Examining therapy duration in adults with induced laryngeal obstruction (ILO)

OBJECTIVE

This study examined the number of therapy sessions required to sufficiently improve (exercise) induced laryngeal obstruction (EILO/ILO) symptoms for discharge. Factors predicting therapy duration were examined as was the likelihood of patients returning for additional therapy sessions following initial discharge.

METHODS

Retrospective observational cohort design. Data for 350 patients were gathered from the University of Wisconsin-Madison Voice and Swallow Clinics Outcome Database. Patients (>18 years of age) diagnosed with EILO/ILO received therapy from a Speech-Language Pathologist (SLP) and were successfully discharged. EILO/ILO treatment details, symptoms, triggers, medical comorbidities, and patient demographics were collected from initial evaluations and subsequent course of therapy.

RESULTS

Patients required an average of 3.59 (SD = 3.7) therapy sessions prior to discharge. A comorbid behavioral health diagnosis (p = .026), higher Vocal Handicap Index Score (p = .009) and reduced physical activity due to EILO/ILO symptoms (p = .032) were associated with increased therapy duration. Patients with ILO or EILO with secondary environmental triggers required significantly more sessions than those with exercise-induced symptoms (p < .01). Eight percent of patients returned for additional sessions following discharge. Patients returning for additional sessions all came from affluent neighborhoods as measured by the Area Deprivation Index (ADI).

CONCLUSIONS

Patients with EILO/ILO required an average of 3.59 therapy sessions prior to discharge. As such, 4 sessions is a reasonable estimate for clinicians to provide patients. Six sessions may be a more conservative estimate for patients who present with a behavioral health diagnosis, a voice complaint, or reduced physical activity from EILO/ILO symptoms.

Paradoxical Vocal Fold Dysfunction Mimicking Bronchial Asthma in a Young Female Patient

Inducible laryngeal obstruction (ILO)/paradoxical vocal fold motion (PVFM) is a reversible narrowing of the larynx that results from vocal fold motion dysfunction. Distinguishing ILO from asthma can be challenging, as they can coexist, and standard tests may not be able to differentiate between the two. However, a flexible laryngoscopy can promptly diagnose ILO. Unfortunately, ILO is often overlooked as a potential cause when evaluating patients with sudden-onset breathing difficulties and respiratory distress. We present a case of a young female who sought frequent treatment at the emergency room (ER) with symptoms of shortness of breath (SOB), rapid heart rate, rapid breathing, and anxiety. Despite receiving treatment for acute asthma attacks, her symptoms persisted. During her most recent hospital admission, a flexible laryngoscopy revealed abnormal vocal fold movements, indicating paradoxical vocal fold dysfunction (PVFD) and muscle tension dysphonia (MTD). A comprehensive treatment approach involving speech therapy, pulmonology, and psychiatry led to significant clinical improvement. This case report highlights the importance of raising awareness among healthcare providers about ILO potentially mimicking bronchial asthma exacerbation.

Deployment-Related Respiratory Disease: Where Are We?

Military personnel and veterans who have deployed to Afghanistan, Iraq, and parts of Southwest Asia (SWA) since 1990 are at risk of developing a host of respiratory symptoms and deployment-related respiratory diseases (DRRDs). This review aims to summarize our current understanding of DRRD and inform pulmonary practitioners of recent updates to DRRD screening, diagnosis, evaluation, and management. The most common respiratory diseases in these patients include asthma, chronic sinonasal disease, laryngeal disease/dysfunction, and distal lung disease. Pulmonary function testing and chest imaging are the most commonly used diagnostic tools, but techniques such as lung clearance index testing via multiple breath washout, forced oscillation testing/impulse oscillometry, and quantitative chest computed tomography (CT) assessment appear promising as noninvasive modalities to aid in lung disease detection in this population. We also summarize guidance on conducting an occupational and deployment exposure history as well as recommendations for testing. Finally, we discuss the Sergeant First Class Heath Robinson Honoring our Promise to Address Comprehensive Toxics Act of 2022 (PACT Act) that includes a list of health conditions that are "presumptively" considered to be related to SWA military deployment toxic exposures, and provide resources for clinicians who evaluate and treat patients with DRRD.

Conundrums in the breathless athlete; exercise induced laryngeal obstruction or asthma?

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.

The Role of Comorbidities in Difficult-to-Control Asthma in Adults and Children

Assessment of asthma comorbidities, conditions that adversely affect the pathobiology of asthma or impair its response to therapies, is a fundamental step in the evaluation and management of patients with difficult-to-treat asthma. Identifying and effectively treating asthma comorbidities, such as obesity, obstructive sleep apnea, and chronic sinusitis with nasal polyps, may improve asthma control and reduce exacerbations. In addition, identifying comorbid T2 inflammatory conditions may help guide optimal selection of biologic therapies. Here, we describe common comorbid conditions found in adult and pediatric difficult-to-control asthma, discuss evidence for the association with asthma morbidity and treatment benefit, and provide information on how and when to assess comorbidities.

Adjustment Disorders in U.S. Active Duty Military Women: A Scoping Review for the Years 2000 to 2018

BACKGROUND

Adjustment disorder (AD) is the most common mental health diagnosis in the U.S. military and is more than twice as likely to be diagnosed in active duty servicewomen as compared with male servicemembers. The literature on ADs, particularly in female servicemembers, has not been reviewed yet. We conducted a scoping review of the literature to explore the degree of research activity and summarize current literature gaps.

METHODS

We created a PRISMA-ScR checklist and prospectively registered it in Open Science Framework. The literature search included articles (including studies and reports) published between 2000 and 2018 in either the grey literature or the following databases: Ovid Medline, CINAHL, Embase, PsycINFO, Web of Science, and Ovid Cochrane. We used DistillerSR to conduct title and abstracts screening, full-text screening, and data charting. The social ecological model for military women's health framework was used to organize the results.

RESULTS

After screening 1,304 records, 29 were included for data charting. Most frequently, studies were descriptive (cross-sectional) (25%), with no randomized controlled studies. The studies primarily focused on ADs' risk factors in servicewomen (76%), followed by military readiness (38%). Only 14% addressed recommendations for treatments based on expert opinion, although they did not directly test interventions, and 7% focused on health outcomes.

CONCLUSIONS

ADs affect the health of U.S. military women and military readiness, yet little is known about their successful treatment or health outcomes. Additional research in those areas is warranted.

Work-Related Upper-Airway Disorders

Work-related rhinitis and laryngeal disorders are common and can significantly contribute to work absences and presenteeism. Each can cause respiratory symptoms that may be misdiagnosed as asthma symptoms, and each may occur as an isolated disorder or may also accompany asthma. Suspicion of these disorders and correct management require a careful medical and occupational history. Investigations for work-related rhinitis include examination of the nose, allergy skin tests, and in some cases, monitoring of peak inspiratory nasal flows at work and off work, or specific challenge tests. Work-related laryngeal disorders require assistance from an otolaryngologist and speech language pathologist.

Clinical Evaluation of Deployed Military Personnel With Chronic Respiratory Symptoms: Study of Active Duty Military for Pulmonary Disease Related to Environmental Deployment Exposures (STAMPEDE) III

BACKGROUND

Chronic respiratory symptoms are frequently reported after Southwest Asia deployment in support of combat operations. The full spectrum of clinical lung diseases related to these deployments is not well characterized.

METHODS

Military personnel with chronic symptoms, primarily exertional dyspnea, underwent a standardized cardiopulmonary evaluation at two tertiary medical centers. Pulmonary function testing consisted of spirometry, lung volume, diffusing capacity, impulse oscillometry, and bronchodilator testing. Further testing included methacholine challenge, exercise laryngoscopy, high-resolution CT scan, ECG, and transthoracic echocardiography.

RESULTS

A total of 380 participants with a mean age of 38.5 ± 8.4 years completed testing. Asthma was the most common diagnosis in 87 patients (22.9%) based on obstructive spirometry/impulse oscillometry and evidence of airway hyperreactivity, whereas another 57 patients (15.0%) had reactivity with normal spirometry. Airway disorders included 25 (6.6%) with laryngeal disorders and 16 (4.2%) with excessive dynamic airway collapse. Interstitial lung disease was identified in six patients (1.6%), whereas 11 patients (2.9%) had fixed obstructive lung disorders. Forty patients (10.5%) had isolated pulmonary function abnormalities and 16 (4.2%) had miscellaneous disorders. The remaining 122 patients (32.1%) with normal studies were classified as undiagnosed exertional dyspnea. Significant comorbidities identified included elevated BMI > 30 kg/m² (34.2%), smoking (36.4%), positive allergy testing (43.7%), sleep apnea (38.5%), and esophageal reflux (13.6%). Mental health disorders and posttraumatic stress disorder were likewise common.

CONCLUSIONS

Postdeployment pulmonary evaluation should focus on common diseases, such as asthma and airway hyperreactivity, and include testing for upper airway disorders. Diffuse lung diseases were rarely diagnosed, whereas numerous comorbidities were common.

Environmental Exposures and Asthma in Active Duty Service Members

PURPOSE OF REVIEW

Reports of respiratory symptoms, including asthma and hyper-reactive airway disease, have been more numerous in the media and medical literature since active duty service members (SM) began to support campaigns in South West Asia (SWA). Numerous environmental exposures have been reported and this review assesses the available evidence surrounding exposures, confounding conditions, and attempts to develop screening mechanisms.

RECENT FINDINGS

While particulate matter exposures and particularly exposure to burn pits have garnered much attention, a 2010 Armed Forces Health Surveillance Center report and 2011 Institute of Medicine publication did not identify a link between exposure to particulate matter with SM respiratory disease. The "Study of Active Duty Military for Pulmonary Disease related to Environmental Deployment Exposure," (STAMPEDE) and STAMPEDE II have not identified effective forms of routine screening and these and other sources point to the importance of other factors in SM respiratory disease. These include higher than anticipated rates of tobacco use in deployed settings, impacts of obesity, recurrence of childhood asthma, and of confounding conditions such as Paradoxical Vocal Fold Motion. As with the general population, a complex set of clinical inputs and environmental exposures surround asthma and similar respiratory processes in SM. Concrete relationships and mechanisms for assessment continue to be assessed and refined, but clear associations and pathways have remained elusive.

Vocal Cord Dysfunction: The Spectrum Across the Ages

Vocal cord dysfunction (VCD) is an upper airway disorder characterized by exaggerated and transient glottic constriction causing respiratory and laryngeal symptoms. Although the origin of VCD symptoms is in the upper airway, it is frequently misdiagnosed as asthma resulting in significant morbidity. VCD can coexist with asthma or mimic allergic conditions affecting the upper airway. VCD may be difficult to diagnose, because patients are intermittently symptomatic and VCD awareness in the medical community is underappreciated. Once VCD is diagnosed and treated, most patients report significant improvement in their symptoms as well as a decrease in asthma medication use.

Feasibility and tolerability of measuring translaryngeal pressure during exercise

Objectives/Hypothesis

To determine if simultaneous tracheal and supraglottic pressure measurement performed during a continuous laryngoscopy exercise (CLE) test is possible, tolerable, and feasible, and if so, whether measurements can be used to determined airflow resistance over the larynx, thus providing an objective outcome measure for the CLE test, the gold standard for diagnosing exercise‐induced laryngeal obstruction.

Study Design

Explorative descriptive clinical study.

Methods

A CLE test was performed with the addition of two pressure sensors (Mikro‐Cath 825‐0101; Millar, Houston, TX) placed at the epiglottic tip and at the fifth tracheal ring. To place sensors, laryngeal anesthesia and a channel scope were required. Tolerability and feasibility was determined by a Likert score and subjective indication from subjects and operators. Adjustments to the technique were made to increase tolerability. The pressure data were continuously collected and analyzed for artifacts, drifts, frequency response, and used with flow data to calculate translaryngeal resistance.

Results

All subjects (n = 7) completed all procedures. Two main areas of concern were identified regarding tolerability: application of topical anesthesia to the larynx and nasal discomfort due to the added diameter of the laryngoscope. Protocol adjustments improved both. Pressure data were obtained from all procedures in all subjects, were consistent, and followed physiological trends.

Conclusions

Continuous measurement of the translaryngeal pressure gradient during a CLE test is possible, feasible, and tolerable. A CLE test with direct measurement of the translaryngeal pressure gradient might become a valuable tool in the objective assessment of respiratory function, and normal values should be established in health and disease.

Level of Evidence

NA Laryngoscope, 129:2748–2753, 2019