery, Haukeland University Hospital, Bergen, Norway.,The Faculty of Health and Social Sciences, Western Norway University of Applied Sciences, Bergen, Norway
| | - Hege Havstad Clemm
- Department of Pediatric and Adolescent Medicine, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Science, University of Bergen, Bergen, Norway
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Dreßler M, Donath H, Quang TU, Hutter M, Trischler J, Zielen S, Schulze J, Blümchen K. Evaluating Children and Adolescents with Suspected Exercise Induced Asthma: Real Life Data. Klin Padiatr 2022; 234:267-276. [PMID: 35114701 DOI: 10.1055/a-1717-2178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Exercise-induced bronchoconstriction (EIB) occurs frequently in children and adolescents and may be a sign of insufficient asthma control. EIB is often evaluated by respiratory symptoms, spirometry, eNO measurement and methacholine testing (MCT) instead of time consuming exercise test. Aim of this study was to analyse the amount of patients for which an exercise challenge in a cold chamber (ECC) was needed for a clear EIB diagnosis, to characterize EIB phenotypes and the incidence of exercise induced laryngeal obstruction (EILO) in a large cohort of patients with EIB. METHODS A retrospective analysis was performed in 595 children and adolescents (mean age 12.1 years) with suspected EIB from January 2014 to December 2018. Complete data sets of skin prick test, spirometry, eNO and MCT were available from 336 patients. RESULTS An ECC to confirm the EIB diagnosis was performed in 125 (37.2%) of patients. Three EIB phenotypes were detected: group 1: EIB without allergic sensitization (n=159); group 2: EIB with other than house dust mite (HDM) sensitization (n=87) and group 3: EIB with HDM sensitization (n=90). MCT and eNO showed significant differences between the subgroups: An eNO>46 ppb and/or a MCT<0.1 mg was found in 23.9% vs. 50.6% vs. 57.8% in group 1-3, respectively. Significantly more patients suffered from EILO in group 1 compared to group 2 and 3 (n=13 vs. n=1). CONCLUSION EIB without sensitization is as often as EIB with sensitization. In patients without sensitization, EILO has to be considered as a possible cause of symptoms during exercise.
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Affiliation(s)
- Melanie Dreßler
- Division of Allergy, Pulmonology and Cystic fibrosis, Department for Children and Adolescents, University Hospital Frankfurt, Goethe-University, Frankfurt, Germany
| | - Helena Donath
- Division of Allergy, Pulmonology and Cystic fibrosis, Department for Children and Adolescents, University Hospital Frankfurt, Goethe-University, Frankfurt, Germany
| | - Thao Uyen Quang
- Division of Allergy, Pulmonology and Cystic fibrosis, Department for Children and Adolescents, University Hospital Frankfurt, Goethe-University, Frankfurt, Germany
| | - Martin Hutter
- Division of Allergy, Pulmonology and Cystic fibrosis, Department for Children and Adolescents, University Hospital Frankfurt, Goethe-University, Frankfurt, Germany
| | - Jordis Trischler
- Division of Allergy, Pulmonology and Cystic fibrosis, Department for Children and Adolescents, University Hospital Frankfurt, Goethe-University, Frankfurt, Germany
| | - Stefan Zielen
- Division of Allergy, Pulmonology and Cystic fibrosis, Department for Children and Adolescents, University Hospital Frankfurt, Goethe-University, Frankfurt, Germany
| | - Johannes Schulze
- Division of Allergy, Pulmonology and Cystic fibrosis, Department for Children and Adolescents, University Hospital Frankfurt, Goethe-University, Frankfurt, Germany
| | - Katharina Blümchen
- Division of Allergy, Pulmonology and Cystic fibrosis, Department for Children and Adolescents, University Hospital Frankfurt, Goethe-University, Frankfurt, Germany
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Clemm H, Røksund OD, Andersen T, Heimdal JH, Karlsen T, Hilland M, Fretheim-Kelly Z, Hufthammer KO, Sandnes A, Hjelle S, Vollsæter M, Halvorsen T. Exercise-induced Laryngeal Obstruction: Protocol for a Randomized Controlled Treatment Trial. Front Pediatr 2022; 10:817003. [PMID: 35198517 PMCID: PMC8858975 DOI: 10.3389/fped.2022.817003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 01/10/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Exercise-induced laryngeal obstruction (EILO) is a common cause of exertional breathing problems in young individuals, caused by paradoxical inspiratory adduction of laryngeal structures, and diagnosed by continuous visualization of the larynx during high-intensity exercise. Empirical data suggest that EILO consists of different subtypes, possibly requiring different therapeutic approaches. Currently applied treatments do not rest on randomized controlled trials, and international guidelines based on good evidence can therefore not be established. This study aims to provide evidence-based information on treatment schemes commonly applied in patients with EILO. METHODS AND ANALYSIS Consenting patients consecutively diagnosed with EILO at Haukeland University Hospital will be randomized into four non-invasive treatment arms, based on promising reports from non-randomized studies: (A) standardized information and breathing advice only (IBA), (B) IBA plus inspiratory muscle training, (C) IBA plus speech therapy, and (D) IBA plus inspiratory muscle training and speech therapy. Differential effects in predefined EILO subtypes will be addressed. Patients failing the non-invasive approach and otherwise qualifying for surgical treatment by current department policy will be considered for randomization into (E) standard or (F) minimally invasive laser supraglottoplasty or (G) no surgery. Power calculations are based on the main outcomes, laryngeal adduction during peak exercise, rated by a validated scoring system before and after the interventions. ETHICS AND DISSEMINATION The study will assess approaches to EILO treatments that despite widespread use, are insufficiently tested in structured, verifiable, randomized, controlled studies, and is therefore considered ethically sound. The study will provide knowledge listed as a priority in a recent statement issued by the European Respiratory Society, requested by clinicians and researchers engaged in this area, and relevant to 5-7% of young people. Dissemination will occur in peer-reviewed journals, at relevant media platforms and conferences, and by engaging with patient organizations and the healthcare bureaucracy.
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Affiliation(s)
- Hege Clemm
- Department of Clinical Science, University of Bergen, Bergen, Norway.,Department of Pediatric and Adolescent Medicine, Haukeland University Hospital, Bergen, Norway
| | - Ola D Røksund
- Department of Pediatric and Adolescent Medicine, Haukeland University Hospital, Bergen, Norway.,Faculty of Health and Social Sciences, Western Norway University of Applied Sciences, Bergen, Norway.,Department of Otolaryngology and Head and Neck Surgery, Haukeland University Hospital, Bergen, Norway
| | - Tiina Andersen
- Faculty of Health and Social Sciences, Western Norway University of Applied Sciences, Bergen, Norway.,Department of Physiotherapy, Haukeland University Hospital, Bergen, Norway.,Norwegian Advisory Unit on Home Mechanical Ventilation, Thoracic Department, Haukeland University Hospital, Bergen, Norway
| | - John-Helge Heimdal
- Department of Otolaryngology and Head and Neck Surgery, Haukeland University Hospital, Bergen, Norway.,Department of Surgery, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Tom Karlsen
- Department of Pediatric and Adolescent Medicine, Haukeland University Hospital, Bergen, Norway
| | - Magnus Hilland
- Department of Pediatric and Adolescent Medicine, Haukeland University Hospital, Bergen, Norway
| | - Zoe Fretheim-Kelly
- Department of Pediatric and Adolescent Medicine, Haukeland University Hospital, Bergen, Norway.,Faculty of Veterinary Medicine, Norwegian University of Life Sciences, Oslo, Norway
| | | | - Astrid Sandnes
- Department of Internal Medicine, Innlandet Hospital Trust, Gjøvik, Norway
| | - Sigrun Hjelle
- Department of Pediatric and Adolescent Medicine, Haukeland University Hospital, Bergen, Norway
| | - Maria Vollsæter
- Department of Clinical Science, University of Bergen, Bergen, Norway.,Department of Pediatric and Adolescent Medicine, Haukeland University Hospital, Bergen, Norway
| | - Thomas Halvorsen
- Department of Clinical Science, University of Bergen, Bergen, Norway.,Department of Pediatric and Adolescent Medicine, Haukeland University Hospital, Bergen, Norway.,Department of Sports Medicine, Norwegian School of Sport Sciences, Oslo, Norway
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Sandnes A, Andersen T, Clemm HH, Hilland M, Heimdal JH, Halvorsen T, Røksund OD, Vollsæter M. Clinical responses following inspiratory muscle training in exercise-induced laryngeal obstruction. Eur Arch Otorhinolaryngol 2021; 279:2511-2522. [PMID: 34954812 PMCID: PMC8986676 DOI: 10.1007/s00405-021-07214-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 12/03/2021] [Indexed: 11/09/2022]
Abstract
Purpose Exercise-induced laryngeal obstruction (EILO) is relatively common in young people. Treatment rests on poor evidence; however, inspiratory muscle training (IMT) has been proposed a promising strategy. We aimed to assess laryngeal outcomes shortly after IMT, and to compare self-reported symptoms with a control group 4–6 years later. Methods Two groups were retrospectively identified from the EILO-register at Haukeland University Hospital, Norway; one group had received only information and breathing advice (IBA), and another additionally IMT (IBA + IMT). At diagnosis, all participants performed continuous laryngoscopy during exercise (CLE), with findings split by glottic and supraglottic scores, and completed a questionnaire mapping exercise-related symptoms. After 2–4 weeks, the IBA + IMT-group was re-evaluated with CLE-test. After 4–6 years, both groups were re-assessed with a questionnaire. Results We identified 116 eligible patients from the EILO-register. Response rates after 4–6 years were 23/58 (40%) and 32/58 (55%) in the IBA and IBA + IMT-group, respectively. At diagnosis, both groups rated symptoms similarly, but laryngeal scores were higher in the IBA + IMT-group (P = 0.003). After 2–4 weeks, 23/32 in the IBA + IMT-group reported symptom improvements, associated with a decrease of mainly glottic scores (1.7–0.3; P < 0.001), contrasting unchanged scores in the 9/32 without symptom improvements. After 4–6 years, exercise-related symptoms and activity levels had decreased to similar levels in both groups, with no added benefit from IMT; however, full symptom resolution was reported by only 8/55 participants. Conclusion Self-reported EILO symptoms had improved after 4–6 years, irrespective of initial treatment. Full symptom resolution was rare, suggesting individual follow-up should be offered. Supplementary Information The online version contains supplementary material available at 10.1007/s00405-021-07214-5.
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Affiliation(s)
- Astrid Sandnes
- Department of Internal Medicine, Innlandet Hospital Trust, Gjøvik, Norway. .,Institute of Clinical Medicine, University of Bergen, Bergen, Norway.
| | - Tiina Andersen
- Department of Physiotherapy, Haukeland University Hospital, Bergen, Norway.,Thoracic Department, Norwegian Advisory Unit on Home Mechanical Ventilation, Bergen, Norway.,The Faculty of Health and Social Sciences, Western Norway University of Applied Sciences, Bergen, Norway
| | - Hege Havstad Clemm
- Department of Pediatrics, Haukeland University Hospital, Bergen, Norway.,Institute of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Magnus Hilland
- Department of Otolaryngology/Head and Neck Surgery, Haukeland University Hospital, Bergen, Norway
| | - John-Helge Heimdal
- Department of Otolaryngology/Head and Neck Surgery, Haukeland University Hospital, Bergen, Norway.,Department of Surgery, Haukeland University Hospital, Bergen, Norway.,Institute of Surgical Science, University of Bergen, Bergen, Norway
| | - Thomas Halvorsen
- Department of Pediatrics, Haukeland University Hospital, Bergen, Norway.,Institute of Clinical Medicine, University of Bergen, Bergen, Norway.,Department of Sports Medicine, Norwegian School of Sport Sciences, Oslo, Norway
| | - Ola Drange Røksund
- Department of Pediatrics, Haukeland University Hospital, Bergen, Norway.,Department of Otolaryngology/Head and Neck Surgery, Haukeland University Hospital, Bergen, Norway.,The Faculty of Health and Social Sciences, Western Norway University of Applied Sciences, Bergen, Norway
| | - Maria Vollsæter
- Department of Pediatrics, Haukeland University Hospital, Bergen, Norway.,Institute of Clinical Medicine, University of Bergen, Bergen, Norway.,Thoracic Department, Norwegian Advisory Unit on Home Mechanical Ventilation, Bergen, Norway
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Maloy W, Schroeder J, Rhodehouse B. Athlete Preparticipation Physical Evaluation. Sports Med Arthrosc Rev 2021; 29:200-6. [PMID: 34730121 DOI: 10.1097/JSA.0000000000000330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Preparticipation evaluations (PPE) are both a traditional and legal requirement by many governing bodies for sport. The ideal goal of the PPE is safe participation in sport for athletes. This article provides an overview of common PPE elements and current best practice recommendations. Descriptions of every possible examination are published elsewhere and are beyond the intent of this article. Additional considerations for transgender, masters athletes, and Special Olympians are also outside the scope of this review, but are well covered in The Preparticipation Physical Evaluation, fifth edition monograph.
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Lie AH, Grønnevik I, Frisk B, Røksund OD, Hammer I, Vollsæter M, Halvorsen T, Clemm HH. Breathing patterns in people with exercise-induced laryngeal obstruction. Physiol Rep 2021; 9:e15086. [PMID: 34822227 PMCID: PMC8613803 DOI: 10.14814/phy2.15086] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 10/05/2021] [Accepted: 10/06/2021] [Indexed: 11/24/2022] Open
Abstract
Exercise-induced laryngeal obstruction (EILO) is common, but we lack readily available diagnostic tools. The larynx represents an important point of resistance in the airways, and we therefore hypothesized that EILO is associated with characteristic breathing patterns possible to record from a standard incremental ergospirometry test. We studied 24 individuals with moderate/severe EILO and 20 individuals with no-EILO, mean (SD) age 17 (6.1) and 24 (6.4) years, respectively. EILO versus no-EILO was verified from maximal continuous laryngoscopy treadmill exercise (CLE) tests, which also included ergospirometry. We described the relationships between minute ventilation ( V ˙ E ) versus tidal volume (VT ) and V ˙ E versus carbon dioxide output ( V ˙ CO 2 ), using respectively quadratic and linear equations, and applied adjusted regression models to compare ergospirometry data and curve parameters. Compared to the no-EILO group, the group with EILO had prolonged inspiratory time (Tin ), lower breathing frequency (Bf ), lower V ˙ E , and lower inspiratory flow rate ( V ˙ in ) at peak exercise. Mathematical modeling of the breathing pattern relationships was feasible in both groups, with similar coefficients of variation. For V ˙ E versus VT , the mathematical curve parameters were similar. For V ˙ E versus V ˙ CO 2 , the slope was similar but the intercept was lower in the EILO group. EILO was associated with prolonged Tin , lower Bf , V ˙ E , and V ˙ E . The relationship between V ˙ E versus VT was similar, whereas for V ˙ E versus V ˙ CO 2 , the slope was almost parallel but shifted downward for the EILO group. Most ergospirometry data overlapped, except V ˙ in which discriminated between EILO and no-EILO in a promising way.
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Affiliation(s)
| | | | - Bente Frisk
- Department of Health and FunctioningWestern Norway University of Applied SciencesBergenNorway
| | - Ola Drange Røksund
- Department of Health and FunctioningWestern Norway University of Applied SciencesBergenNorway
- Department of Pediatric and Adolescent MedicineHaukeland University HospitalBergenNorway
| | - Ida Hammer
- Department of Pediatric and Adolescent MedicineHaukeland University HospitalBergenNorway
| | - Maria Vollsæter
- Department of Clinical ScienceUniversity of BergenBergenNorway
- Department of Pediatric and Adolescent MedicineHaukeland University HospitalBergenNorway
| | - Thomas Halvorsen
- Department of Clinical ScienceUniversity of BergenBergenNorway
- Department of Pediatric and Adolescent MedicineHaukeland University HospitalBergenNorway
| | - Hege H. Clemm
- Department of Clinical ScienceUniversity of BergenBergenNorway
- Department of Pediatric and Adolescent MedicineHaukeland University HospitalBergenNorway
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Dillenhöfer S, Hinrichs B, Kohl A, Kuhnigk M, Maas R, Pfeiffer-kascha D, Rutt T, Schlegtendal A, Seidenberg J, Spindler T, Suerbaum C, Wilmsmeyer B, Zeidler S, Koerner-rettberg C. Die induzierbare laryngeale Obstruktion (ILO) – Ursachen, klinische Präsentation, Diagnostik und Therapie: Positionspaper der Arbeitsgruppe „Dysfunktionelle Respiratorische Symptome“ der Gesellschaft für Pädiatrische Pneumologie (GPP). Monatsschr Kinderheilkd 2021; 169:1075-82. [DOI: 10.1007/s00112-021-01159-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
ZusammenfassungWiederholt episodenhaft auftretende Atemnot ist im Kindes- und Jugendalter ein häufiges Symptom. Neben anstrengungsinduzierter Bronchialobstruktion im Rahmen eines Asthma bronchiale ist eine funktionelle Genese eine sehr häufige Differenzialdiagnose. Dennoch wird diese Diagnose häufig nicht oder mit langer Latenz gestellt. Unter dem Oberbegriff „ILO“ („inducible laryngeal obstruction“) werden sowohl funktionelle supraglottische Obstruktionen durch Kollaps der Knorpelstrukturen als auch Dysfunktionen auf Glottisebene wie „vocal cord dysfunction“ (VCD) subsumiert. Körperliche Anstrengung ist ein häufiger Auslöser; es werden jedoch auch Beschwerdebilder ohne Anstrengungsbezug beobachtet. Es wird der Erkenntnisstand zur Pathophysiologie referiert und die klinische Präsentation beschrieben. Ein wesentlicher Fokus des Artikels liegt im Folgenden auf der Darstellung eines sinnvollen und Ressourcen-orientierten diagnostischen Vorgehens. Der CLE-Test („continuous laryngoscopy exercise test“) als Provokationsmethode unter Wach-Videolaryngoskopie ist der Goldstandard, jedoch wird diese Diagnostik im deutschsprachigen Raum nicht flächendeckend vorgehalten. Dieses Positionspapier stellt daher die diagnostische Wertigkeit verschiedener anderer Diagnostik-Algorithmen und anamnestischer Informationen heraus. Ein weiterer Schwerpunkt des Papiers besteht in der detaillierten Vorstellung geeigneter atemphysiotherapeutischer Interventionen.
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Olin JT, Shaffer M, Nauman E, Durso CS, Fan EM, Staudenmayer H, Christopher KL, Gartner-Schmidt J. Development and validation of the Exercise-Induced Laryngeal Obstruction Dyspnea Index (EILODI). J Allergy Clin Immunol 2021; 149:1437-1444. [PMID: 34619181 DOI: 10.1016/j.jaci.2021.09.027] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 09/06/2021] [Accepted: 09/23/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Exercise-induced laryngeal obstruction (EILO) causes exertional dyspnea and is important for its effect on quality of life, diagnostic confusion with exercise-induced asthma, and health care resource utilization. There is no validated patient-reported outcome measure specific to EILO. OBJECTIVE We sought to develop, validate, and define a minimal clinically important difference for a patient-reported outcome measure to be used with adolescents and young adults with EILO. METHODS A multidisciplinary group created a preliminary measure, modified by a 10-member participant focus group, with 20 items scored along a 5-point Likert scale. A subsequent cohort of participants recruited from a clinic, aged 12 to 21 years, with confirmed EILO by continuous laryngoscopy during exercise testing (1) completed the measure at 3 points in time over 28 days and (2) provided anchoring data in the form of a daily exercise log and categorical self-assessments of clinical improvement. Thirty additional participants without exertional dyspnea served as controls. RESULTS Two hundred nineteen subjects with mild to severe EILO participated in the exploratory factor analysis, which identified 7 factors within the preliminary outcome measure. After a process of item reduction, a 12-item metric with a total score ranging from 0 to 48 was developed. Mean scores of patients with EILO and healthy controls at baseline were 28.8 ± 7.4 and 4.5 ± 7.4, respectively. A minimal clinically important difference of 6 was determined by comparison of index change with changes in categorical self-assessments of improvement. CONCLUSIONS This is the first patient-reported outcome measure specifically designed for adolescents and young adults with EILO.
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Affiliation(s)
- James Tod Olin
- Department of Pediatrics, National Jewish Health, Denver, Colo; Department of Medicine, National Jewish Health, Denver, Colo.
| | - Monica Shaffer
- Department of Rehabilitation Medicine, National Jewish Health, Denver, Colo
| | - Emily Nauman
- Department of Rehabilitation Medicine, National Jewish Health, Denver, Colo
| | | | - Elizabeth M Fan
- Department of Pediatrics, National Jewish Health, Denver, Colo
| | - Herman Staudenmayer
- Department of Psychiatry, University of Colorado School of Medicine, Aurora, Colo
| | - Kent L Christopher
- Department of Medicine, University of Colorado School of Medicine, Aurora, Colo
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Word L, Dubois MD, Lelonge Y, Hupin D, Prades JM, Gavid M. Exercise laryngoscopy in athletes and sportsmen: an easy way to assess exercise-induced laryngeal obstruction. Acta Otolaryngol 2021; 141:965-970. [PMID: 34666608 DOI: 10.1080/00016489.2021.1987516] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Exercise-induced laryngeal obstruction (EILO) is an exercise-dependent dyspnoea, linked to a laryngeal closure during physical effort. It may concern from 5% to 7% of adolescents and young athletic adults. EILO is a quite recently described condition: standardized diagnostic criteria and consensual management are still to come. Formal diagnosis of EILO requires a continuous laryngoscopy during exercise (CLE). This test allows visualization of laryngeal abnormalities during an effort but is only accessible in specialized centres. AIMS We wanted to assess performance of a simplified CLE (sCLE) procedure for EILO diagnosis in everyday practice. MATERIAL AND METHODS The procedure consisted in a continuous flexible videolaryngoscopy during a cycloergometre cardio-pulmonary exercise test. Screening questionnaire and visual scoring of laryngeal abnormalities were performed. Patients clinically suspected of EILO were included from 2018 to 2020. RESULTS Seventeen consecutive subjects had an indication for sCLE. Fifteen patients underwent sCLE, and EILO-linked significative abnormalities were observed in 80% of them, thus confirming the diagnosis. CONCLUSIONS CLE can be done successfully in a simple way. Due to its simplicity, tolerance and contribution in EILO diagnosis, this simplified version of CLE may promote its widespread use in ENT and pulmonology practices, as an affordable confirmation test.
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Affiliation(s)
- Ludovic Word
- Service d’ORL et de Chirurgie Cervico-Faciale, CHU de Saint-Etienne, Saint-Etienne, France
| | - Marie-Dominique Dubois
- Service d’ORL et de Chirurgie Cervico-Faciale, CHU de Saint-Etienne, Saint-Etienne, France
| | - Yann Lelonge
- Service d’ORL et de Chirurgie Cervico-Faciale, CHU de Saint-Etienne, Saint-Etienne, France
| | - David Hupin
- Médecine du sport, CHU de Saint-Etienne, Saint-Etienne, France
| | - Jean-Michel Prades
- Service d’ORL et de Chirurgie Cervico-Faciale, CHU de Saint-Etienne, Saint-Etienne, France
| | - Marie Gavid
- Service d’ORL et de Chirurgie Cervico-Faciale, CHU de Saint-Etienne, Saint-Etienne, France
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Walsted ES, Famokunwa B, Andersen L, Rubak SL, Buchvald F, Pedersen L, Dodd J, Backer V, Nielsen KG, Getzin A, Hull JH. Characteristics and impact of exercise-induced laryngeal obstruction: an international perspective. ERJ Open Res 2021; 7:00195-2021. [PMID: 34195253 PMCID: PMC8236618 DOI: 10.1183/23120541.00195-2021] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 04/12/2021] [Indexed: 01/21/2023] Open
Abstract
Background Exercise-induced laryngeal obstruction (EILO) is a common cause of exertional breathlessness and wheeze yet is frequently misdiagnosed as asthma. Insight regarding the demographic characteristics, laryngeal abnormalities and impact of EILO is currently limited, with data only available from individual centre reports. The aim of this work was to provide a broader perspective from a collaboration between multiple international expert centres. Methods Five geographically distinct clinical paediatric and adult centres (3 Denmark, 1 UK, 1 USA) with an expertise in assessing unexplained exertional breathlessness completed database entry of key characteristic features for all cases referred with suspected EILO over a 5-year period. All included cases completed clinical asthma workup and continuous laryngoscopy during exercise (CLE) testing for EILO. Results Data were available for 1007 individuals (n=713 female (71%)) with a median (range) age of 24 (8–76) years, and of these 586 (58%) were diagnosed with EILO. In all centres, EILO was frequently misdiagnosed as asthma; on average there was a 2-year delay to diagnosis of EILO, and current asthma medication was discontinued in 20%. Collapse at the supraglottic level was seen in 60%, whereas vocal cord dysfunction (VCD) was only detected/visualised in 18%. Nearly half (45%) of individuals with EILO were active participants in recreational-level sports, suggesting that EILO is not simply confined to competitive/elite athletes. Conclusion Our findings indicate that key clinical characteristics and the impact of EILO/VCD are similar in globally distinct regions, facilitating improved awareness of this condition to enhance recognition and avoid erroneous asthma treatment. Exercise-induced laryngeal obstruction is a prevalent cause of exertional breathlessness and wheeze. In this international multicentre collaboration, 1007 patients waited, on average, 2 years for diagnosis and 20% were mistreated as asthmatic.https://bit.ly/3auXpcp
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Affiliation(s)
- Emil S Walsted
- Dept of Respiratory Medicine, Bispebjerg Hospital, Copenhagen, Denmark.,Dept of Respiratory Medicine, Royal Brompton Hospital, London, UK
| | - Bamidele Famokunwa
- Academic Respiratory Unit, University of Bristol, Southmead Hospital, Bristol, UK
| | - Louise Andersen
- Dept of Pediatrics and Adolescent Medicine, Aarhus University Hospital Skejby, Aarhus, Denmark
| | - Sune L Rubak
- Dept of Pediatrics and Adolescent Medicine, Aarhus University Hospital Skejby, Aarhus, Denmark
| | - Frederik Buchvald
- Pediatric Pulmonary Service, Dept of Pediatrics and Adolescent Medicine, Rigshospitalet, Denmark
| | - Lars Pedersen
- Dept of Respiratory Medicine, Bispebjerg Hospital, Copenhagen, Denmark
| | - James Dodd
- Academic Respiratory Unit, University of Bristol, Southmead Hospital, Bristol, UK
| | - Vibeke Backer
- Dept of ENT and Centre for Physical Activity Research, Rigshospitalet and Copenhagen University, Copenhagen, Denmark
| | - Kim G Nielsen
- Pediatric Pulmonary Service, Dept of Pediatrics and Adolescent Medicine, Rigshospitalet, Denmark.,Dept of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | | | - James H Hull
- Dept of Respiratory Medicine, Royal Brompton Hospital, London, UK
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IREWALL TOMMIE, BÄCKLUND CATHARINA, NORDANG LEIF, RYDING MARIE, STENFORS NIKOLAI. High Prevalence of Exercise-induced Laryngeal Obstruction in a Cohort of Elite Cross-country Skiers. Med Sci Sports Exerc 2021; 53:1134-1141. [PMID: 33315808 PMCID: PMC8126484 DOI: 10.1249/mss.0000000000002581] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Exercise-induced laryngeal obstruction (EILO) is a differential diagnosis for asthma and prevalent in athletes referred for exercise-induced dyspnea. The aim of this study was to estimate the prevalence of EILO in elite cross-country skiers, known for a high prevalence of asthma. METHOD Elite cross-country skiers were invited for screening of EILO. Screening consisted of clinical assessment, questionnaires, skin prick test, spirometry, eucapnic voluntary hyperventilation test, and continuous laryngoscopy during exercise test. Current asthma was defined as physician-diagnosed asthma and use of asthma medication during the last 12 months. EILO was defined as ≥2 points at the supraglottic or glottic level during exercise at maximal effort, using a visual grade score system. RESULT A total of 89 (51% female) cross-country skiers completed the study. EILO was identified in 27% of the skiers, 83% of whom were female. All skiers with EILO had supraglottic EILO, and there was no glottic EILO. Current asthma was present in 34 (38%) of the skiers, 10 (29%) of whom had concomitant EILO. In the skiers with EILO, a higher proportion reported wheeze or shortness of breath after exercise, compared with skiers without EILO. In skiers with EILO and current asthma, compared with skiers with asthma only, a higher proportion reported wheeze or shortness of breath after exercise. Asthma medication usage did not differ between these groups. CONCLUSION EILO is common in elite cross-country skiers, especially females. Asthma and EILO may coexist, and the prevalence of respiratory symptoms is higher in skiers with both. Testing for EILO should be considered in cross-country skiers with respiratory symptoms.
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Affiliation(s)
- TOMMIE IREWALL
- Division of Medicine, Department of Public Health and Clinical Medicine, Umeå University, Umeå, SWEDEN
| | - CATHARINA BÄCKLUND
- Unit of Physiotherapy, Östersund Hospital, Region Jämtland Härjedalen, SWEDEN
| | - LEIF NORDANG
- Department of Surgical Sciences, Otorhinolaryngology and Head and Neck Surgery, Uppsala University, Uppsala, SWEDEN
| | - MARIE RYDING
- Unit of Otorhinolaryngology, Östersund Hospital, Region Jämtland Härjedalen, SWEDEN
| | - NIKOLAI STENFORS
- Division of Medicine, Department of Public Health and Clinical Medicine, Umeå University, Umeå, SWEDEN
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Ajami RIP, Arribas MB, Santiago VS, Gómez CDM, Gil EA, Andújar FR, García PF, González JÁC, Asensi JRV. Adaptation in Pediatric Population of the Continuous Laryngoscopy Exercise Test for Diagnosis of Exercise-inducible Laryngeal Obstruction. Open Respiratory Archives 2021. [PMID: 37497070 PMCID: PMC10369573 DOI: 10.1016/j.opresp.2021.100092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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Giraud L, Wuyam B, Destors M, Atallah I. Exercise-induced laryngeal obstruction: From clinical examination to continuous laryngoscopy during exercise. Eur Ann Otorhinolaryngol Head Neck Dis 2021:S1879-7296(21)00023-5. [PMID: 33622626 DOI: 10.1016/j.anorl.2021.02.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
The diagnosis of exercise-induced laryngeal obstruction (EILO) should be suspected when exercise triggers inspiratory stridor. EILO is common in adolescent populations and has a significant impact on sports. Identification of laryngeal obstruction during continuous laryngoscopy during exercise (CLE) is the gold standard diagnostic tool for this disorder, which is not widely known in France. The challenge faced by otolaryngologists is to identify, among patients referred by pulmonologists or sports physicians, those with exercise-induced inspiratory symptoms or poorly controlled exercise-induced asthma, in whom a diagnosis of EILO is strongly suspected. Laryngoscopy at rest may reveal a laryngeal, glottic or supraglottic abnormality predictive of obstruction at increased inspiratory airflow. When pulmonary function tests are normal or in the case of failure of treatment of exercise-induced asthma, the otolaryngologist must complete the examination by a CLE test to confirm the diagnosis of EILO and identify the site of obstruction. This examination is well tolerated, minimally invasive and allows identification of the site of airflow obstruction, allowing specific conservative or surgical treatment. This technical note describes in detail clinical examination and CLE testing in patients with suspected EILO.
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Engan M, Hammer IJ, Bekken M, Halvorsen T, Fretheim-Kelly ZL, Vollsæter M, Bovim LPV, Røksund OD, Clemm H. Reliability of maximum oxygen uptake in cardiopulmonary exercise testing with continuous laryngoscopy. ERJ Open Res 2021; 7:00825-2020. [PMID: 33614778 PMCID: PMC7882785 DOI: 10.1183/23120541.00825-2020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 11/25/2020] [Indexed: 11/29/2022] Open
Abstract
Aims A cardiopulmonary exercise test (CPET) is the gold standard to evaluate symptom-limiting exercise intolerance, while continuous laryngoscopy performed during exercise (CLE) is required to diagnose exercise-induced laryngeal obstruction. Combining CPET with CLE would save time and resources; however, the CPET data may be distorted by the extra equipment. We therefore aimed to study whether CPET with CLE influences peak oxygen uptake (V′O2peak) and other gas exchange parameters when compared to a regular CPET. Methods Forty healthy athletes without exercise-related breathing problems, 15–35 years of age, performed CPET to peak exercise with and without an added CLE set-up, in randomised order 2–4 days apart, applying an identical computerised treadmill protocol. Results At peak exercise, the mean difference (95% confidence interval) between CPET with and without extra CLE set-up for V′O2peak, respiratory exchange ratio (RER), minute ventilation (V′E) and heart rate (HR) was 0.2 (−0.4 to 0.8) mL·kg−1·min−1, 0.01(−0.007 to 0.027) units, 2.6 (−1.3 to 6.5) L·min−1 and 1.4 (−0.8 to 3.5) beats·min−1, respectively. Agreement (95% limits of agreement) for V′O2peak, RER and V′E was 0.2 (±3.7) mL·kg−1·min−1, 0.01 (±0.10) units and 2.6 (±24.0) L·min−1, respectively. No systematic or proportional bias was found except for the completed distance, which was 49 m (95% CI 16 to 82 m) longer during CPET. Conclusion Parameters of gas exchange, including V′O2peak and RER, obtained from a maximal CPET performed with the extra CLE set-up can be used interchangeably with data obtained from standard CPET, thus preventing unnecessary additional testing. Cardiopulmonary exercise testing (CPET) with concurrent continuous laryngoscopy provides reliable measures for maximal oxygen consumption and other CPET datahttps://bit.ly/36wVJhb
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Affiliation(s)
- Mette Engan
- Dept of Pediatric and Adolescent Medicine, Haukeland University Hospital, Bergen, Norway.,Dept of Clinical Science, University of Bergen, Bergen, Norway.,These authors contributed equally
| | - Ida Jansrud Hammer
- Dept of Pediatric and Adolescent Medicine, Haukeland University Hospital, Bergen, Norway.,These authors contributed equally
| | - Marianne Bekken
- Dept of Clinical Science, University of Bergen, Bergen, Norway
| | - Thomas Halvorsen
- Dept of Pediatric and Adolescent Medicine, Haukeland University Hospital, Bergen, Norway.,Dept of Clinical Science, University of Bergen, Bergen, Norway.,Dept of Sports Medicine, Norwegian School of Sport Sciences, Oslo, Norway
| | - Zoe Louise Fretheim-Kelly
- Dept of Clinical Science, University of Bergen, Bergen, Norway.,Faculty of Veterinary Medicine, Norwegian University of Life Sciences, Oslo, Norway
| | - Maria Vollsæter
- Dept of Pediatric and Adolescent Medicine, Haukeland University Hospital, Bergen, Norway.,Dept of Clinical Science, University of Bergen, Bergen, Norway
| | | | - Ola Drange Røksund
- Dept of Pediatric and Adolescent Medicine, Haukeland University Hospital, Bergen, Norway.,Faculty of Health and Social Sciences, Western Norway University of Applied Sciences, Bergen, Norway
| | - Hege Clemm
- Dept of Pediatric and Adolescent Medicine, Haukeland University Hospital, Bergen, Norway.,Dept of Clinical Science, University of Bergen, Bergen, Norway
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Engan M, Hammer IJ, Stensrud T, Gundersen H, Edvardsen E, Clemm HH. Changes in pulmonary function and feasibility of portable continuous laryngoscopy during maximal uphill running. BMJ Open Sport Exerc Med 2021; 6:e000815. [PMID: 33403123 PMCID: PMC7772557 DOI: 10.1136/bmjsem-2020-000815] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/26/2020] [Indexed: 11/10/2022] Open
Abstract
Objective To evaluate changes in pulmonary function and feasibility of portable continuous laryngoscopy during maximal uphill running. Methods Healthy volunteers participated in an uphill race. Forced expiratory volume in 1 s (FEV1) and forced vital capacity (FVC) were obtained before and 5 and 10 min after finishing the race. Capillary blood lactate concentration ([BLa-]) and Borg score for perceived exertion were registered immediately after the race. One participant wore a portable video-laryngoscope during the race, and the video was assessed for technical performance. Results Twenty adult subjects participated with a mean (SD) age of 40.2 (9.7) years. Mean (SD) race duration and post-exercise [BLa-] was 13.9 (2.3) min and 10.7 (2.1) mmol/L, respectively, and the median (range) Borg score for perceived exertion was 9 (5–10).
Mean percentage change (95% CI) 5 and 10 min post-exercise in FEV1 were 6.9 (3.7 to 10.2) % and 5.9 (2.7 to 9.0) %, respectively, and in FVC 5.2 (2.3 to 8.1) % and 4.7 (1.6 to 7.9) %, respectively. The recorded video of the larynx was of good quality. Conclusions Maximal aerobic field exercise induced bronchodilatation in the majority of the healthy non-asthmatic participants. It is feasible to perform continuous video-laryngoscopy during heavy uphill exercise.
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Affiliation(s)
- Mette Engan
- Department of Pediatric and Adolescent Medicine, Haukeland University Hospital, Bergen, Norway.,Institute of Clinical Science, University of Bergen, Bergen, Norway
| | - Ida Jansrud Hammer
- Department of Pediatric and Adolescent Medicine, Haukeland University Hospital, Bergen, Norway
| | - Trine Stensrud
- Institute of Sports Medicine, The Norwegian School of Sport Sciences, Oslo, Norway
| | - Hilde Gundersen
- Department of Sport, Food and Natural Sciences, Western Norway University of Applied Sciences, Bergen, Norway
| | - Elisabeth Edvardsen
- Institute of Physical Performance, The Norwegian School of Sport Sciences, Oslo, Norway
| | - Hege Havstad Clemm
- Department of Pediatric and Adolescent Medicine, Haukeland University Hospital, Bergen, Norway.,Institute of Clinical Science, University of Bergen, Bergen, Norway
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Vollsæter M, Stensrud T, Maat R, Halvorsen T, Røksund OD, Sandnes A, Clemm H. Exercise Related Respiratory Problems in the Young-Is It Exercise-Induced Bronchoconstriction or Laryngeal Obstruction? Front Pediatr 2021; 9:800073. [PMID: 35047465 PMCID: PMC8762363 DOI: 10.3389/fped.2021.800073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 12/09/2021] [Indexed: 11/13/2022] Open
Abstract
Complaints of breathlessness during heavy exercise is common in children and adolescents, and represent expressions of a subjective feeling that may be difficult to verify and to link with specific diagnoses through objective tests. Exercise-induced asthma and exercise-induced laryngeal obstruction are two common medical causes of breathing difficulities in children and adolescents that can be challenging to distinguish between, based only on the complaints presented by patients. However, by applying a systematic clinical approach that includes rational use of tests, both conditions can usually be diagnosed reliably. In this invited mini-review, we suggest an approach we find feasible in our everyday clinical work.
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Affiliation(s)
- Maria Vollsæter
- Department of Paediatrics and Adolescent Medicine, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Science, Section for Paediatrics, University of Bergen, Bergen, Norway
| | - Trine Stensrud
- Department of Sports Medicine, Norwegian School of Sport Sciences, Oslo, Norway
| | - Robert Maat
- Department of Otorhinolaryngology, Saxenburgh Medical Center, Hardenberg, Netherlands
| | - Thomas Halvorsen
- Department of Paediatrics and Adolescent Medicine, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Science, Section for Paediatrics, University of Bergen, Bergen, Norway.,Department of Sports Medicine, Norwegian School of Sport Sciences, Oslo, Norway
| | - Ola Drange Røksund
- Department of Paediatrics and Adolescent Medicine, Haukeland University Hospital, Bergen, Norway.,Faculty of Health and Social Sciences, Bergen University College, Bergen, Norway
| | - Astrid Sandnes
- Department of Internal Medicine, Innlandet Hospital Trust, Gjøvik, Norway
| | - Hege Clemm
- Department of Paediatrics and Adolescent Medicine, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Science, Section for Paediatrics, University of Bergen, Bergen, Norway
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Benestad MR, Drageset J, Clemm H, Røksund OD, Vollsæter M, Halvorsen T, Hysing M, Vederhus BJ. Self-Reported Health in Adolescents With Exercise-Induced Laryngeal Obstruction; A Cross-Sectional Study. Front Pediatr 2021; 9:617759. [PMID: 34307244 PMCID: PMC8295467 DOI: 10.3389/fped.2021.617759] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 06/09/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Exercise-induced laryngeal obstruction (EILO) is common in young people with exertional breathing difficulties. Psychological characteristics have been proposed as underlying contributors; however, the evidence for this is limited. Objectives: Describe self-reported health, self-efficacy, and anxiety symptoms in adolescents with EILO, and address possible associations with EILO subtypes and severity. Methods: Cross-sectional study of 71/180 (39%) adolescents tested for EILO at Haukeland University Hospital during 2014-2016, age range 14-18 years. Validated questionnaires were used to assess general self-rated health, subjective health complaints (Health Behavior in School-aged Children-Symptom Check List; HBSC-SCL), general self-efficacy (GSE), and anxiety symptoms (SCARED). The outcomes were compared with normative data from comparable unselected populations. Results: The HBSC-SCL items for somatic complaints revealed weekly or more often occurrence of headache in 42%, abdominal pain in 30%, backache in 31%, and dizziness in 32%. For psychological complaints, corresponding figures were 26% for feeling low, 43% for irritability or bad mood, 33% for feeling nervous, and 38% for sleep problems. Mean (range) GSE score was 3.13 (2.2-4.0), and reports suggesting anxiety symptoms were rare. The outcomes were in line with normative data from comparable unselected populations. Self-rated health, and scores obtained for HBSC-SCL, GSE, and SCARED were similarly distributed across EILO subtypes and severity. Conclusion: Self-reported health, self-efficacy, and level of anxiety symptoms in adolescents with laryngoscopically confirmed EILO were similar to data obtained in comparable unselected populations, irrespective of EILO subtype and severity. The findings challenge the notion that pediatric EILO is causally related to psychological problems.
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Affiliation(s)
- Merete R Benestad
- The Faculty of Health and Social Sciences, Western Norway University of Applied Sciences, Bergen, Norway.,Department of Pediatrics, Haukeland University Hospital, Bergen, Norway
| | - Jorunn Drageset
- The Faculty of Health and Social Sciences, Western Norway University of Applied Sciences, Bergen, Norway.,Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Hege Clemm
- Department of Pediatrics, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Science, Faculty of Medicine, University of Bergen, Bergen, Norway
| | - Ola D Røksund
- The Faculty of Health and Social Sciences, Western Norway University of Applied Sciences, Bergen, Norway.,Department of Otolaryngology/Head and Neck Surgery, Haukeland University Hospital, Bergen, Norway
| | - Maria Vollsæter
- Department of Pediatrics, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Science, Faculty of Medicine, University of Bergen, Bergen, Norway
| | - Thomas Halvorsen
- Department of Clinical Science, Faculty of Medicine, University of Bergen, Bergen, Norway.,Norwegian School of Sport Sciences, Oslo, Norway
| | - Mari Hysing
- Department of Psychosocial Science, Faculty of Psychology, University of Bergen, Bergen, Norway
| | - Bente J Vederhus
- The Faculty of Health and Social Sciences, Western Norway University of Applied Sciences, Bergen, Norway.,Department of Pediatrics, Haukeland University Hospital, Bergen, Norway
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Famokunwa B, Kemp S, Selby J, Madani G, Sandhu G, Hull JH. Life-threatening laryngeal injury in Elite Rugby Union: Prevention and management laryngeal trauma in rugby. Clin Case Rep 2021; 9:494-498. [PMID: 33489203 PMCID: PMC7813074 DOI: 10.1002/ccr3.3565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Revised: 10/18/2020] [Accepted: 10/26/2020] [Indexed: 11/07/2022] Open
Abstract
Laryngeal trauma is a life-threatening injury in contact sports. Due to its potentially devastating consequences, the prevention, diagnosis, and management of neck trauma both pitch side and at the hospital are essential for athletes.
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Affiliation(s)
| | | | - Julia Selby
- Department of Respiratory MedicineRoyal Brompton HospitalLondonUK
| | - Gitta Madani
- Department of RadiologyCharing Cross HospitalLondonUK
| | - Guri Sandhu
- Department of ENT Charing Cross HospitalLondonUK
| | - James H. Hull
- Department of Respiratory MedicineRoyal Brompton HospitalLondonUK
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Hengeveld VS, van der Kamp MR, Thio BJ, Brannan JD. The Need for Testing-The Exercise Challenge Test to Disentangle Causes of Childhood Exertional Dyspnea. Front Pediatr 2021; 9:773794. [PMID: 35071131 PMCID: PMC8770982 DOI: 10.3389/fped.2021.773794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 12/13/2021] [Indexed: 11/13/2022] Open
Abstract
Exertional dyspnea is a common symptom in childhood which can induce avoidance of physical activity, aggravating the original symptom. Common causes of exertional dyspnea are exercise induced bronchoconstriction (EIB), dysfunctional breathing, physical deconditioning and the sensation of dyspnea when reaching the physiological limit. These causes frequently coexist, trigger one another and have overlapping symptoms, which can impede diagnoses and treatment. In the majority of children with exertional dyspnea, EIB is not the cause of symptoms, and in asthmatic children it is often not the only cause. An exercise challenge test (ECT) is a highly specific tool to diagnose EIB and asthma in children. Sensitivity can be increased by simulating real-life environmental circumstances where symptoms occur, such as environmental factors and exercise modality. An ECT reflects daily life symptoms and impairment, and can in an enjoyable way disentangle common causes of exertional dyspnea.
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Affiliation(s)
- Vera S Hengeveld
- Department of Pediatrics, Medisch Spectrum Twente, Enschede, Netherlands
| | - Mattiènne R van der Kamp
- Department of Pediatrics, Medisch Spectrum Twente, Enschede, Netherlands.,Department of Biomedical Signals and Systems, University of Twente, Enschede, Netherlands
| | - Boony J Thio
- Department of Pediatrics, Medisch Spectrum Twente, Enschede, Netherlands
| | - John D Brannan
- Ludwig Engel Centre for Respiratory Research, Westmead Institute for Medical Research, Westmead, NSW, Australia.,Department of Respiratory and Sleep Medicine, John Hunter Hospital, New Lambton Heights, NSW, Australia
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Sails J, Hull JH, Allen H, Darville L, Walsted ES, Price OJ. High prevalence of exercise-induced stridor during Parkrun: a cross-sectional field-based evaluation. BMJ Open Respir Res 2020; 7:7/1/e000618. [PMID: 32998911 PMCID: PMC7528425 DOI: 10.1136/bmjresp-2020-000618] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 07/31/2020] [Accepted: 08/18/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND AND OBJECTIVE The differential diagnosis for exercise-associated breathlessness is broad, however, when a young athletic individual presents with respiratory symptoms, they are most often prescribed inhaler therapy for presumed exercise-induced asthma (EIA). The purpose of this study was therefore to use a novel sound-based approach to assessment to evaluate the prevalence of exertional respiratory symptoms and characterise abnormal breathing sounds in a large cohort of recreationally active individuals. METHODS Cross-sectional field-based evaluation of individuals completing Parkrun. PHASE 1: Prerace, clinical assessment and baseline spirometry were conducted. At peak exercise and immediately postrace, breathing was monitored continuously using a smartphone. Recordings were analysed retrospectively and coded for signs of the predominant respiratory noise. PHASE 2: A subpopulation that reported symptoms with at least one audible sign of respiratory dysfunction was randomly selected and invited to attend the laboratory on a separate occasion to undergo objective clinical workup to confirm or refute EIA. RESULTS Forty-eight participants (22.6%) had at least one audible sign of respiratory dysfunction; inspiratory stridor (9.9%), expiratory wheeze (3.3%), combined stridor+wheeze (3.3%), cough (6.1%). Over one-third of the cohort (38.2%) were classified as symptomatic. Ten individuals attended a follow-up appointment, however, only one had objective evidence of EIA. CONCLUSIONS The most common audible sign, detected in approximately 1 in 10 individuals, was inspiratory stridor, a characteristic feature of upper airway closure occurring during exercise. Further work is now required to further validate the precision and feasibility of this diagnostic approach in cohorts reporting exertional breathing difficulty.
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Affiliation(s)
- Joe Sails
- Clinical Exercise and Respiratory Physiology Research Group, Carnegie School of Sport, Leeds Beckett University, Leeds, UK
| | - James H Hull
- Department of Respiratory Medicine, Royal Brompton Hospital, London, UK.,Institute of Sport, Exercise and Health (ISEH), University College London, London, UK
| | - Hayden Allen
- Clinical Exercise and Respiratory Physiology Research Group, Carnegie School of Sport, Leeds Beckett University, Leeds, UK
| | - Liam Darville
- Clinical Exercise and Respiratory Physiology Research Group, Carnegie School of Sport, Leeds Beckett University, Leeds, UK
| | - Emil S Walsted
- Clinical Exercise and Respiratory Physiology Research Group, Carnegie School of Sport, Leeds Beckett University, Leeds, UK.,Department of Respiratory Medicine, Royal Brompton Hospital, London, UK.,Department of Respiratory Medicine, Bispebjerg Hospital, Copenhagen, Denmark
| | - Oliver J Price
- Clinical Exercise and Respiratory Physiology Research Group, Carnegie School of Sport, Leeds Beckett University, Leeds, UK .,Leeds Institute of Medical Research at St. James', University of Leeds, Leeds, UK
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Abstract
OBJECTIVE Vocal cord dysfunction (VCD) is characterized by paradoxical vocal fold movement (PVFM) during inspiration. The aim of this study was to determine whether ultrasound could accurately differentiate between normal and PVFM during respirations in a resting state. DESIGN Prospective, single-subject design. SETTING Academic medical center. PATIENTS A speech-language pathologist who was able to volitionally alternate between normal and PVFM when breathing at rest was recruited to participate in the study. INTERVENTIONS The subject was instructed to randomly alternate between normal and PVFM 20 times (10 times each). A single investigator imaged the vocal folds using ultrasound and reported when the subject alternated between the 2 respiratory states. MAIN OUTCOME MEASURES The subject recorded when they changed between the 2 respiratory states, whether the investigator identified with the change occurred, and if the correct respiratory state was identified. RESULTS The investigator recognized when the subject changed respiratory states and correctly identified the new respiratory state 100% of the time. CONCLUSIONS The findings of the current study were promising and suggest that ultrasound may have utility in the diagnosis of VCD. However, because of the preliminary nature of these results, further research is required before recommending its clinical implementation.
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Hull JH, Godbout K, Boulet LP. Exercise-Associated Dyspnea and Stridor: Thinking Beyond Asthma. J Allergy Clin Immunol Pract 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] [What about the content of this article? (0)] [Affiliation(s)] [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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Norlander K, Johansson H, Emtner M, Janson C, Nordvall L, Nordang L. Differences in laryngeal movements during exercise in healthy and dyspnoeic adolescents. Int J Pediatr Otorhinolaryngol 2020; 129:109765. [PMID: 31706111 DOI: 10.1016/j.ijporl.2019.109765] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 10/30/2019] [Accepted: 10/30/2019] [Indexed: 01/25/2023]
Abstract
OBJECTIVES To compare glottic and supraglottic movements in healthy adolescents and adolescents experiencing dyspnoea during strenuous exercise. METHODS Using the continuous laryngoscopy exercise (CLE)-test laryngeal movements during exercise were analysed in healthy controls (n = 28) and compared to subjects with exercise induced bronchoconstriction (EIB) (n = 10), exercise induced laryngeal obstruction (EILO) (n = 10) and subjects experiencing exercise-induced dyspnoea without having any of these diagnoses (n = 31). Images from the video recordings were assessed regarding glottic angle, glottic area and supraglottic area using the software measuring tool EILOMEA. RESULTS No significant differences were detected between controls, the dyspnoea group without a diagnosis of EIB or EILO and the EIB group regarding glottis angle, glottis area or supraglottic area at maximum effort. All three parameters differed significantly in the EILO group compared to the other groups (p=<0.001). In the group with EILO all but one had supraglottic obstruction (corresponding to a CLE-test score ≥2). Movement of the laryngeal structures, corresponding to a CLE-test score of 1, at glottic and/or supraglottic level was seen in 26 of 35 (74%) of controls, 34 out of 41 (83%) of patients in the dyspnoea group, and in 25 of 38 (66%) of EIB-subjects. CONCLUSION Minor movements at both glottic and supraglottic level are equally common in healthy controls as among adolescents with exercise induced dyspnoea without EIB or EILO and adolescents with EIB. Adolescents with EILO had a statistically significant more pronounced supraglottic obstruction than the other groups.
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Affiliation(s)
- Katarina Norlander
- Department of Surgical Sciences, Otorhinolaryngology and Head & Neck Surgery, Uppsala University, Akademiska Sjukhuset, 751 85, Uppsala, Sweden
| | - Henrik Johansson
- Department of Neuroscience, Physiotherapy, Uppsala University, Box 593 BMC, 751 24, Uppsala, Sweden.
| | - Margareta Emtner
- Department of Neuroscience, Physiotherapy, Uppsala University, Box 593 BMC, 751 24, Uppsala, Sweden
| | - Christer Janson
- Department of Medical Sciences, Respiratory, Allergy and Sleep Research, Akademiska Sjukhuset, 751 85, Uppsala, Sweden
| | - Lennart Nordvall
- Department of Women's and Children's Health, Uppsala University, Akademiska Sjukhuset, 751 85, Uppsala, Sweden
| | - Leif Nordang
- Department of Surgical Sciences, Otorhinolaryngology and Head & Neck Surgery, Uppsala University, Akademiska Sjukhuset, 751 85, Uppsala, Sweden
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Famokunwa B, Sandhu G, Hull JH. Surgical intervention for exercise-induced laryngeal obstruction: A UK perspective. Laryngoscope 2020; 130:E667-E673. [PMID: 31913523 DOI: 10.1002/lary.28497] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 11/05/2019] [Accepted: 12/12/2019] [Indexed: 01/28/2023]
Abstract
OBJECTIVES Exercise-induced laryngeal obstruction (EILO) is a prevalent cause of exertional breathlessness and wheeze in young individuals. Typically diagnosed using the continuous laryngoscopy during exercise (CLE) test, treatment is largely based on breathing retraining promoting improved laryngeal function. In some cases, these techniques fail to alleviate symptoms, and surgical intervention with supraglottoplasty can be valuable in the supraglottic form of EILO. Globally, there is currently limited experience utilizing a surgical approach to EILO, and data regarding the optimum surgical technique and published outcomes and complication rates are thus limited. STUDY DESIGN Retrospective observational case series. METHODS In this report, we describe our experience as the only UK center undertaking supraglottoplasty for EILO. We report the surgical outcome of 19 patients (n = 16 female), mean age, 29.6 ± 13.1 years, referred for surgery with moderate to severe supraglottic EILO. Follow-up clinic ± CLE was performed within 4 months (median = 6 weeks), and CLE scores were evaluated before and following surgery. RESULTS We found a beneficial effect of surgery on supraglottic CLE scores (median score reducing from 3/3 to 1/3 postoperatively [P < .05] overall) with 79% (n = 15) of patients reporting an improvement in their exercise capacity. One patient developed an apparent increased tendency for glottic-level EILO following surgery; however, no voice- or swallowing-related complications were encountered. CONCLUSIONS This study is the first to report the UK experience, surgical technique, and outcome for EILO surgery. The findings indicate that EILO surgery appears to be a safe and effective option for individuals with moderate to severe supraglottic-type EILO who have failed initial conservative treatment. LEVEL OF EVIDENCE 5 Laryngoscope, 130:E667-E673, 2020.
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Affiliation(s)
- Bamidele Famokunwa
- North Bristol Lung Centre, Bristol Royal Infirmary, Bristol, United Kingdom
| | - Guri Sandhu
- Department of Laryngology, Charing Cross Hospital London, London, United Kingdom
| | - James H Hull
- Department of Respiratory Medicine, Royal Brompton Hospital, London, United Kingdom
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