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Quigley N, Mistry SG, Vasant DH, Vasani S. Practical multidisciplinary framework for the assessment and management of patients with unexplained chronic aerodigestive symptoms. BMJ Open Gastroenterol 2023; 10:e000883. [PMID: 37996120 PMCID: PMC10668155 DOI: 10.1136/bmjgast-2022-000883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Accepted: 10/20/2023] [Indexed: 11/25/2023] Open
Abstract
OBJECTIVE Patients experiencing unexplained chronic throat symptoms (UCTS) are frequently referred to gastroenterology and otolaryngology outpatient departments for investigation. Often despite extensive investigations, an identifiable structural abnormality to account for the symptoms is not found. The objective of this article is to provide a concise appraisal of the evidence-base for current approaches to the assessment and management of UCTS, their clinical outcomes, and related healthcare utilisation. DESIGN This multidisciplinary review critically examines the current understanding of aetiological theories and pathophysiological drivers in UCTS and summarises the evidence base underpinning various diagnostic and management approaches. RESULTS The evidence gathered from the review suggests that single-specialty approaches to UCTS inadequately capture the substantial heterogeneity and pervasive overlaps among clinical features and biopsychosocial factors and suggests a more unified approach is needed. CONCLUSION Drawing on contemporary insights from the gastrointestinal literature for disorders of gut-brain interaction, this article proposes a refreshed interdisciplinary approach characterised by a positive diagnosis framework and patient-centred therapeutic model. The overarching aim of this approach is to improve patient outcomes and foster collaborative research efforts.
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Affiliation(s)
- Nathan Quigley
- Otolaryngology Department, Royal Brisbane and Woman's Hospital Health Service District, Herston, Queensland, Australia
| | - Sandeep G Mistry
- Department of Ear Nose and Throat, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Dipesh H Vasant
- Neurogastroenterology Unit, Gastroenterology Department, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
- Division of Diabetes, Endocrinology and Gastroenterology, University of Manchester, Manchester, UK
| | - Sarju Vasani
- Otolaryngology Department, Royal Brisbane and Woman's Hospital Health Service District, Herston, Queensland, Australia
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2
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Koh J, Leong P, Bardin PG. A new paradigm for vocal cord dysfunction/inducible laryngeal obstruction: Swift diagnosis and streamlined management pathways. Respirology 2023; 28:911-913. [PMID: 37612245 DOI: 10.1111/resp.14574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 08/02/2023] [Indexed: 08/25/2023]
Affiliation(s)
- Joo Koh
- Ear Nose and Throat Surgery, Monash Hospital, Monash Health and University, Hudson Institute, Melbourne, Victoria, Australia
| | - Paul Leong
- Monash Lung and Sleep Allergy Immunology, Monash Hospital, Monash Health and University, Hudson Institute, Melbourne, Victoria, Australia
| | - Philip G Bardin
- Monash Lung and Sleep Allergy Immunology, Monash Hospital, Monash Health and University, Hudson Institute, Melbourne, Victoria, Australia
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Plaza Moral V, Alobid I, Álvarez Rodríguez C, Blanco Aparicio M, Ferreira J, García G, Gómez-Outes A, Garín Escrivá N, Gómez Ruiz F, Hidalgo Requena A, Korta Murua J, Molina París J, Pellegrini Belinchón FJ, Plaza Zamora J, Praena Crespo M, Quirce Gancedo S, Sanz Ortega J, Soto Campos JG. GEMA 5.3. Spanish Guideline on the Management of Asthma. OPEN RESPIRATORY ARCHIVES 2023; 5:100277. [PMID: 37886027 PMCID: PMC10598226 DOI: 10.1016/j.opresp.2023.100277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2023] Open
Abstract
The Spanish Guideline on the Management of Asthma, better known by its acronym in Spanish GEMA, has been available for more than 20 years. Twenty-one scientific societies or related groups both from Spain and internationally have participated in the preparation and development of the updated edition of GEMA, which in fact has been currently positioned as the reference guide on asthma in the Spanish language worldwide. Its objective is to prevent and improve the clinical situation of people with asthma by increasing the knowledge of healthcare professionals involved in their care. Its purpose is to convert scientific evidence into simple and easy-to-follow practical recommendations. Therefore, it is not a monograph that brings together all the scientific knowledge about the disease, but rather a brief document with the essentials, designed to be applied quickly in routine clinical practice. The guidelines are necessarily multidisciplinary, developed to be useful and an indispensable tool for physicians of different specialties, as well as nurses and pharmacists. Probably the most outstanding aspects of the guide are the recommendations to: establish the diagnosis of asthma using a sequential algorithm based on objective diagnostic tests; the follow-up of patients, preferably based on the strategy of achieving and maintaining control of the disease; treatment according to the level of severity of asthma, using six steps from least to greatest need of pharmaceutical drugs, and the treatment algorithm for the indication of biologics in patients with severe uncontrolled asthma based on phenotypes. And now, in addition to that, there is a novelty for easy use and follow-up through a computer application based on the chatbot-type conversational artificial intelligence (ia-GEMA).
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Affiliation(s)
| | - Isam Alobid
- Otorrinolaringología, Hospital Clinic de Barcelona, España
| | | | | | - Jorge Ferreira
- Hospital de São Sebastião – CHEDV, Santa Maria da Feira, Portugal
| | | | - Antonio Gómez-Outes
- Farmacología clínica, Agencia Española de Medicamentos y Productos Sanitarios (AEMPS), Madrid, España
| | - Noé Garín Escrivá
- Farmacia Hospitalaria, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | | | | | - Javier Korta Murua
- Neumología Pediátrica, Hospital Universitario Donostia, Donostia-San, Sebastián, España
| | - Jesús Molina París
- Medicina de familia, semFYC, Centro de Salud Francia, Fuenlabrada, Dirección Asistencial Oeste, Madrid, España
| | | | - Javier Plaza Zamora
- Farmacia comunitaria, Farmacia Dr, Javier Plaza Zamora, Mazarrón, Murcia, España
| | | | | | - José Sanz Ortega
- Alergología Pediátrica, Hospital Católico Universitario Casa de Salud, Valencia, España
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4
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Leong P, Gibson PG, Vertigan AE, Hew M, McDonald VM, Bardin PG. Vocal cord dysfunction/inducible laryngeal obstruction-2022 Melbourne Roundtable Report. Respirology 2023; 28:615-626. [PMID: 37221142 PMCID: PMC10947219 DOI: 10.1111/resp.14518] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 05/08/2023] [Indexed: 05/25/2023]
Abstract
Vocal cord dysfunction/inducible laryngeal obstruction (VCD/ILO), is a common condition characterized by breathlessness associated with inappropriate laryngeal narrowing. Important questions remain unresolved, and to improve collaboration and harmonization in the field, we convened an international Roundtable conference on VCD/ILO in Melbourne, Australia. The aims were to delineate a consistent approach to VCD/ILO diagnosis, appraise disease pathogenesis, outline current management and model(s) of care and identify key research questions. This report summarizes discussions, frames key questions and details recommendations. Participants discussed clinical, research and conceptual advances in the context of recent evidence. The condition presents in a heterogenous manner, and diagnosis is often delayed. Definitive diagnosis of VCD/ILO conventionally utilizes laryngoscopy demonstrating inspiratory vocal fold narrowing >50%. Computed tomography of the larynx is a new technology with potential for swift diagnosis that requires validation in clinical pathways. Disease pathogenesis and multimorbidity interactions are complex reflecting a multi-factorial, complex condition, with no single overarching disease mechanism. Currently there is no evidence-based standard of care since randomized trials for treatment are non-existent. Recent multidisciplinary models of care need to be clearly articulated and prospectively investigated. Patient impact and healthcare utilization can be formidable but have largely escaped inquiry and patient perspectives have not been explored. Roundtable participants expressed optimism as collective understanding of this complex condition evolves. The Melbourne VCD/ILO Roundtable 2022 identified clear priorities and future directions for this impactful condition.
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Affiliation(s)
- Paul Leong
- Monash HealthMelbourneVictoriaAustralia
- Monash UniversityMelbourneVictoriaAustralia
| | - Peter G. Gibson
- John Hunter HospitalNewcastleNew South WalesAustralia
- Centre of Excellence in Treatable TraitsUniversity of NewcastleNewcastleNew South WalesAustralia
| | - Anne E. Vertigan
- John Hunter HospitalNewcastleNew South WalesAustralia
- Centre of Excellence in Treatable TraitsUniversity of NewcastleNewcastleNew South WalesAustralia
| | - Mark Hew
- Alfred HospitalMelbourneVictoriaAustralia
| | - Vanessa M. McDonald
- John Hunter HospitalNewcastleNew South WalesAustralia
- Centre of Excellence in Treatable TraitsUniversity of NewcastleNewcastleNew South WalesAustralia
| | - Philip G. Bardin
- Monash HealthMelbourneVictoriaAustralia
- Monash UniversityMelbourneVictoriaAustralia
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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] [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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6
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Koh JH, Ruane LE, Phyland D, Hamza K, Fukusho R, Leahy E, Avram A, Yap G, Lau KK, MacDonald MI, Leong P, Baxter M, Bardin PG. Computed Tomography Imaging of the Larynx for Diagnosis of Vocal Cord Dysfunction. NEJM EVIDENCE 2023; 2:EVIDoa2200183. [PMID: 38320086 DOI: 10.1056/evidoa2200183] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
BACKGROUND: Vocal cord dysfunction/inducible laryngeal obstruction (VCD/ILO) is characterized by breathlessness and often mimics or accompanies severe asthma. The disorder occurs intermittently, and the diagnosis is established by using laryngoscopy. Dynamic computed tomography (CT) imaging of the larynx at low-radiation doses has the potential to provide an alternative method to make the diagnosis of VCD/ILO. METHODS: We report two case series: in series A, laryngoscopy (diagnostic standard) and CT imaging of the larynx were each performed within 1 hour of each other (n=31), and in series B, the procedures were performed on separate days 4 to 6 weeks apart (n=72). Diagnosis of VCD/ILO by laryngoscopy used conventional criteria, and diagnosis by CT imaging was based on vocal cord narrowing in excess of a validated normal threshold. In each series, we evaluated the accuracy of CT imaging of the larynx to establish a diagnosis of VCD/ILO compared with laryngoscopy. RESULTS: In series A, the sensitivity of CT imaging of the larynx was 53.8%, and specificity was 88.9%; in series B, the sensitivity of CT imaging of the larynx was 76.2%, and specificity was 93.3%. At a disease prevalence of 30% (which was known to be the case in our clinic), the positive predictive value was 67.5% in series A and 83% in series B. Negative predictive values were 81.8% and 90.1% in series A and B, respectively, and false-positive rates were 11.1% and 6.7%. CONCLUSIONS: When the population prevalence was assumed to be 30%, low-dose CT imaging of the larynx detected VCD/ILO with negative predictive values greater than 80% in both series settings and agreed with each other within 9 percentage points. Positive predictive values for laryngeal CT imaging varied substantially between the settings of the two case series. (Supported by Monash Lung and Sleep Institute and Grant APP ID 1198362 and others.)
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Affiliation(s)
- Joo H Koh
- Monash Lung Sleep Allergy & Immunology, Monash Health and University, Melbourne, Victoria, Australia
- Ear, Nose, and Throat Surgery, Monash Health, Melbourne, Victoria, Australia
| | - Laurence E Ruane
- Monash Lung Sleep Allergy & Immunology, Monash Health and University, Melbourne, Victoria, Australia
- Hudson Institute and School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
| | - Debra Phyland
- Ear, Nose, and Throat Surgery, Monash Health, Melbourne, Victoria, Australia
| | - Kais Hamza
- School of Mathematical Sciences, Monash University, Melbourne, Victoria, Australia
| | - Risa Fukusho
- Monash Lung Sleep Allergy & Immunology, Monash Health and University, Melbourne, Victoria, Australia
| | - Elizabeth Leahy
- Monash Lung Sleep Allergy & Immunology, Monash Health and University, Melbourne, Victoria, Australia
| | - Adriana Avram
- Monash Lung Sleep Allergy & Immunology, Monash Health and University, Melbourne, Victoria, Australia
| | - Grace Yap
- Monash Lung Sleep Allergy & Immunology, Monash Health and University, Melbourne, Victoria, Australia
| | - Kenneth K Lau
- Diagnostic Imaging, Monash Health and University, Melbourne, Victoria, Australia
| | - Martin I MacDonald
- Monash Lung Sleep Allergy & Immunology, Monash Health and University, Melbourne, Victoria, Australia
- Hudson Institute and School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
| | - Paul Leong
- Monash Lung Sleep Allergy & Immunology, Monash Health and University, Melbourne, Victoria, Australia
- Hudson Institute and School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
| | - Malcolm Baxter
- Monash Lung Sleep Allergy & Immunology, Monash Health and University, Melbourne, Victoria, Australia
- Ear, Nose, and Throat Surgery, Monash Health, Melbourne, Victoria, Australia
| | - Philip G Bardin
- Monash Lung Sleep Allergy & Immunology, Monash Health and University, Melbourne, Victoria, Australia
- Hudson Institute and School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
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7
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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] [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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Niggemann B, Maas R, Suerbaum C, Spindler T, Kohl A, Koerner-Rettberg C, Burghardt R. "Psychological characteristics of functional respiratory disorders in children and adolescents-Pilot study". Pediatr Pulmonol 2022; 57:3027-3034. [PMID: 36114693 DOI: 10.1002/ppul.26129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 07/31/2022] [Accepted: 08/14/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND Aim of our prospective, multicenter, nonrandomized study was to identify characteristic features and similarities of patients with functional respiratory disorders regarding socio-familial and behavioral aspects, in comparison with controls in a cross-sectional analysis using standardized psychological questionnaires. Furthermore, we investigated the longitudinal outcome of symptoms, effects of primary interventions and the stability of psychological traits 6 months after diagnosis and primary intervention. METHODS Initially, 106 patients (68 females, 27 males) and 58 controls (33 females, 25 males) were recruited for the study. Mean age was 12.6 years in patients and 11.9 years in controls. RESULTS The child behavior checklist (CBCL) showed significantly increased scores for anxious/depressed (p = 0.002) and schizoid/obsessive (p = 0.001) behavior in patients. A trend was evident for internalizing behavior (p = 0.009) and for a higher total score (p = 0.008). In the self-assessment youth self-report (YSR), there was a trend towards higher values for anxious/depressed behavior in patients (p = 0.06) and towards more externalizing behavior (p = 0.029) in the control group. After 6 months, 31% of the patients were free of symptoms, 42% had improved. For themselves, parents reported a decreased burden from 56% to 23% (p < 0.001) and decreased impairment from 57% to 30% (p < 0.008). For their children, parents reported a decrease from 45% to 16% (p < 0.0001) and from 74% to 37% (p < 0.0001), respectively. A longitudinal comparison from T1 to T2 showed no statistically significant changes in all three psychological questionnaires (CBCL, YSR, and SOMS-KJ). CONCLUSIONS In summary, we show that patients with functional respiratory disorders differ from healthy subjects, with internalizing behavior being a characteristic trait. The outcome in terms of symptoms, perceived psycho-familial burden and impairment after 6 months is encouraging. However, we are aware that our preliminary data offer thought-provoking impulses rather than firm findings.
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Affiliation(s)
- Bodo Niggemann
- Department of Pediatric Pneumology and Immunology, University Children's Hospital Charité, Berlin, Germany
| | - Ronja Maas
- Pediatric Psychiatry, Psychotherapy and Psychosomatics, Children's Hospital, Klinikum Frankfurt/Oder, Frankfurt/Oder, Brandenburg, Germany
| | - Claudia Suerbaum
- Centre for Pneumology and Pediatric Pneumology, Düsseldorf, Germany
| | - Thomas Spindler
- Specialized Clinic for Pediatric Pneumology and Allergology, Wangen, Germany
| | - Andreas Kohl
- Pediatric Respiratory Medicine Practice, Kiel, Germany
| | | | - Roland Burghardt
- Pediatric Psychiatry, Psychotherapy and Psychosomatics, Children's Hospital, Klinikum Frankfurt/Oder, Frankfurt/Oder, Brandenburg, Germany
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9
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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] [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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10
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Stojanovic S, Zubrinich C, Sverrild A, Mahoney J, Denton E, Lee J, Hew M. Laryngoscopy diagnosis of inducible laryngeal obstruction during supervised challenge for suspected anaphylaxis. Clin Exp Allergy 2022; 52:924-928. [PMID: 35535788 DOI: 10.1111/cea.14156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 04/23/2022] [Accepted: 04/28/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Stephanie Stojanovic
- Allergy, Asthma and Clinical Immunology, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Celia Zubrinich
- Allergy, Asthma and Clinical Immunology, The Alfred Hospital, Melbourne, Victoria, Australia.,School of Public Health & Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Asger Sverrild
- Allergy, Asthma and Clinical Immunology, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Janine Mahoney
- Speech Pathology, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Eve Denton
- Allergy, Asthma and Clinical Immunology, The Alfred Hospital, Melbourne, Victoria, Australia.,School of Public Health & Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Joy Lee
- Allergy, Asthma and Clinical Immunology, The Alfred Hospital, Melbourne, Victoria, Australia.,School of Public Health & Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Mark Hew
- Allergy, Asthma and Clinical Immunology, The Alfred Hospital, Melbourne, Victoria, Australia.,School of Public Health & Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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11
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Koh J, Baxter M, Phyland D, Ruane L, Avram A, Leahy E, Lau K, MacDonald M, Leong P, Bardin P. Innovations during the Covid-19 pandemic to maintain delivery of care for vocal cord dysfunction (VCD) in a multidisciplinary team (MDT) clinic. Respirology 2022; 27:671-673. [PMID: 35509217 PMCID: PMC9347761 DOI: 10.1111/resp.14276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 04/14/2022] [Indexed: 11/29/2022]
Abstract
See relatedReply
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Affiliation(s)
- Joo Koh
- Monash Health Ear Nose and Throat Surgery, Melbourne, Victoria, Australia.,School of Clinical Sciences, Monash Health & University, Melbourne, Victoria, Australia
| | - Malcolm Baxter
- Monash Health Ear Nose and Throat Surgery, Melbourne, Victoria, Australia.,School of Clinical Sciences, Monash Health & University, Melbourne, Victoria, Australia
| | - Debra Phyland
- Monash Health Ear Nose and Throat Surgery, Melbourne, Victoria, Australia
| | - Laurence Ruane
- School of Clinical Sciences, Monash Health & University, Melbourne, Victoria, Australia.,Australia Monash Lung, Sleep, Allergy and Immunology, Melbourne, Victoria, Australia
| | - Adriana Avram
- Australia Monash Lung, Sleep, Allergy and Immunology, Melbourne, Victoria, Australia
| | - Elizabeth Leahy
- Australia Monash Lung, Sleep, Allergy and Immunology, Melbourne, Victoria, Australia
| | - Kenneth Lau
- Monash Health Diagnostic Imaging, Monash Hospital and University, Melbourne, Victoria, Australia
| | - Martin MacDonald
- School of Clinical Sciences, Monash Health & University, Melbourne, Victoria, Australia.,Australia Monash Lung, Sleep, Allergy and Immunology, Melbourne, Victoria, Australia
| | - Paul Leong
- School of Clinical Sciences, Monash Health & University, Melbourne, Victoria, Australia.,Australia Monash Lung, Sleep, Allergy and Immunology, Melbourne, Victoria, Australia
| | - Philip Bardin
- School of Clinical Sciences, Monash Health & University, Melbourne, Victoria, Australia.,Australia Monash Lung, Sleep, Allergy and Immunology, Melbourne, Victoria, Australia
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12
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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] [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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13
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de Carvalho-Pinto RM, Cançado JED, Pizzichini MMM, Fiterman J, Rubin AS, Cerci A, Cruz ÁA, Fernandes ALG, Araujo AMS, Blanco DC, Cordeiro G, Caetano LSB, Rabahi MF, de Menezes MB, de Oliveira MA, Lima MA, Pitrez PM. 2021 Brazilian Thoracic Association recommendations for the management of severe asthma. J Bras Pneumol 2021; 47:e20210273. [PMID: 34932721 PMCID: PMC8836628 DOI: 10.36416/1806-3756/e20210273] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 08/05/2021] [Indexed: 12/20/2022] Open
Abstract
Advances in the understanding that severe asthma is a complex and heterogeneous disease and in the knowledge of the pathophysiology of asthma, with the identification of different phenotypes and endotypes, have allowed new approaches for the diagnosis and characterization of the disease and have resulted in relevant changes in pharmacological management. In this context, the definition of severe asthma has been established, being differentiated from difficult-to-control asthma. These recommendations address this topic and review advances in phenotyping, use of biomarkers, and new treatments for severe asthma. Emphasis is given to topics regarding personalized management of the patient and selection of biologicals, as well as the importance of evaluating the response to treatment. These recommendations apply to adults and children with severe asthma and are targeted at physicians involved in asthma treatment. A panel of 17 Brazilian pulmonologists was invited to review recent evidence on the diagnosis and management of severe asthma, adapting it to the Brazilian reality. Each of the experts was responsible for reviewing a topic or question relevant to the topic. In a second phase, four experts discussed and structured the texts produced, and, in the last phase, all experts reviewed and approved the present manuscript and its recommendations.
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Affiliation(s)
- Regina Maria de Carvalho-Pinto
- . Divisão de Pneumologia, Instituto do Coração − InCor − Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
| | | | | | - Jussara Fiterman
- . Hospital São Lucas, Pontifícia Universidade Católica do Rio Grande do Sul − PUCRS − Porto Alegre (RS) Brasil
| | - Adalberto Sperb Rubin
- . Universidade Federal de Ciências da Saúde de Porto Alegre − UFCSPA − Porto Alegre (RS) Brasil
- . Santa Casa de Misericórdia de Porto Alegre, Porto Alegre (RS) Brasil
| | - Alcindo Cerci
- . Universidade Estadual de Londrina − UEL − Londrina (PR) Brasil
- . Pontifícia Universidade Católica do Paraná − PUCPR − Londrina (PR) Brasil
| | - Álvaro Augusto Cruz
- . Universidade Federal da Bahia − UFBA − Salvador (BA) Brasil
- . Fundação ProAR, Salvador (BA) Brasil
| | | | - Ana Maria Silva Araujo
- . Instituto de Doenças do Tórax, Universidade Federal do Rio de Janeiro − IDT/UFRJ − Rio de Janeiro (RJ) Brasil
| | - Daniela Cavalet Blanco
- . Escola de Medicina, Pontifícia Universidade Católica do Rio Grande do Sul − PUCRS − Porto Alegre (RS), Brasil
| | - Gediel Cordeiro
- . Hospital Júlia Kubitschek, Fundação Hospitalar do Estado de Minas Gerais - FHEMIG - Belo Horizonte (MG) Brasil
- . Hospital Madre Teresa, Belo Horizonte (MG) Brasil
| | | | - Marcelo Fouad Rabahi
- . Faculdade de Medicina, Universidade Federal de Goiás − UFG − Goiânia (GO) Brasil
| | - Marcelo Bezerra de Menezes
- . Departamento de Clínica Médica, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto (SP) Brasil
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14
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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] [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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15
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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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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16
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Zheng M, Arora N, Bhatt N, O'Dell K, Johns M. Factors Associated With Tolerance for In-Office Laryngeal Laser Procedures. Laryngoscope 2021; 131:E2292-E2297. [PMID: 33405311 DOI: 10.1002/lary.29370] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 11/13/2020] [Accepted: 12/28/2020] [Indexed: 11/08/2022]
Abstract
OBJECTIVES/HYPOTHESIS A variety of laryngeal pathologies are increasingly being managed with in-office KTP laser (IOKTP) endoscopic procedures. The primary goal of this study was to identify patient characteristics and disease-related features that correlated with tolerance for IOKTP. STUDY DESIGN Retrospective chart review. METHODS The study was a retrospective review of adult patients undergoing office-based laryngeal laser procedures between November 2016 and December 2019 at a tertiary care center. Two blinded otolaryngologist reviewers scored videotaped recordings of IOKTP procedures and assessed severity and distribution of disease using a modified Derkay score, and evaluated procedure tolerance using a visual analog scale. RESULTS A total of 56 patients who received IOKTP procedures for laryngeal pathology were reviewed, 42 male and 14 female, with a mean age of 61 years. Gender, age, and BMI were not correlated with tolerance. There was a moderate, negative correlation between tolerance and total number of pathological anatomic laryngeal subsites (rs(56) = -0.35, P = .01). There was a weak, negative correlation between tolerance and total modified Derkay score (rs(56) = -0.29, P = .03). The median tolerance score was lower for patients with posterior lesions (Mdn = 6.4) compared with patients with non-posterior lesions (Mdn = 7.4), P = .04, and lower for current or former smokers (Mdn = 6.5) compared with never smokers (Mdn = 7.3), P = .04. CONCLUSION Patients with large disease burden or posterior lesions and patients with smoking history may exhibit poorer tolerance of IOKTP procedures, factors which can help guide pre-procedural counseling and management decisions. LEVEL OF EVIDENCE IV Laryngoscope, 131:E2292-E2297, 2021.
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Affiliation(s)
- Melissa Zheng
- Department of Otolaryngology-Head and Neck Surgery, University of Southern California, Los Angeles, California, U.S.A
| | - Nikhil Arora
- Keck School of Medicine, University of Southern California, Los Angeles, California, U.S.A
| | - Neel Bhatt
- Department of Otolaryngology-Head and Neck Surgery, University of Southern California, Los Angeles, California, U.S.A
| | - Karla O'Dell
- Department of Otolaryngology-Head and Neck Surgery, University of Southern California, Los Angeles, California, U.S.A
| | - Michael Johns
- Department of Otolaryngology-Head and Neck Surgery, University of Southern California, Los Angeles, California, U.S.A
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17
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Lee JH, An J, Won HK, Kang Y, Kwon HS, Kim TB, Cho YS, Moon HB, Song WJ, Hull JH. Prevalence and impact of comorbid laryngeal dysfunction in asthma: A systematic review and meta-analysis. J Allergy Clin Immunol 2020; 145:1165-1173. [PMID: 31940470 DOI: 10.1016/j.jaci.2019.12.906] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 12/15/2019] [Accepted: 12/30/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND Laryngeal or vocal cord dysfunction has long been regarded as a mimic of asthma; however, recent evidence indicates that it may be a significant comorbid condition in patients with asthma. OBJECTIVE We aimed to systematically estimate the prevalence of comorbid laryngeal dysfunction (LD) in adults with asthma and characterize its clinical impact on asthma. METHODS Electronic databases were searched for relevant studies published until June 2019. Studies were included if LD was objectively defined by direct visualization of laryngeal movement. Outcomes included the prevalence of LD and its association with clinical asthma indicators, such as severity, control, and quality of life. Random effects meta-analyses were performed to calculate the estimates. RESULTS A total of 21 studies involving 1637 patients were identified. Overall, the pooled prevalence of LD in adults with asthma was 25% (95% CI = 15%-37%; I2 = 96%). Prevalence estimates differed according to the diagnostic test utilized, with the lowest overall prevalence (4% [95% CI = 0%-10%; I2 = 90%]) seen when LD was diagnosed by resting laryngoscopy without external stimuli; however, it was much higher when diagnosed by laryngoscopy studies utilizing an external trigger, such as exercise (38% [95% CI = 24%-53%; I2 = 90%]) or in studies using a computed tomography-based diagnostic protocol (36% [95% CI = 24%-49%; I2 = 78%]). Only 7 studies reported the associations between LD and clinical asthma indicators; inconsistencies between studies limited meaningful conclusions. CONCLUSION LD may be a common comorbidity in asthma, affecting about 25% of adult patients. Further prospective studies are needed to better characterize its clinical impact and the benefits of detecting and managing LD in patients with asthma.
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Affiliation(s)
- Ji-Hyang Lee
- Department of Allergy and Clinical Immunology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Jin An
- Department of Allergy and Clinical Immunology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Ha-Kyeong Won
- Department of Internal Medicine, Veterans Health Service Medical Center, Seoul, Korea
| | - Yewon Kang
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Korea
| | - Hyouk-Soo Kwon
- Department of Allergy and Clinical Immunology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Tae-Bum Kim
- Department of Allergy and Clinical Immunology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - You Sook Cho
- Department of Allergy and Clinical Immunology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Hee-Bom Moon
- Department of Allergy and Clinical Immunology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Woo-Jung Song
- Department of Allergy and Clinical Immunology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea.
| | - James H Hull
- National Heart & Lung Institute, Imperial College London & Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom.
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18
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Daley CP, Ruane LE, Leong P, Lau KK, Low K, Hamza K, Finlay P, MacDonald M, Baxter M, Bardin PG. Vocal Cord Dysfunction in Patients Hospitalized with Symptoms of Acute Asthma Exacerbation. Am J Respir Crit Care Med 2020; 200:782-785. [PMID: 31150268 DOI: 10.1164/rccm.201902-0396le] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
| | | | - Paul Leong
- Monash UniversityMelbourne, Australiaand
| | | | - Kathy Low
- Monash UniversityMelbourne, Australiaand
| | - Kais Hamza
- Monash UniversityMelbourne, Australiaand
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19
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Lee J, Denton E, Hoy R, Tay TR, Bondarenko J, Hore-Lacy F, Radhakrishna N, O'Hehir RE, Dabscheck E, Abramson MJ, Hew M. Paradoxical Vocal Fold Motion in Difficult Asthma Is Associated with Dysfunctional Breathing and Preserved Lung Function. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:2256-2262. [PMID: 32173506 DOI: 10.1016/j.jaip.2020.02.037] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 01/13/2020] [Accepted: 02/23/2020] [Indexed: 01/19/2023]
Abstract
BACKGROUND Many patients with difficult asthma also have coexisting vocal cord dysfunction (VCD), evident by paradoxical vocal fold motion (PVFM) on laryngoscopy. OBJECTIVE Among patients with difficult asthma, we sought to identify clinical features associated with laryngoscopy-diagnosed PVFM. METHODS Consecutive patients with "difficult asthma" referred by respiratory specialists underwent systematic assessment in this observational study. Those with a high clinical suspicion for VCD were referred for laryngoscopy, either at rest or after mannitol provocation. Statistical analyses were performed to identify clinical factors associated with PVFM, and a multivariate logistic regression model was fitted to control for confounders. RESULTS Of 169 patients with difficult asthma, 63 (37.3%) had a high clinical probability of VCD. Of 42 who underwent laryngoscopy, 32 had PVFM confirmed. Patients with PVFM more likely had preserved lung function (prebronchodilator forced expiratory ratio 74% ± 11 vs 62% ± 16, P < .001); physiotherapist-confirmed dysfunctional breathing (odds ratio [OR] = 5.52, 95% confidence interval [CI]: 2.4-12.7, P < .001), gastro-oesophageal reflux (OR = 2.6, 95% CI: 1.16-5.8, P = .02), and a lower peripheral eosinophil count (0.09 vs 0.23, P = .004). On multivariate logistic regression, independent predictors for PVFM were dysfunctional breathing (OR = 4.93, 95% CI: 2-12, P < .001) and preserved lung function (OR = 1.07, 95% CI: 1.028-1.106, P < .001). CONCLUSION Among specialist-referred patients with difficult asthma, VCD pathogenesis may overlap with dysfunctional breathing but is not associated with severe airflow obstruction. Dysfunctional breathing and preserved lung function may serve as clinical clues for the presence of VCD.
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Affiliation(s)
- Joy Lee
- Allergy, Asthma & Clinical Immunology, The Alfred Hospital, Melbourne, VIC, Australia; School of Public Health & Preventive Medicine, Monash University, Melbourne, VIC, Australia.
| | - Eve Denton
- Allergy, Asthma & Clinical Immunology, The Alfred Hospital, Melbourne, VIC, Australia; School of Public Health & Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Ryan Hoy
- Allergy, Asthma & Clinical Immunology, The Alfred Hospital, Melbourne, VIC, Australia; School of Public Health & Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Tunn Ren Tay
- Department of Respiratory & Critical Care Medicine, Changi General Hospital, Singapore
| | - Janet Bondarenko
- Allergy, Asthma & Clinical Immunology, The Alfred Hospital, Melbourne, VIC, Australia
| | - Fiona Hore-Lacy
- Allergy, Asthma & Clinical Immunology, The Alfred Hospital, Melbourne, VIC, Australia
| | - Naghmeh Radhakrishna
- Allergy, Asthma & Clinical Immunology, The Alfred Hospital, Melbourne, VIC, Australia
| | - Robyn E O'Hehir
- Allergy, Asthma & Clinical Immunology, The Alfred Hospital, Melbourne, VIC, Australia; Department of Respiratory Medicine, Allergy and Clinical Immunology, Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Eli Dabscheck
- Allergy, Asthma & Clinical Immunology, The Alfred Hospital, Melbourne, VIC, Australia
| | - Michael J Abramson
- Allergy, Asthma & Clinical Immunology, The Alfred Hospital, Melbourne, VIC, Australia; School of Public Health & Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Mark Hew
- Allergy, Asthma & Clinical Immunology, The Alfred Hospital, Melbourne, VIC, Australia; School of Public Health & Preventive Medicine, Monash University, Melbourne, VIC, Australia
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20
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Panagiotou M, Koulouris NG, Rovina N. Physical Activity: A Missing Link in Asthma Care. J Clin Med 2020; 9:jcm9030706. [PMID: 32150999 PMCID: PMC7141291 DOI: 10.3390/jcm9030706] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 02/28/2020] [Accepted: 03/02/2020] [Indexed: 12/12/2022] Open
Abstract
Asthma is the commonest respiratory disease and one of unceasingly increasing prevalence and burden. As such, asthma has attracted a major share or scientific interest and clinical attention. With the various clinical and pathophysiological aspects of asthma having been extensively investigated, the important association between asthma and physical activity remains underappreciated and insufficiently explored. Asthma impacts adversely on physical activity. Likewise, poor physical activity may lead to worse asthma outcomes. This concise clinical review presents the current recommendations for physical activity, discusses the available evidence on physical activity in asthma, and examines the causes of low physical activity in adult asthmatic patients. It also reviews the effect of daily physical activity and exercise training on the pathology and clinical outcomes of asthma. Finally, it summarizes the evidence on interventions targeting physical activity in asthma.
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21
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Leong P, Ruane LE, Phyland D, Koh J, MacDonald MI, Baxter M, Lau KK, Hamza K, Bardin PG. Inspiratory vocal cord closure in COPD. Eur Respir J 2020; 55:13993003.01466-2019. [DOI: 10.1183/13993003.01466-2019] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 01/22/2020] [Indexed: 11/05/2022]
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22
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Roberts G. Diagnostic and other challenges. Clin Exp Allergy 2019; 48:1582-1583. [PMID: 30489680 DOI: 10.1111/cea.13315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- G Roberts
- Clinical and Experimental Sciences and Human Development and Health, Faculty of Medicine, University of Southampton, Southampton, UK.,NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK.,The David Hide Asthma and Allergy Research Centre, St Mary's Hospital, Isle of Wight, UK
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23
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Roberts G, Almqvist C, Boyle R, Crane J, Hogan SP, Marsland B, Saglani S, Woodfolk JA. Developments in the field of allergy in 2017 through the eyes of Clinical and Experimental Allergy. Clin Exp Allergy 2019; 48:1606-1621. [PMID: 30489681 DOI: 10.1111/cea.13318] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
In this article, we described the development in the field of allergy as described by Clinical and Experimental Allergy in 2017. Experimental models of allergic disease, basic mechanisms, clinical mechanisms, allergens, asthma and rhinitis and clinical allergy are all covered.
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Affiliation(s)
- G Roberts
- Faculty of Medicine, Clinical and Experimental Sciences and Human Development and Health, University of Southampton, Southampton, UK.,NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK.,The David Hide Asthma and Allergy Research Centre, St Mary's Hospital, Isle of Wight, UK
| | - C Almqvist
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.,Pediatric Allergy and Pulmonology Unit at Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - R Boyle
- Department of Paediatrics, Imperial College London, London, UK
| | - J Crane
- Department of Medicine, University of Otago Wellington, Wellington, New Zealand
| | - S P Hogan
- Mary H Weiser Food Allergy Center, Department of Pathology, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - B Marsland
- Department of Immunology and Pathology, Monash University, Melbourne, Victoria, Australia
| | - S Saglani
- National Heart & Lung Institute, Imperial College London, London, UK
| | - J A Woodfolk
- Division of Asthma, Allergy and Immunology, Department of Medicine, University of Virginia School of Medicine, Charlottesville, Virginia
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24
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Anderson WC, Stukus DR. Pediatric Asthma Masqueraders. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 6:1083-1084.e9. [PMID: 29747972 DOI: 10.1016/j.jaip.2017.09.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Revised: 09/06/2017] [Accepted: 09/18/2017] [Indexed: 10/17/2022]
Affiliation(s)
- William C Anderson
- Department of Pediatrics, Section of Allergy and Immunology, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, Colo
| | - David R Stukus
- Division of Allergy and Immunology, Department of Pediatrics, Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, Ohio.
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25
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Roberts G. Vocal cord dysfunction, food allergy and a RCT. Clin Exp Allergy 2019; 47:146-147. [PMID: 28134503 DOI: 10.1111/cea.12884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- G Roberts
- Clinical and Experimental Sciences and Human Development and Health, Faculty of Medicine, University of Southampton, Southampton, UK.,NIHR Southampton Respiratory Biomedical Research Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK.,The David Hide Asthma and Allergy Research Centre, St Mary's Hospital, Isle of Wight, UK
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26
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Famokunwa B, Walsted ES, Hull JH. Assessing laryngeal function and hypersensitivity. Pulm Pharmacol Ther 2019; 56:108-115. [PMID: 31004747 DOI: 10.1016/j.pupt.2019.04.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 04/13/2019] [Accepted: 04/17/2019] [Indexed: 10/27/2022]
Abstract
The larynx is one of the most highly innervated organs in humans, adapted to simultaneously deliver several key respiratory functions including airway protection, swallowing and phonation. In some individuals the larynx can adopt a state that could be considered 'dysfunctional' or maladaptive; resulting in or contributing to a range of clinical disorders such as chronic refractory cough, inducible laryngeal obstruction (previously termed paradoxical vocal fold movement or vocal cord dysfunction), muscle tension dysphonia and globus pharyngeus. These disorders appear to display significant overlap in clinical symptomology and in many cases have features of concomitant or allied sensory dysfunction; often described as laryngeal hypersensitivity. The recognition and accurate assessment of both laryngeal dysfunction±hypersensitivity is important to ensure accurate diagnosis and effective delivery of targeted treatment and therapeutic monitoring. Accordingly, there is increasing in the methodologies proposed to assess laryngeal function. These range from simple questionnaires to targeted investigation(s), assessing both sensory function and the laryngeal motor response, under both resting and provoked situations. This review provides a brief overview of the current state of knowledge in the field of laryngeal dysfunction and hypersensitivity assessment.
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Affiliation(s)
- B Famokunwa
- Bristol Royal Infirmary, Bristol, BS2 8HW, UK
| | - E S Walsted
- Respiratory Research Unit, Bispebjerg Hospital, Copenhagen, Denmark; Department of Respiratory Medicine, Royal Brompton Hospital, London, SW3 6HP, UK
| | - J H Hull
- Department of Respiratory Medicine, Royal Brompton Hospital, London, SW3 6HP, UK.
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Vandenplas O, Godet J, Hurdubaea L, Rifflart C, Suojalehto H, Walusiak-Skorupa J, Munoz X, Sastre J, Klusackova P, Moore V, Merget R, Talini D, Kirkeleit J, Mason P, Folletti I, Cullinan P, Moscato G, Quirce S, Hoyle J, Sherson D, Kauppi P, Preisser A, Meyer N, de Blay F. Severe Occupational Asthma: Insights From a Multicenter European Cohort. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 7:2309-2318.e4. [PMID: 30914232 DOI: 10.1016/j.jaip.2019.03.017] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 02/13/2019] [Accepted: 03/08/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND Although sensitizer-induced occupational asthma (OA) accounts for an appreciable fraction of adult asthma, the severity of OA has received little attention. OBJECTIVE The aim of this study was to characterize the burden and determinants of severe OA in a large multicenter cohort of subjects with OA. METHODS This retrospective study included 997 subjects with OA ascertained by a positive specific inhalation challenge completed in 20 tertiary centers in 11 European countries during the period 2006 to 2015. Severe asthma was defined by a high level of treatment and any 1 of the following criteria: (1) daily need for a reliever medication, (2) 2 or more severe exacerbations in the previous year, or (3) airflow obstruction. RESULTS Overall, 162 (16.2%; 95% CI, 14.0%-18.7%) subjects were classified as having severe OA. Multivariable logistic regression analysis revealed that severe OA was associated with persistent (vs reduced) exposure to the causal agent at work (odds ratio [OR], 2.78; 95% CI, 1.50-5.60); a longer duration of the disease (OR, 1.04; 95% CI, 1.00-1.07); a low level of education (OR, 2.69; 95% CI, 1.73-4.18); childhood asthma (OR, 2.92; 95% CI, 1.13-7.36); and sputum production (OR, 2.86; 95% CI, 1.87-4.38). In subjects removed from exposure, severe OA was associated only with sputum production (OR, 3.68; 95% CI, 1.87-7.40); a low education level (OR, 3.41; 95% CI, 1.72-6.80); and obesity (OR, 1.98; 95% CI, 0.97-3.97). CONCLUSIONS This study indicates that a substantial proportion of subjects with OA experience severe asthma and identifies potentially modifiable risk factors for severe OA that should be targeted to reduce the adverse impacts of the disease.
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Affiliation(s)
- Olivier Vandenplas
- Department of Chest Medicine, Centre Hospitalier Universitaire UCL Namur, Université Catholique de Louvain, Yvoir, Belgium.
| | - Julien Godet
- Groupe Méthode Recherche Clinique, Pôle de Santé Publique, Strasbourg University, Strasbourg, France
| | - Laura Hurdubaea
- Division of Asthma and Allergy, Department of Chest Diseases, University Hospital of Strasbourg and Fédération de Médecine translationnelle, Strasbourg University, Strasbourg, France
| | - Catherine Rifflart
- Department of Chest Medicine, Centre Hospitalier Universitaire UCL Namur, Université Catholique de Louvain, Yvoir, Belgium
| | - Hille Suojalehto
- Occcupational Medicine, Finnish Institute of Occupational Health, Helsinki, Finland
| | - Jolanta Walusiak-Skorupa
- Department of Occupational Diseases and Environmental Health, Nofer Institute of Occupational Medicine, Lodz, Poland
| | - Xavier Munoz
- Servei Pneumologia, Hospital Vall d'Hebron, Universitat Autonoma de Barcelona and CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
| | - Joaquin Sastre
- Department of Allergy, Fundacion Jimenez Dıaz and CIBER de Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Pavlina Klusackova
- Department of Occupational Medicine, 1st Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Vicky Moore
- Occupational Lung Disease Unit, Birmingham Heartlands Hospital, Birmingham, United Kingdom
| | - Rolf Merget
- Institute for Prevention and Occupational Medicine of the German Social Accident Insurance (IPA), Ruhr University, Bochum, Germany
| | - Donatella Talini
- Cardio-Thoracic and Vascular Department, University of Pisa, Pisa, Italy
| | - Jorunn Kirkeleit
- Department of Occupational Medicine, Haukeland University Hospital, Bergen, Norway
| | - Paola Mason
- Unit of Occupational Medicine and Public Health, University of Padova, Padova, Italy
| | - Ilenia Folletti
- Department of Medicine, Section of Occupational Medicine, Respiratory Diseases and Occupational and Environmental Toxicology, University of Perugia, Perugia, Italy
| | - Paul Cullinan
- Department of Occupational and Environmental Medicine, Royal Brompton Hospital and Imperial College (NHLI), Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom
| | - Gianna Moscato
- Department of Public Health, Experimental and Forensic Medicine, University of Pavia, and Allergy and Immunology Unit, Istituti Clinici Scientifici Maugeri, IRCCS, Pavia, Italy
| | - Santiago Quirce
- Department of Allergy, Hospital La Paz Institute for Health Research (IdiPAZ) and CIBER de Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Jennifer Hoyle
- Department of Respiratory Medicine, North Manchester General Hospital, Manchester, United Kingdom
| | - David Sherson
- Department of Pulmonary Medicine and Occupational Medicine, Odense University Hospital, Odense, Denmark
| | - Paula Kauppi
- Department of Allergy, Skin and Allergy Hospital, Helsinki University Central Hospital, Helsinki, Finland
| | - Alexandra Preisser
- Institute for Occupational and Maritime Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Nicolas Meyer
- Groupe Méthode Recherche Clinique, Pôle de Santé Publique, Strasbourg University, Strasbourg, France
| | - Frédéric de Blay
- Division of Asthma and Allergy, Department of Chest Diseases, University Hospital of Strasbourg and Fédération de Médecine translationnelle, Strasbourg University, Strasbourg, France
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Tiotiu A, Plavec D, Novakova S, Mihaicuta S, Novakova P, Labor M, Bikov A. Current opinions for the management of asthma associated with ear, nose and throat comorbidities. Eur Respir Rev 2018; 27:27/150/180056. [PMID: 30463872 DOI: 10.1183/16000617.0056-2018] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Accepted: 10/03/2018] [Indexed: 11/05/2022] Open
Abstract
Ear, nose and throat (ENT) comorbidities are common in patients with asthma and are frequently associated with poorer asthma outcomes. All these comorbidities are "treatable traits" in asthma. Identification and management of these disorders may spare medication usage and contribute to improved asthma control and quality of life, and a decrease in exacerbation rates.This review summarises recent data about the prevalence, clinical impact and treatment effects of ENT comorbidities in asthma including allergic rhinitis, chronic rhinosinusitis with and without nasal polyposis, aspirin-exacerbated respiratory disease, obstructive sleep apnoea and vocal cord dysfunction.Many of these comorbidities are possible to be managed by the pulmonologist, but the collaboration with the ENT specialist is essential for patients with chronic rhinosinusitis or vocal cord dysfunction. Further rigorous research is needed to study the efficacy of comorbidity treatment to improve asthma outcomes, in particular with the development of biotherapies in severe asthma that can also be beneficial in some ENT diseases.
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Affiliation(s)
- Angelica Tiotiu
- Pulmonology Dept, University Hospital, Nancy, France .,EA 3450 DevAH, Development, Adaptation, Cardio-Respiratory Regulations and Motor Control, University of Lorraine, Nancy, France
| | | | - Silviya Novakova
- Allergy Unit, University Hospital "St. George", Plovdiv, Bulgaria
| | | | - Plamena Novakova
- Dept of Allergology and Asthma, Aleksandrovska Hospital, Sofia, Bulgaria
| | - Marina Labor
- Pulmonology Dept, University Hospital Centre Osijek, Osijek, Croatia
| | - Andras Bikov
- NIHR Clinical Research Facility, Manchester University NHS Foundation Trust, Manchester, UK
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Bardin PG, Low K, Ruane L, Lau KK. Controversies and conundrums in vocal cord dysfunction. THE LANCET RESPIRATORY MEDICINE 2018; 5:546-548. [PMID: 28664856 DOI: 10.1016/s2213-2600(17)30221-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Accepted: 05/24/2017] [Indexed: 10/19/2022]
Affiliation(s)
- Philip G Bardin
- Monash Lung & Sleep, Monash University and Medical Centre, Melbourne, Australia; Hudson Institute, Melbourne, Australia.
| | - Kathy Low
- Monash Lung & Sleep, Monash University and Medical Centre, Melbourne, Australia; Hudson Institute, Melbourne, Australia
| | - Laurence Ruane
- Monash Lung & Sleep, Monash University and Medical Centre, Melbourne, Australia; Hudson Institute, Melbourne, Australia
| | - Kenneth K Lau
- Diagnostic Imaging, Monash University and Medical Centre, Melbourne, Australia
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Tay TR, Hew M. Comorbid "treatable traits" in difficult asthma: Current evidence and clinical evaluation. Allergy 2018; 73:1369-1382. [PMID: 29178130 DOI: 10.1111/all.13370] [Citation(s) in RCA: 99] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/21/2017] [Indexed: 01/07/2023]
Abstract
The care of patients with difficult-to-control asthma ("difficult asthma") is challenging and costly. Despite high-intensity asthma treatment, these patients experience poor asthma control and face the greatest risk of asthma morbidity and mortality. Poor asthma control is often driven by severe asthma biology, which has appropriately been the focus of intense research and phenotype-driven therapies. However, it is increasingly apparent that extra-pulmonary comorbidities also contribute substantially to poor asthma control and a heightened disease burden. These comorbidities have been proposed as "treatable traits" in chronic airways disease, adding impetus to their evaluation and management in difficult asthma. In this review, eight major asthma-related comorbidities are discussed: rhinitis, chronic rhinosinusitis, gastroesophageal reflux, obstructive sleep apnoea, vocal cord dysfunction, obesity, dysfunctional breathing and anxiety/depression. We describe the prevalence, impact and treatment effects of these comorbidities in the difficult asthma population, emphasizing gaps in the current literature. We examine the associations between individual comorbidities and highlight the potential for comorbidity clusters to exert combined effects on asthma outcomes. We conclude by outlining a pragmatic clinical approach to assess comorbidities in difficult asthma.
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Affiliation(s)
- T. R. Tay
- Allergy, Asthma and Clinical Immunology; The Alfred Hospital; Melbourne Vic. Australia
- Department of Respiratory and Critical Care Medicine; Changi General Hospital; Singapore
| | - M. Hew
- Allergy, Asthma and Clinical Immunology; The Alfred Hospital; Melbourne Vic. Australia
- School of Public Health & Preventive Medicine; Monash University; Melbourne Vic. Australia
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Cheng T, Carpenter D, Cohen S, Witsell D, Frank-Ito DO. Investigating the effects of laryngotracheal stenosis on upper airway aerodynamics. Laryngoscope 2018; 128:E141-E149. [PMID: 29044543 PMCID: PMC5867224 DOI: 10.1002/lary.26954] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Revised: 08/09/2017] [Accepted: 09/10/2017] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Very little is known about the impact of laryngotracheal stenosis (LTS) on inspiratory airflow and resistance, especially in air hunger states. This study investigates the effect of LTS on airway resistance and volumetric flow across three different inspiratory pressures. METHODS Head-and-neck computed tomography scans of 11 subjects from 2010 to 2016 were collected. Three-dimensional reconstructions of the upper airway from the nostrils to carina, including the oral cavity, were created for one subject with a normal airway and for 10 patients with LTS. Airflow simulations were conducted using computational fluid dynamics modeling at three different inspiratory pressures (10, 25, 40 pascals [Pa]) for all subjects under two scenarios: 1) inspiration through nostrils only (MC), and 2) through both nostrils and mouth (MO). RESULTS Volumetric flows in the normal subject at the three inspiratory pressures were considerably higher (MC: 11.8-26.1 L/min; MO: 17.2-36.9 L/min) compared to those in LTS (MC: 2.86-6.75 L/min; MO: 4.11-9.00 L/min). Airway resistances in the normal subject were 0.051 to 0.092 pascal seconds per milliliter (Pa.s)/mL (MC) and 0.035-0.065 Pa.s/mL (MO), which were approximately tenfold lower than those of subjects with LTS: 0.39 to 0.89 Pa.s/mL (MC) and 0.45 to 0.84 Pa.s/mL (MO). Furthermore, subjects with glottic stenosis had the greatest resistance, whereas subjects with subglottic stenosis had the greatest variability in resistance. Subjects with tracheal stenosis had the lowest resistance. CONCLUSION This pilot study demonstrates that LTS increases resistance and decreases airflow. Mouth breathing significantly improved airflow and resistance but cannot completely compensate for the effects of stenosis. Furthermore, location of stenosis appears to modulate the effect of the stenosis on resistance differentially. LEVEL OF EVIDENCE NA. Laryngoscope, 128:E141-E149, 2018.
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Affiliation(s)
- Tracy Cheng
- Division of Head and Neck Surgery & Communication Sciences, Duke University Medical Center, Durham, NC, USA
| | - David Carpenter
- Division of Head and Neck Surgery & Communication Sciences, Duke University Medical Center, Durham, NC, USA
| | - Seth Cohen
- Division of Head and Neck Surgery & Communication Sciences, Duke University Medical Center, Durham, NC, USA
| | - David Witsell
- Division of Head and Neck Surgery & Communication Sciences, Duke University Medical Center, Durham, NC, USA
| | - Dennis O. Frank-Ito
- Division of Head and Neck Surgery & Communication Sciences, Duke University Medical Center, Durham, NC, USA
- Division of Head and Neck Surgery & Communication Sciences, Duke University MedicalCenter, Durham, NC, USA
- Computational Biology & Bioinformatics PhD Program, Duke University, Durham, NC, USA
- Department of Mechanical Engineering and Materials Science, Duke University, Durham, NC
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Wilson R, Greenhawt M. Influence of rhinitis control and inspiratory loop flattening on perceived asthma control. Ann Allergy Asthma Immunol 2017; 119:387-389. [PMID: 28958379 DOI: 10.1016/j.anai.2017.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Revised: 08/08/2017] [Accepted: 08/10/2017] [Indexed: 10/18/2022]
Affiliation(s)
- Rachel Wilson
- Central Michigan University College of Medicine, Mt Pleasant, Michigan
| | - Matthew Greenhawt
- Division of Allergy and Clinical Immunology, The University of Michigan Medical School, Ann Arbor, Michigan; Section of Allergy and Immunology, Department of Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado.
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Affiliation(s)
- James H Hull
- a Department of Respiratory Medicine , Royal Brompton Hospital , London , UK
| | - Emil S Walsted
- a Department of Respiratory Medicine , Royal Brompton Hospital , London , UK.,b Respiratory Research Unit , Bispebjerg University Hospital , Copenhagen , Denmark
| | - Vibeke Backer
- b Respiratory Research Unit , Bispebjerg University Hospital , Copenhagen , Denmark
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O'Donnell DE, Elbehairy AF, Berton DC, Domnik NJ, Neder JA. Advances in the Evaluation of Respiratory Pathophysiology during Exercise in Chronic Lung Diseases. Front Physiol 2017; 8:82. [PMID: 28275353 PMCID: PMC5319975 DOI: 10.3389/fphys.2017.00082] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Accepted: 01/30/2017] [Indexed: 11/13/2022] Open
Abstract
Dyspnea and exercise limitation are among the most common symptoms experienced by patients with various chronic lung diseases and are linked to poor quality of life. Our understanding of the source and nature of perceived respiratory discomfort and exercise intolerance in chronic lung diseases has increased substantially in recent years. These new mechanistic insights are the primary focus of the current review. Cardiopulmonary exercise testing (CPET) provides a unique opportunity to objectively evaluate the ability of the respiratory system to respond to imposed incremental physiological stress. In addition to measuring aerobic capacity and quantifying an individual's cardiac and ventilatory reserves, we have expanded the role of CPET to include evaluation of symptom intensity, together with a simple "non-invasive" assessment of relevant ventilatory control parameters and dynamic respiratory mechanics during standardized incremental tests to tolerance. This review explores the application of the new advances in the clinical evaluation of the pathophysiology of exercise intolerance in chronic obstructive pulmonary disease (COPD), chronic asthma, interstitial lung disease (ILD) and pulmonary arterial hypertension (PAH). We hope to demonstrate how this novel approach to CPET interpretation, which includes a quantification of activity-related dyspnea and evaluation of its underlying mechanisms, enhances our ability to meaningfully intervene to improve quality of life in these pathologically-distinct conditions.
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Affiliation(s)
- Denis E. O'Donnell
- Division of Respiratory Medicine, Department of Medicine, Queen's University and Kingston General HospitalKingston, ON, Canada
| | - Amany F. Elbehairy
- Division of Respiratory Medicine, Department of Medicine, Queen's University and Kingston General HospitalKingston, ON, Canada
- Department of Chest Diseases, Faculty of Medicine, Alexandria UniversityAlexandria, Egypt
| | - Danilo C. Berton
- Division of Respiratory Medicine, Department of Medicine, Queen's University and Kingston General HospitalKingston, ON, Canada
| | - Nicolle J. Domnik
- Division of Respiratory Medicine, Department of Medicine, Queen's University and Kingston General HospitalKingston, ON, Canada
| | - J. Alberto Neder
- Division of Respiratory Medicine, Department of Medicine, Queen's University and Kingston General HospitalKingston, ON, Canada
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