Laryngeal response to high-intensity exercise in healthy athletes

Introduction

Exercise-induced laryngeal obstruction (EILO) is a common cause of exertional breathing problems. The current diagnostic approach rests on evaluation of laryngeal obstruction visualised by laryngoscopy performed continuously throughout a maximal exercise test (continuous laryngoscopy exercise (CLE) test) in patients who present with compatible symptoms. Laryngeal responses to high-intensity exercise in endurance athletes are not well described, potentially leading to inaccurate reference values and increasing the risk of misdiagnosing EILO.

Aim

To investigate laryngeal responses to high-intensity exercise in a healthy population of endurance athletes with no self-reported perception of respiratory problems.

Methods

A cross-sectional study was conducted at Haukeland University Hospital, Bergen, Norway, inviting amateur and professional athletes with no self-reported breathing problems who performed endurance training minimum four sessions weekly. Thirty-six eligible athletes completed a questionnaire detailing exercise habits and past and current respiratory symptoms. They performed a standardised CLE test from which cardiopulmonary exercise data and corresponding laryngeal responses were recorded. The CLE tests were evaluated in retrospect by two independent raters according to preset criteria providing a CLE score. The CLE score rates the severity of laryngeal obstruction during moderate and maximum exercise on the glottic and supraglottic regions on a scale ranging from 0 (no obstruction) to 3 (maximum obstruction).

Results

Twenty-nine (81%) athletes (15 females) aged 15-35 years completed a CLE test. Ten participants (33%) had a supraglottic CLE subscore of 2 or 3. Among these, two also had a glottic CLE subscore of 2 or 3. Notably, none had isolated glottic obstruction.

Conclusion

In healthy well-trained endurance athletes with no prior perception of respiratory symptoms, the laryngeal response to high-intensity exercise was diverse. Supraglottic laryngeal obstruction was observed in one-third of the athletes. The findings underline that a diagnosis of EILO should rest on observed laryngeal obstruction supported by compatible symptoms.

Triaging of acutely ill children transported by ambulance

BACKGROUND

The Western Norway Regional Health Authority uses SATS Norge (SATS-N), a modified version of the South African Triage Scale, in all accident and emergency departments (A&E) and ambulance services in the region. The purpose of the study was to examine the validity of the paediatric component of SATS-N used for children transported to hospital by ambulance for emergency medical assistance.

MATERIAL AND METHOD

We conducted a retrospective observational study which included all children in the age group 0-14 years, admitted by ambulance to A&E at Haukeland University Hospital for emergency medical assistance in the period from January to June 2020. The five triage levels in SATS-N were dichotomised to high triage level (the two highest triage categories) or low triage level (the three lowest triage categories). Sensitivity was calculated as the proportion of patients assigned to the high triage level among those who were directly transferred from A&E to a high dependency unit, and specificity as the proportion of patients assigned to the low triage level among those who were not directly transferred to a high dependency unit.

RESULTS

Of a total of 303 patient transports, 270 (89 %) were triaged in the ambulance and 243 (80 %) in the A&E. In the pre-hospital and A&E settings, the sensitivity of SATS-N was 96 % and 88 %, and specificity was 46 % and 60 %, respectively.

INTERPRETATION

For children admitted to hospital by ambulance, SATS-N had high sensitivity and low specificity for identifying patients who needed to be directly transferred from A&E to a high dependency unit.

Validation of a modified South African triage scale in a high-resource setting: a retrospective cohort study

BACKGROUND

Triage systems are widely used in emergency departments, but are not always validated. The South African Triage Scale (SATS) has mainly been studied in resource-limited settings. The aim of this study was to determine the validity of a modified version of the SATS for the general population of patients admitted to an ED at a tertiary hospital in a high-income country. The secondary objective was to study the triage performance according to age and patient categories.

METHODS

We conducted a retrospective cohort study of patients presenting to the Emergency Department of Haukeland University Hospital in Norway during a four-year period. We used short-term mortality, ICU admission, and the need for immediate surgery and other interventions as the primary endpoints.

RESULTS

A total of 162,034 emergency department visits were included in the analysis. The negative predictive value of a low triage level to exclude severe illness was 99.1% (95% confidence interval: 99.0-99.2%). The level of overtriage, defined as the proportion of patients assigned to a high triage level who were not admitted to the hospital, was 4.1% (3.9-4.2%). Receiver operating characteristic (ROC) curves showed an area under the ROC for the detection of severe illness of 0.874 (95% confidence interval: 0.870-0.879) for all patients and 0.856 (0.837-0.875), 0.884 (0.878-0.890) and 0.869 (0.862-0.876) for children, adults and elderly individuals respectively.

CONCLUSION

We found that the modified SATS had a good sensitivity to identify short-term mortality, ICU admission, and the need for rapid surgery and other interventions. The sensitivity was higher in adults than in children and higher in medical patients than in surgical patients. The over- and undertriage rates were acceptable.

Use of inhaled ipratropium bromide to improve exercise-induced laryngeal obstruction cannot be recommended

Introduction

Exercise-induced laryngeal obstruction (EILO) is a common cause of exertional breathing problems in young adults. Current management generally consists of breathing advice, speech therapy, inspiratory muscle training or supraglottoplasty in highly motivated subjects with supraglottic collapse. Inhaled ipratropium bromide (IB) is a muscarinic receptor antagonist used to treat asthma that is suggested in a few reports to improve EILO symptoms. The aim of the present study was to investigate effects of inhaled IB in EILO diagnosed by continuous laryngoscopy exercise (CLE) test and classified by CLE scores.

Methods

A randomised crossover trial was conducted at Haukeland University Hospital, Bergen, Norway, enrolling participants diagnosed with EILO defined by characteristic symptoms and CLE score ≥3 (range 0-12). Two consecutive CLE tests were performed within 2 weeks, one test with and one test without prior administration of inhaled IB in a randomised order. Main outcomes were the CLE score, dyspnoea measured using a modified BORG scale (range 0-10) and cardiopulmonary exercise data provided by the CLE test.

Results

20 participants (14 females) aged 12-25 years participated, and all ran to exhaustion on both tests. Mean CLE score, BORG score and peak oxygen consumption were similar in tests performed with and without IB; mean differences (95% confidence interval) were 0.08 (-0.28-0.43), 0.35 (-0.29-0.99) and -0.4 (-1.9-1.1) mL·kg^-1·min^-1, respectively.

Conclusion

Inhaled IB did not improve CLE score, dyspnoea or exercise capacity in subjects with EILO. The study does not support the use of inhaled IB to treat EILO.

Introduction of a high dependency unit at a large paediatric and adolescent medicine department

BACKGROUND

A goal has been set to establish paediatric high dependency units (PHDUs) in Norwegian hospitals. We sought to describe the patient population in one such unit, and to investigate whether the need for admission to an intensive care unit (ICU) changed after the unit was established.

MATERIAL AND METHOD

Information was obtained from electronic patient records, patient administration systems and the quality register for the PHDU at the Department of Paediatrics and Adolescent Medicine at Haukeland University Hospital. All patients admitted to the PHDU within five years of its opening in 2017 were included. A comparison was made between ICU patients in the five years before and the five years after the establishment of the PHDU.

RESULTS

The PHDU had a total of 851 patient admissions in the period 2017-2021, increasing from 125 in 2017 to 247 in 2021. This accounted for 3.5 % and 7.6 % of the total number of patients admitted to the Department of Paediatrics and Adolescent Medicine in these years, respectively. The ICU had 185 paediatric patient admissions in the period 2012-2016 and 187 in the period 2017-2021, which constituted 0.9 % and 1.1 % of all patients admitted to the Department of Paediatrics and Adolescent Medicine during the periods, respectively. After the start-up of the PHDU, a lower proportion of patients were admitted to the ICU in the diagnostic groups diabetic ketoacidosis (15 % in 2017-2021 versus 20 % in 2012-2016) and sepsis (12 % in 2017-2021 versus 19 % in 2012-2016).

INTERPRETATION

The introduction of a PHDU was not associated with a simultaneous reduction in the number of ICU admissions overall. For diabetic ketoacidosis and sepsis, however, the proportion of transfers to the ICU was reduced.

Reliability of trans-laryngeal airway resistance measurements during maximal exercise

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.

Reliability of maximum oxygen uptake in cardiopulmonary exercise testing with continuous laryngoscopy

Aims

A cardiopulmonary exercise test (CPET) is the gold standard to evaluate symptom-limiting exercise intolerance, while continuous laryngoscopy performed during exercise (CLE) is required to diagnose exercise-induced laryngeal obstruction. Combining CPET with CLE would save time and resources; however, the CPET data may be distorted by the extra equipment. We therefore aimed to study whether CPET with CLE influences peak oxygen uptake (V′_O2peak) and other gas exchange parameters when compared to a regular CPET.

Methods

Forty healthy athletes without exercise-related breathing problems, 15–35 years of age, performed CPET to peak exercise with and without an added CLE set-up, in randomised order 2–4 days apart, applying an identical computerised treadmill protocol.

Results

At peak exercise, the mean difference (95% confidence interval) between CPET with and without extra CLE set-up for V′_O2peak, respiratory exchange ratio (RER), minute ventilation (V′_E) and heart rate (HR) was 0.2 (−0.4 to 0.8) mL·kg⁻¹·min⁻¹, 0.01(−0.007 to 0.027) units, 2.6 (−1.3 to 6.5) L·min⁻¹ and 1.4 (−0.8 to 3.5) beats·min⁻¹, respectively. Agreement (95% limits of agreement) for V′_O2peak, RER and V′_E was 0.2 (±3.7) mL·kg⁻¹·min⁻¹, 0.01 (±0.10) units and 2.6 (±24.0) L·min⁻¹, respectively. No systematic or proportional bias was found except for the completed distance, which was 49 m (95% CI 16 to 82 m) longer during CPET.

Conclusion

Parameters of gas exchange, including V′_O2peak and RER, obtained from a maximal CPET performed with the extra CLE set-up can be used interchangeably with data obtained from standard CPET, thus preventing unnecessary additional testing.

Cardiopulmonary exercise testing (CPET) with concurrent continuous laryngoscopy provides reliable measures for maximal oxygen consumption and other CPET datahttps://bit.ly/36wVJhb

Changes in pulmonary function and feasibility of portable continuous laryngoscopy during maximal uphill running

Objective

To evaluate changes in pulmonary function and feasibility of portable continuous laryngoscopy during maximal uphill running.

Methods

Healthy volunteers participated in an uphill race. Forced expiratory volume in 1 s (FEV₁) and forced vital capacity (FVC) were obtained before and 5 and 10 min after finishing the race. Capillary blood lactate concentration ([BLa^-]) and Borg score for perceived exertion were registered immediately after the race. One participant wore a portable video-laryngoscope during the race, and the video was assessed for technical performance.

Results

Twenty adult subjects participated with a mean (SD) age of 40.2 (9.7) years. Mean (SD) race duration and post-exercise [BLa^-] was 13.9 (2.3) min and 10.7 (2.1) mmol/L, respectively, and the median (range) Borg score for perceived exertion was 9 (5–10).

Mean percentage change (95% CI) 5 and 10 min post-exercise in FEV₁ were 6.9 (3.7 to 10.2) % and 5.9 (2.7 to 9.0) %, respectively, and in FVC 5.2 (2.3 to 8.1) % and 4.7 (1.6 to 7.9) %, respectively. The recorded video of the larynx was of good quality.

Conclusions

Maximal aerobic field exercise induced bronchodilatation in the majority of the healthy non-asthmatic participants. It is feasible to perform continuous video-laryngoscopy during heavy uphill exercise.

Left Vocal Cord Paralysis, Lung Function and Exercise Capacity in Young Adults Born Extremely Preterm With a History of Neonatal Patent Ductus Arteriosus Surgery-A National Cohort Study

Background: Left vocal cord paralysis (LVCP) is a known complication of patent ductus arteriosus (PDA) surgery in extremely preterm (EP) born neonates; however, consequences of LVCP beyond the first year of life are insufficiently described. Both voice problems and breathing difficulties during physical activity could be expected with an impaired laryngeal inlet. More knowledge may improve the follow-up of EP-born subjects who underwent PDA surgery and prevent confusion between LVCP and other diagnoses. Objectives: Examine the prevalence of LVCP in a nationwide cohort of adults born EP with a history of PDA surgery, and compare symptoms, lung function, and exercise capacity between groups with and without LVCP, and vs. controls born EP and at term. Methods: Adults born EP (<28 weeks' gestation or birth weight <1,000 g) in Norway during 1999-2000 who underwent neonatal PDA surgery and controls born EP and at term were invited to complete questionnaires mapping voice-and respiratory symptoms, and to perform spirometry and maximal treadmill exercise testing. In the PDA-surgery group, exercise tests were performed with a laryngoscope positioned to evaluate laryngeal function. Results: Thirty out of 48 (63%) eligible PDA-surgery subjects were examined at mean (standard deviation) age 19.4 (0.8) years, sixteen (53%) had LVCP. LVCP was associated with self-reported voice symptoms and laryngeal obstruction during exercise, not with lung function or peak oxygen consumption (VO₂peak). In the PDA-surgery group, forced expiratory volume in 1 second z-score (z-FEV₁) was reduced compared to EP-born controls (n = 30) and term-born controls (n = 36); mean (95% confidence interval) z-FEV₁ was -1.8 (-2.3, -1.2), -0.7 (-1.1, -0.3) and -0.3 (-0.5, -0.0), respectively. For VO₂peak, corresponding figures were 37.5 (34.9, 40.2), 38.1 (35.1, 41.1), and 43.6 (41.0, 46.5) ml/kg/min, respectively. Conclusions: LVCP was common in EP-born young adults who had undergone neonatal PDA surgery. Within the PDA-surgery group, LVCP was associated with self-reported voice symptoms and laryngeal obstruction during exercise, however we did not find an association with lung function or exercise capacity. Overall, the PDA-surgery group had reduced lung function compared to EP-born and term-born controls, whereas exercise capacity was similarly reduced for both the PDA-surgery and EP-born control groups when compared to term-born controls.

Vascular Endothelial Function Assessed by Flow-Mediated Vasodilatation in Young Adults Born Very Preterm or With Extremely Low Birthweight: A Regional Cohort Study

Background: Preterm birth and low birthweight have been associated with increased risk of cardiovascular disease in young adults. Endothelial dysfunction is established as an early marker for development of atherosclerotic cardiovascular disease. Previous studies of endothelial function in young adults born very preterm or with extremely low birthweight have, however, shown diverging results. Objective: We aimed to evaluate the risk of cardiovascular disease as measured by vascular endothelial function in young adults born very preterm (<29 weeks of gestation) or with extremely low birthweight (<1,000 g), compared with term-born controls. Methods: This study included 50 young adults born very preterm or with extremely low birthweight and 49 term-born controls born in Norway in the periods 1982-1985, 1991-1992, and 1999-2000 at mean age 28 (±6) years. The endothelial function was assessed by ultrasound measured flow-mediated dilatation (FMD) of the right brachial artery. The arterial diameter was measured at baseline, after release of 5 min of occlusion, and after sublingual administration of nitroglycerine. FMD was reported as absolute and percentage diameter change from baseline and relative to nitroglycerine-induced dilatation. Results: The participants were mainly normal weight non-smokers, without hypertension, diabetes, or established cardiovascular disease. The cases and controls had mean blood pressure 112/71 (SD 12/9) and 112/69 (SD 11/8) mmHg, body mass index 24.0 (SD 4.2) and 24.4 (SD 4.5) kg/m², and HbA1c 32.7 (SD 2.5) and 33.0 (SD 2.6) mmol/mol, respectively. For both groups, 4 (8%) were smokers. Mean FMD for the adults born very preterm or with extremely low birthweight was 0.17 mm (95% CI 0.14, 0.21) vs. 0.24 mm (95% CI 0.20, 0.28) for the controls (p = 0.01), corresponding to a percentage increase of 5.4% (95% CI 4.2, 6.6) and 7.6% (95% CI 6.2, 8.9), respectively (p = 0.02). The FMD relative to maximal nitroglycerine-induced dilatation was 20% and 31%, respectively (p = 0.001). Conclusions: Young adults born very preterm or with extremely low birthweight have significantly lower FMD compared with the term-born controls suggesting an increased risk of cardiovascular disease.

Electromagnetic inductance plethysmography to study airflow after nebulized saline in bronchiolitis

BACKGROUND

Spirometric effects from therapeutic interventions in infants with severe respiratory distress cannot readily be measured, hampering development of better treatment for acute bronchiolitis. Inhaled normal saline is regularly used in these infants, with little knowledge of how this influences lung physiology.

OBJECTIVES

Assess feasibility of infant lung function testing using electromagnetic inductance plethysmography (EIP) in a clinical setting in a busy pediatric department, and explore effects from inhaled normal saline on tidal flow-volume loops in infants with acute bronchiolitis.

METHODS

Observational study conducted at the Children's Clinic, Haukeland University Hospital, Bergen, Norway during the winters 2016 and 2017, enrolling children with bronchiolitis below six months of age. EIP was performed immediately before and 5 and 20 min after saline inhalation. EIP is a noninvasive method to measure tidal breathing parameters by quantifying volume changes in the chest and abdomen during respiration. The method consists of an electromagnet/antenna and a patient vest.

RESULTS

EIP was successfully applied in 36/45 (80%) enrolled infants at mean (standard deviation) age 2.9 (2.5) months, after a hospital stay of 2.2 (1.9) days. After saline inhalation, tidal expiratory to inspiratory time ratio (Te/Ti) had increased significantly, whereas the other relevant flow/volume parameters had changed numerically in a direction compatible with a more obstructive pattern.

CONCLUSIONS

EIP could successfully be used to obtain tidal breathing parameters in infants with respiratory distress and appears a promising tool for assessment of therapeutic interventions in bronchiolitis. Saline inhalations should be used with caution as placebo in intervention studies.

Predicting physical activity in a national cohort of children born extremely preterm

Predicting physical activity in a national cohort of children born extremely preterm.

OBJECTIVES

To compare physical activity among school-aged children born extremely preterm or with extremely low birthweight (EP/ELBW) to term-born children, and to identify early predictors for physical inactivity in the EP/ELBW-children.

METHODS

A national cohort born during 1999-2000 at gestational age < 28 weeks or birthweight <1000 g and term-born controls were assessed. EP/ELBW-children without neurodevelopmental disabilities were labeled "healthy". At five years, we examined the EP/ELBW-children's motor, mental and intellectual functioning using the Movement Assessment Battery for Children (MABC), The Strength and Difficulties Questionnaire (SDQ) and The Wechsler Preschool and Primary Scale of Intelligence-revised. At 11 years, the parents reported their children's physical activity (PA) in questionnaires.

RESULTS

Information was obtained from 231/372 EP/ELBW and 57/61 term-born children. At 11 years, EP/ELBW-children had fewer exercise events per week, were less engaged in team sports, had lower endurance, lower sports proficiency, and were less vigorous during PA than term-born children (p < 0.05). Low sports proficiency in the healthy EP/ELBW-children at 11 years was predicted (odds ratio; 95% confidence interval) by abnormal MABC-score (3.0; 1.0 to 8.7), and abnormal SDQ-score (4.0; 1.6 to 10.0) at 5 years. Lower endurance at PA was predicted by abnormal MABC-score (2.6; 1.0 to 6.6), abnormal SDQ-score (3.0; 1.4 to 6.5), and borderline intellectual functioning (4.2; 1.8 to 10.1).

CONCLUSIONS

Eleven-year-old EP/ELBW-children were less physically active than term-born. In healthy EP/ELBW-children, impaired motor coordination, borderline intellectual functioning and behavioral problems at 5 years of age predicted unfavorable PA habits at 11 years.

Voice and Exercise Related Respiratory Symptoms in Extremely Preterm Born Children After Neonatal Patent Ductus Arteriosus

Objective: To investigate voice characteristics and exercise related respiratory symptoms in extremely preterm born 11-year-old children, focusing particularly on associations with management of a patent ductus arteriosus (PDA). Study design: Prospective follow-up of all children born in Norway during 1999-2000 at gestational age <28 weeks or with birthweight <1,000 g. Neonatal data were obtained prospectively on custom-made registration forms completed by neonatologists. Voice characteristics and exercise related respiratory symptoms were obtained at 11 years by parental questionnaires. Result: Questionnaires were returned for 228/372 (61%) eligible children, of whom 137 had no history of PDA. PDA had been noted in 91 participants, of whom 36 had been treated conservatively, 21 with indomethacin, and 34 with surgery. Compared to the children treated with indomethacin or conservatively, the odds ratio (95% confidence interval) for the surgically treated children were 3.4 (1.3; 9.2) for having breathing problems during exercise, 16.9 (2.0; 143.0) for having a hoarse voice, 4.7 (1.3; 16.7) for a voice that breaks when shouting, 4.6 (1.1; 19.1) for a voice that disturbs singing, and 3.7 (1.1; 12.3) for problems shouting or speaking loudly. The significance of surgery per se was uncertain since the duration of mechanical ventilation was associated with the same outcomes. Conclusion: Extremely preterm born children with a neonatal history of PDA surgery had more problems with voice and breathing during exercise in mid-childhood than those whose PDA had been handled otherwise. The study underlines the causal heterogeneity of exercise related respiratory symptoms in preterm born children.

Comparison of physical activity and body composition in a cohort of children born extremely preterm or with extremely low birth weight to matched term-born controls: a follow-up study

OBJECTIVES

To compare physical activity and body composition in a cohort of children born extremely preterm/extremely low birth weight (EP/ELBW) with term-born (TB) controls.

METHODS

A regional cohort of children born during 1999-2000 at gestational age <28 weeks or with birth weight <1000 g and their individually matched TB controls were examined in 2010-2011. Information on physical activity was obtained from parental questionnaires, and body composition was determined by anthropometry and dual X-ray absorptiometry.

RESULTS

Fifty-seven EP/ELBW and 57 TB controls were included at a mean age of 11.6 years. Compared with the TB children, the EP/ELBW-born children exercised less often (22% vs 44% exercised more than 3 days per week), had lower physical endurance and poorer proficiency in sports and play and were less vigorous during exercise (p<0.05). They also had lower values (mean; 95 % CI) for muscle mass (0.9; 0.3-1.5 kg), total bone mineral density z-score (0.30; 0.13-0.52 units) and fat mass ratio (0.14; 0.06-0.21 units). The association between physical activity and bone mineral and skeletal muscle mass accrual was significantly weaker for the EP/ELBW-born than the TB children.

CONCLUSIONS

The EP/ELBW-born children were less physically active, had signs of an unfavourable body composition with less muscle mass and lower bone mineral density than the TB controls. The association between physical activity and the measures of body composition was weaker in the group of EP/ELBW-born children.