1
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Ohtani M, Kono M, Tamagawa S, Kouda K, Hotomi M. Epiglottic retraction is useful in diagnosis of exercise-induced laryngeal obstruction. Acta Otolaryngol 2024:1-6. [PMID: 39316781 DOI: 10.1080/00016489.2024.2405002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2024] [Accepted: 09/11/2024] [Indexed: 09/26/2024]
Abstract
Background: Exercise-induced laryngeal obstruction (EILO) is distinguished as upper airway obstruction accompanied by inspiratory dyspnoea and stridor during highly intensive exercises. Epiglottic retraction in the diagnosis of EILO has not been sufficiently explored. Aims/objectives: We highlight the importance of epiglottic retraction in patients with EILO by evaluation by several diagnostic methods for EILO. Consideration of epiglottic retraction may be important for accurate diagnosis of EILO. Results: Epiglottic retraction could be observed in three patients by laryngoscopy during heavy breathing and in two patients by continuous laryngoscopy during exercise. Stridor occurred by the forward prolapse of the arytenoids, but not by epiglottic retraction. In comparison with three athletes from other sports, lung volume was significantly greater in four swimmers although it was not different related to depending on the existence of epiglottic retraction. Conclusions and significance: Laryngoscopy during heavy breathing is suggested to be useful to detect the epiglottic retraction, which might be overlooked if only continuous laryngoscopy during exercise is used. Epiglottic retraction was not rare in Japanese swimmers' exercise-induced laryngeal obstruction in our cohort and it might be related to the greater lung volume.
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Affiliation(s)
- Makiko Ohtani
- Department of Otorhinolaryngology - Head and Neck Surgery, Wakayama Medical University, Wakayama, Japan
| | - Masamitsu Kono
- Department of Otorhinolaryngology - Head and Neck Surgery, Wakayama Medical University, Wakayama, Japan
| | - Shunji Tamagawa
- Department of Otorhinolaryngology - Head and Neck Surgery, Wakayama Medical University, Wakayama, Japan
| | - Ken Kouda
- Department of Rehabilitation Medicine, Wakayama Medical University, Wakayama, Japan
| | - Muneki Hotomi
- Department of Otorhinolaryngology - Head and Neck Surgery, Wakayama Medical University, Wakayama, Japan
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2
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Thomander T, Malmberg LP, Toppila-Salmi S, Aaltonen LM, Kauppi P. The continuous laryngoscopy exercise test in severe or in difficult-to-treat asthma in adults: a systematic review. J Asthma 2023; 60:1-10. [PMID: 35125054 DOI: 10.1080/02770903.2022.2029481] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE A systematic review was performed to determine if the continuous laryngoscopy exercise test (CLE) has been used in the diagnostics of exercise dyspnea in adults with asthma, and whether inducible laryngeal obstruction (ILO) is found in those with asthma or with severe or difficult-to-treat asthma. DATA SOURCES We used Scopus and PubMed databases. The articles published up to 13 August 2019 were considered. STUDY SELECTIONS We excluded manuscripts that did not contain information about adult patients with asthma. We included six studies from 59 search results in Scopus and none from the 17 search results in PubMed. RESULTS The articles included 455 study individuals. Of these, 229 (50.3%) had diagnosed asthma or were treated with asthma medication. Altogether 31/229 (13.5%) subjects with diagnosis of asthma or previous asthma treatment had exercise-induced laryngeal obstruction (EILO) as comorbidity. The CLE test was performed on 229 patients with asthma. The method was used only for differential diagnosis of exercise-induced dyspnea to confirm EILO. At least 10/455 (2.2%) out of the 455 subjects experienced adverse events. CONCLUSIONS This systematic review revealed that only a small proportion of patients with asthma had undergone the CLE test to assess exercise-induced dyspnea. None of the selected manuscripts reported severity of asthma. Whether CLE provides a valuable diagnostic tool for patients with severe or difficult-to-treat asthma cannot be determined according to this review.
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Affiliation(s)
- Tuuli Thomander
- Doctoral Programme in Clinical Research, University of Helsinki, Helsinki, Finland.,Department of Allergology, Skin and Allergy Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - L Pekka Malmberg
- Department of Clinical Physiology, Inflammation Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Sanna Toppila-Salmi
- Department of Allergology, Skin and Allergy Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Leena-Maija Aaltonen
- Department of Otorhinolaryngology, Head and Neck Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Paula Kauppi
- Pulmonary Department, Heart and Lung Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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3
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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] [MESH Headings] [Grants] [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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4
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Clemm HH, Olin JT, McIntosh C, Schwellnus M, Sewry N, Hull JH, Halvorsen T. Exercise-induced laryngeal obstruction (EILO) in athletes: a narrative review by a subgroup of the IOC Consensus on 'acute respiratory illness in the athlete'. Br J Sports Med 2022; 56:622-629. [PMID: 35193856 PMCID: PMC9120388 DOI: 10.1136/bjsports-2021-104704] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/02/2022] [Indexed: 02/06/2023]
Abstract
Exercise-induced laryngeal obstruction (EILO) is caused by paradoxical inspiratory adduction of laryngeal structures during exercise. EILO is an important cause of upper airway dysfunction in young individuals and athletes, can impair exercise performance and mimic lower airway dysfunction, such as asthma and/or exercise-induced bronchoconstriction. Over the past two decades, there has been considerable progress in the recognition and assessment of EILO in sports medicine. EILO is a highly prevalent cause of unexplained dyspnoea and wheeze in athletes. The preferred diagnostic approach is continuous visualisation of the larynx (via laryngoscopy) during high-intensity exercise. Recent data suggest that EILO consists of different subtypes, possibly caused via different mechanisms. Several therapeutic interventions for EILO are now in widespread use, but to date, no randomised clinical trials have been performed to assess their efficacy or inform robust management strategies. The aim of this review is to provide a state-of-the-art overview of EILO and guidance for clinicians evaluating and treating suspected cases of EILO in athletes. Specifically, this review examines the pathophysiology of EILO, outlines a diagnostic approach and presents current therapeutic algorithms. The key unmet needs and future priorities for research in this area are also covered.
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Affiliation(s)
- Hege Havstad Clemm
- Department of Pediatric and Adolescent Medicine, Haukeland Universityhospital, Bergen, Norway .,Faculty of Medicine and Dentistry, Department of Clinical Science, University of Bergen, Bergen, Norway
| | - J Tod Olin
- Department of Pediatrics and Medicine, National Jewish Health, Denver, Colorado, USA
| | | | - Martin Schwellnus
- Sport, Exercise Medicine and Lifestyle Institute (SEMLI), Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa.,IOC Research Centre, South Africa
| | - Nicola Sewry
- Sport, Exercise Medicine and Lifestyle Institute (SEMLI), Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa.,IOC Research Centre, South Africa
| | - James H Hull
- Department of Respiratory Medicine, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Thomas Halvorsen
- Department of Pediatric and Adolescent Medicine, Haukeland Universityhospital, Bergen, Norway.,Faculty of Medicine and Dentistry, Department of Clinical Science, University of Bergen, Bergen, Norway.,Norwegian School of Sports Sciences, Oslo, Norway
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5
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Abstract
Functional respiratory disorders (FRDs) are those characterized by respiratory symptoms without anatomic or organic etiology. Clinicians caring for children encounter these disorders and should be familiar with diagnosis and treatment. FRDs encompass the habit cough syndrome and its variants, vocal cord dysfunction, hyperventilation disorders, functional dyspnea, and sighing syndrome. Failure to identify these disorders results in unnecessary testing and medication. This article reviews the clinical presentation, manifestation, and treatment of respiratory FRDs in children. How health care providers can successfully identify and treat these reversible conditions in the clinical setting is discussed.
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6
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Engan M, Hammer IJ, Stensrud T, Gundersen H, Edvardsen E, Clemm HH. Changes in pulmonary function and feasibility of portable continuous laryngoscopy during maximal uphill running. BMJ Open Sport Exerc Med 2021; 6:e000815. [PMID: 33403123 PMCID: PMC7772557 DOI: 10.1136/bmjsem-2020-000815] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/26/2020] [Indexed: 11/10/2022] Open
Abstract
Objective To evaluate changes in pulmonary function and feasibility of portable continuous laryngoscopy during maximal uphill running. Methods Healthy volunteers participated in an uphill race. Forced expiratory volume in 1 s (FEV1) and forced vital capacity (FVC) were obtained before and 5 and 10 min after finishing the race. Capillary blood lactate concentration ([BLa-]) and Borg score for perceived exertion were registered immediately after the race. One participant wore a portable video-laryngoscope during the race, and the video was assessed for technical performance. Results Twenty adult subjects participated with a mean (SD) age of 40.2 (9.7) years. Mean (SD) race duration and post-exercise [BLa-] was 13.9 (2.3) min and 10.7 (2.1) mmol/L, respectively, and the median (range) Borg score for perceived exertion was 9 (5–10).
Mean percentage change (95% CI) 5 and 10 min post-exercise in FEV1 were 6.9 (3.7 to 10.2) % and 5.9 (2.7 to 9.0) %, respectively, and in FVC 5.2 (2.3 to 8.1) % and 4.7 (1.6 to 7.9) %, respectively. The recorded video of the larynx was of good quality. Conclusions Maximal aerobic field exercise induced bronchodilatation in the majority of the healthy non-asthmatic participants. It is feasible to perform continuous video-laryngoscopy during heavy uphill exercise.
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Affiliation(s)
- Mette Engan
- Department of Pediatric and Adolescent Medicine, Haukeland University Hospital, Bergen, Norway.,Institute of Clinical Science, University of Bergen, Bergen, Norway
| | - Ida Jansrud Hammer
- Department of Pediatric and Adolescent Medicine, Haukeland University Hospital, Bergen, Norway
| | - Trine Stensrud
- Institute of Sports Medicine, The Norwegian School of Sport Sciences, Oslo, Norway
| | - Hilde Gundersen
- Department of Sport, Food and Natural Sciences, Western Norway University of Applied Sciences, Bergen, Norway
| | - Elisabeth Edvardsen
- Institute of Physical Performance, The Norwegian School of Sport Sciences, Oslo, Norway
| | - Hege Havstad Clemm
- Department of Pediatric and Adolescent Medicine, Haukeland University Hospital, Bergen, Norway.,Institute of Clinical Science, University of Bergen, Bergen, Norway
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7
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Hull JH, Godbout K, Boulet LP. Exercise-Associated Dyspnea and Stridor: Thinking Beyond Asthma. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:2202-2208. [PMID: 32061900 DOI: 10.1016/j.jaip.2020.01.057] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 01/21/2020] [Accepted: 01/21/2020] [Indexed: 12/26/2022]
Abstract
Breathlessness during sport can be caused by various cardiorespiratory conditions, but when associated with stridor, usually arises from an upper airway etiology. The term exercise-induced laryngeal obstruction (EILO) is now used to describe the phenomenon of transient glottic closure occurring in association with physical activity. Exercise-related laryngeal closure is most commonly encountered in athletic individuals and likely affects between 5% and 7% of all young adults and adolescents. The diagnosis of EILO is not always straightforward because features can overlap with exercise-induced asthma/exercise-induced bronchoconstriction. EILO can therefore remain misdiagnosed for years, and most patients receive inappropriate asthma therapy. In contrast with asthma, EILO symptoms are usually most prominent at maximal exercise intensity and resolve quickly on exercise cessation. It is important to recognize that EILO and asthma can coexist in a proportion of athletes. The criterion standard test for diagnosing EILO is continuous laryngoscopy during exercise testing, although eucapnic voluntary hyperpnea testing has also been used. Various surgical or pharmacological interventions can be used to treat EILO, but first-line treatment is breathing technique work. Further research is needed to establish the optimal treatment algorithm, and more work is needed to increase awareness of this important clinical entity.
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Affiliation(s)
- James H Hull
- Department of Respiratory Medicine, Royal Brompton Hospital, London, United Kingdom
| | - Krystelle Godbout
- Institut universitaire de cardiologie et de pneumologie de Québec - Université Laval, Québec, Québec, Canada
| | - Louis-Philippe Boulet
- Institut universitaire de cardiologie et de pneumologie de Québec - Université Laval, Québec, Québec, Canada.
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8
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Famokunwa B, Sandhu G, Hull JH. Surgical intervention for exercise-induced laryngeal obstruction: A UK perspective. Laryngoscope 2020; 130:E667-E673. [PMID: 31913523 DOI: 10.1002/lary.28497] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 11/05/2019] [Accepted: 12/12/2019] [Indexed: 01/28/2023]
Abstract
OBJECTIVES Exercise-induced laryngeal obstruction (EILO) is a prevalent cause of exertional breathlessness and wheeze in young individuals. Typically diagnosed using the continuous laryngoscopy during exercise (CLE) test, treatment is largely based on breathing retraining promoting improved laryngeal function. In some cases, these techniques fail to alleviate symptoms, and surgical intervention with supraglottoplasty can be valuable in the supraglottic form of EILO. Globally, there is currently limited experience utilizing a surgical approach to EILO, and data regarding the optimum surgical technique and published outcomes and complication rates are thus limited. STUDY DESIGN Retrospective observational case series. METHODS In this report, we describe our experience as the only UK center undertaking supraglottoplasty for EILO. We report the surgical outcome of 19 patients (n = 16 female), mean age, 29.6 ± 13.1 years, referred for surgery with moderate to severe supraglottic EILO. Follow-up clinic ± CLE was performed within 4 months (median = 6 weeks), and CLE scores were evaluated before and following surgery. RESULTS We found a beneficial effect of surgery on supraglottic CLE scores (median score reducing from 3/3 to 1/3 postoperatively [P < .05] overall) with 79% (n = 15) of patients reporting an improvement in their exercise capacity. One patient developed an apparent increased tendency for glottic-level EILO following surgery; however, no voice- or swallowing-related complications were encountered. CONCLUSIONS This study is the first to report the UK experience, surgical technique, and outcome for EILO surgery. The findings indicate that EILO surgery appears to be a safe and effective option for individuals with moderate to severe supraglottic-type EILO who have failed initial conservative treatment. LEVEL OF EVIDENCE 5 Laryngoscope, 130:E667-E673, 2020.
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Affiliation(s)
- Bamidele Famokunwa
- North Bristol Lung Centre, Bristol Royal Infirmary, Bristol, United Kingdom
| | - Guri Sandhu
- Department of Laryngology, Charing Cross Hospital London, London, United Kingdom
| | - James H Hull
- Department of Respiratory Medicine, Royal Brompton Hospital, London, United Kingdom
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9
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Barker N, Thevasagayam R, Ugonna K, Kirkby J. Pediatric Dysfunctional Breathing: Proposed Components, Mechanisms, Diagnosis, and Management. Front Pediatr 2020; 8:379. [PMID: 32766182 PMCID: PMC7378385 DOI: 10.3389/fped.2020.00379] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 06/04/2020] [Indexed: 12/17/2022] Open
Abstract
Dysfunctional breathing (DB) is an overarching term describing deviations in the normal biomechanical patterns of breathing which have a significant impact on quality of life, performance and functioning. Whilst it occurs in both children and adults, this article focuses specifically on children. DB can be viewed as having two components; breathing pattern disorder (BPD) and inducible laryngeal obstruction (ILO). They can be considered in isolation, however, are intricately related and often co-exist. When both are suspected, we propose both BPD and ILO be investigated within an all-encompassing multi-disciplinary dysfunctional breathing clinic. The MDT clinic can diagnose DB through expert history taking and a choice of appropriate tests/examinations which may include spirometry, breathing pattern analysis, exercise testing and laryngoscopic examination. Use of the proposed algorithm presented in this article will aid decision making regarding choosing the most appropriate tests and understanding the diagnostic implications of these tests. The most common symptoms of DB are shortness of breath and chest discomfort, often during exercise. Patients with DB typically present with normal spirometry and an altered breathing pattern at rest which is amplified during exercise. In pediatric ILO, abnormalities of the upper airway such as cobblestoning are commonly seen followed by abnormal activity of the upper airway structures provoked by exercise. This may be associated with a varying degree of stridor. The symptoms, however, are often misdiagnosed as asthma and the picture can be further complicated by the common co-presentation of DB and asthma. Associated conditions such as asthma, extra-esophageal reflux, rhinitis, and allergy must be treated appropriately and well controlled before any directed therapy for DB can be started if therapy is to be successful. DB in pediatrics is commonly treated with a course of non-pharmaceutical therapy. The therapy is provided by an experienced physiotherapist, speech and language therapist or psychologist depending on the dominant features of the DB presentation (i.e., BPD or ILO in combination or in isolation) and some patients will benefit from input from more than one of these disciplines. An individualized treatment program based on expert assessment and personalized goals will result in a return to normal function with reoccurrence being rare.
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Affiliation(s)
- Nicki Barker
- Sheffield Children's NHS Foundation Trust, Sheffield, United Kingdom
| | - Ravi Thevasagayam
- Sheffield Children's NHS Foundation Trust, Sheffield, United Kingdom
| | - Kelechi Ugonna
- Sheffield Children's NHS Foundation Trust, Sheffield, United Kingdom
| | - Jane Kirkby
- Sheffield Children's NHS Foundation Trust, Sheffield, United Kingdom
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10
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Fretheim-Kelly ZL, Halvorsen T, Clemm H, Roksund O, Heimdal JH, Vollsæter M, Fintl C, Strand E. Exercise Induced Laryngeal Obstruction in Humans and Equines. A Comparative Review. Front Physiol 2019; 10:1333. [PMID: 31736771 PMCID: PMC6831747 DOI: 10.3389/fphys.2019.01333] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Accepted: 10/07/2019] [Indexed: 12/03/2022] Open
Abstract
Dynamic obstructions of the larynx are a set of disorders that occur during exercise in equines and humans. There are a number of similarities in presentation, diagnosis, pathophysiology and treatment. Both equines and humans present with exercise intolerance secondary to dyspnea. During laryngoscopy at rest, the larynx appears to function normally. Abnormalities are only revealed during laryngoscopy at exercise, seemingly triggered by increased ventilatory demands, and quickly resolve after cessation of exercise. Lower airway disease (asthma being the most prevalent condition), cardiac disease and lack of fitness are the major differentials in both species. Laryngoscopic examination during exercise should be performed from rest to peak exertion to allow for a comprehensive diagnosis, including where the airway collapse begins, and thereafter how it progresses. Dynamic disorders with most visual similarity between humans and equines are: aryepiglottic fold collapse (both species); equine dynamic laryngeal collapse (DLC) relative to some forms of human combined supraglottic/glottic collapse; and epiglottic retroversion (both species). Quantitative grading techniques, such as airway pressure measurement, that have proven effective in veterinary research are currently being piloted in human studies. Conditions that appear visually similar are treated in comparable ways. The similarities of anatomy and certain types of dynamic collapse would suggest that the equine larynx provides a good model for human upper respiratory tract obstruction during exercise. Thus, close collaboration between veterinarians and medical personal may lead to further advancements in understanding pathophysiologic processes, and enhance the development of improved diagnostic tests and treatments that will benefit both species.
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Affiliation(s)
- Zoe Louise Fretheim-Kelly
- Faculty of Veterinary Medicine, Norwegian University of Life Sciences, Oslo, Norway.,Department of Clinical Science, Faculty of Medicine, University of Bergen, Bergen, Norway
| | - Thomas Halvorsen
- Department of Clinical Science, Faculty of Medicine, University of Bergen, Bergen, Norway.,Department of Sports Medicine, Norwegian School of Sport Sciences, Oslo, Norway
| | - Hege Clemm
- Department of Pediatrics, Haukeland University Hospital, Bergen, Norway
| | - Ola Roksund
- Department of Pediatrics, Haukeland University Hospital, Bergen, Norway.,Faculty of Health and Social Sciences, Western Norway University of Applied Sciences, Bergen, Norway
| | - John-Helge Heimdal
- Department of Clinical Science, Faculty of Medicine, University of Bergen, Bergen, Norway.,Department of Oral Surgery, Haukeland University Hospital, Bergen, Norway
| | - Maria Vollsæter
- Department of Pediatrics, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Constanze Fintl
- Faculty of Veterinary Medicine, Norwegian University of Life Sciences, Oslo, Norway
| | - Eric Strand
- Faculty of Veterinary Medicine, Norwegian University of Life Sciences, Oslo, Norway
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11
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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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12
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Hull JH, Walsted ES, Orton CM, Williams P, Ward S, Pavitt MJ. Feasibility of portable continuous laryngoscopy during exercise testing. ERJ Open Res 2019; 5:00219-2018. [PMID: 30740460 PMCID: PMC6360209 DOI: 10.1183/23120541.00219-2018] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Accepted: 12/08/2018] [Indexed: 01/19/2023] Open
Abstract
Exercise-induced laryngeal obstruction (EILO) is a prevalent and yet still under-recognised cause of exertional breathlessness [1]. The transient closure of the larynx, which develops during EILO, results in dyspnoea, cough, inspiratory wheeze (i.e. stridor) and tightness in the throat on physical exertion. It is estimated that EILO is present in 6% of adolescents and as many as one in four athletes with unexplained respiratory symptoms [1, 2]. Despite improved recognition over the past 5 years [3, 4], it remains frequently misdiagnosed and mistreated as asthma [2, 5]. Exercise-induced laryngeal obstruction (EILO) is a prevalent problem causing exertional breathlessness and wheeze. This report demonstrates the feasibility and safety of a diagnostic approach to EILO, using a portable laryngoscope during exercise.http://ow.ly/eM6L30njDst
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Affiliation(s)
- James H Hull
- Dept of Respiratory Medicine, Royal Brompton Hospital, London, UK
| | - Emil S Walsted
- Dept of Respiratory Medicine, Royal Brompton Hospital, London, UK.,Respiratory Research Unit, Bispebjerg Hospital, Copenhagen, Denmark
| | | | - Parris Williams
- Dept of Respiratory Medicine, Royal Brompton Hospital, London, UK
| | - Simon Ward
- Dept of Respiratory Medicine, Royal Brompton Hospital, London, UK
| | - Mathew J Pavitt
- Dept of Respiratory Medicine, Royal Brompton Hospital, London, UK
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13
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Sandnes A, Andersen T, Clemm HH, Hilland M, Vollsæter M, Heimdal JH, Eide GE, Halvorsen T, Røksund OD. Exercise-induced laryngeal obstruction in athletes treated with inspiratory muscle training. BMJ Open Sport Exerc Med 2019; 5:e000436. [PMID: 30792880 PMCID: PMC6350751 DOI: 10.1136/bmjsem-2018-000436] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/18/2018] [Indexed: 02/04/2023] Open
Abstract
Background Exercise-induced laryngeal obstruction (EILO) is common in athletes and presents with dyspnoea, chest tightness, inspiratory stridor and sometimes panic reactions. The evidence for conservative treatment is weak, but case reports suggest effects from inspiratory muscle training (IMT). We aimed to explore effects from IMT used in athletes with EILO. Method Twenty-eight athletes, mean age 16.4 years, diagnosed with EILO at our clinic, participated in a 6-week treatment programme, using a resistive flow-dependent IMT device (Respifit S). Four athletes competed at international level, 13 at national and 11 at regional levels. Video-recorded continuous transnasal flexible laryngoscopy was performed from rest to peak exercise (continuous laryngoscopy exercise (CLE) test) and scored before and 2–4 weeks after the training period. Ergospirometric variables were obtained from this CLE set-up. Lung function was measured according to guidelines. Symptom scores and demographic variables were obtained from a questionnaire. Results After the treatment period, symptoms had decreased in 22/28 (79%) participants. Mean overall CLE score had improved after treatment (p<0.001), with the scores becoming normal in five athletes but worse in two. Most of the improvement was explained by changes at the glottic laryngeal level (p=0.009). Ergospirometric variables revealed significantly higher peak minute ventilation explained by higher tidal volumes and were otherwise unchanged. Conclusion This explorative study underlines the heterogeneous treatment response of EILO and suggests that IMT may become an efficient conservative treatment tool in subgroups, possibly contributing to better control of the vocal folds. The signals from this study should be tested in future controlled interventional studies.
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Affiliation(s)
- Astrid Sandnes
- Department of Medicine, Innlandet Hospital Trust, Gjøvik, Norway.,Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Tiina Andersen
- Department of Clinical Science, University of Bergen, Bergen, Norway.,Thoracic Department, Norwegian Advisory Unit on Home Mechanical Ventilation, Bergen, Norway.,Department of Physiotherapy, Haukeland University Hospital, Bergen, Norway
| | - Hege Havstad Clemm
- Department of Clinical Science, University of Bergen, Bergen, Norway.,Department of Pediatrics, Haukeland University Hospital, Bergen, Norway
| | - Magnus Hilland
- Department of Otolaryngology/Head and Neck surgery, Haukeland University Hospital, Bergen, Norway
| | - Maria Vollsæter
- Department of Clinical Science, University of Bergen, Bergen, Norway.,Thoracic Department, Norwegian Advisory Unit on Home Mechanical Ventilation, Bergen, Norway.,Department of Pediatrics, Haukeland University Hospital, Bergen, Norway
| | - John-Helge Heimdal
- Department of Otolaryngology/Head and Neck surgery, Haukeland University Hospital, Bergen, Norway.,Department of Surgery, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Geir Egil Eide
- Centre for Clinical Research, Haukeland University Hospital, Bergen, Norway.,Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Thomas Halvorsen
- Department of Clinical Science, University of Bergen, Bergen, Norway.,Department of Pediatrics, Haukeland University Hospital, Bergen, Norway
| | - Ola Drange Røksund
- Department of Physiotherapy, Haukeland University Hospital, Bergen, Norway.,Department of Pediatrics, Haukeland University Hospital, Bergen, Norway.,The Faculty of Health and Social Sciences, Western Norway University of Applied Sciences, Bergen, Norway
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14
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Olin JT. Exercise-Induced Laryngeal Obstruction: When Pediatric Exertional Dyspnea Does not Respond to Bronchodilators. Front Pediatr 2019; 7:52. [PMID: 30881950 PMCID: PMC6405419 DOI: 10.3389/fped.2019.00052] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2018] [Accepted: 02/07/2019] [Indexed: 12/03/2022] Open
Abstract
Exertional dyspnea is a common complaint in general pediatric practice. While a high proportion of the general pediatric population has asthma, other diagnoses, including exercise-induced laryngeal obstruction should be considered, especially when asthma therapy is not sufficient to control symptoms. This review describes some of the key clinical features of exercised-induced laryngeal obstruction as well as preferred diagnostic and therapeutic approaches. Importantly, current diagnostic technology has considerably improved in the last decade at specialty centers. At the same time, infrastructure for clinical trials is emerging and there is not strong evidence to support specific therapies at the current time.
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Affiliation(s)
- J Tod Olin
- Department of Pediatrics, National Jewish Health, Denver, CO, United States
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15
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Hull JH, Walsted ES, Feary J, Cullinan P, Scadding G, Bailey E, Selby J. Continuous laryngoscopy during provocation in the assessment of inducible laryngeal obstruction. Laryngoscope 2018; 129:1863-1866. [DOI: 10.1002/lary.27620] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 09/15/2018] [Accepted: 09/24/2018] [Indexed: 11/08/2022]
Affiliation(s)
- James Harry Hull
- From the Department of Respiratory Medicine; Royal Brompton Hospital; London United Kingdom
| | - Emil Schwarz Walsted
- From the Department of Respiratory Medicine; Royal Brompton Hospital; London United Kingdom
- Respiratory Research Unit, Bispebjerg University Hospital; Copenhagen Denmark
| | - Johanna Feary
- From the Department of Respiratory Medicine; Royal Brompton Hospital; London United Kingdom
- Department of Occupational and Environmental Medicine; Royal Brompton Hospital; London United Kingdom
| | - Paul Cullinan
- From the Department of Respiratory Medicine; Royal Brompton Hospital; London United Kingdom
- Department of Occupational and Environmental Medicine; Royal Brompton Hospital; London United Kingdom
| | - Guy Scadding
- From the Department of Respiratory Medicine; Royal Brompton Hospital; London United Kingdom
| | - Emma Bailey
- From the Department of Respiratory Medicine; Royal Brompton Hospital; London United Kingdom
| | - Julia Selby
- From the Department of Respiratory Medicine; Royal Brompton Hospital; London United Kingdom
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16
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Olin JT, Hull JH. Exercise and the Total Airway: A Call to Action. Immunol Allergy Clin North Am 2018; 38:xv-xix. [PMID: 29631744 DOI: 10.1016/j.iac.2018.02.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- J Tod Olin
- Pediatric Exercise Tolerance Center, Department of Pediatrics, Division of Pediatric Pulmonology, National Jewish Health, 1400 Jackson Street, Denver, CO 80206, USA.
| | - James H Hull
- Royal Brompton Hospital, Imperial College, Department of Respiratory Medicine, Royal Brompton Hospital, Fulham Road, London SW3 6HP, UK.
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17
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Røksund OD, Olin JT, Halvorsen T. Working Towards a Common Transatlantic Approach for Evaluation of Exercise-Induced Laryngeal Obstruction. Immunol Allergy Clin North Am 2018; 38:281-292. [PMID: 29631736 DOI: 10.1016/j.iac.2018.01.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Exertional dyspnea can be a manifestation of dysfunction in a variety of organ systems. Exercise-induced laryngeal obstruction (EILO), a condition previously known as vocal cord dysfunction and paradoxic vocal fold motion, is defined as inappropriate, reversible narrowing of the larynx during vigorous exercise. EILO is usually characterized by typical symptoms, which nevertheless frequently are confused with those of other conditions, including asthma. Laryngoscopy performed as symptoms evolve from rest to peak exercise is pivotal in patient work-up. Moving forward, laryngoscopy findings that definitively characterize EILO need to be defined as do objective measures that can quantitate absolute laryngeal measurements during exercise.
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Affiliation(s)
- Ola Drange Røksund
- The Faculty of Health and Social Sciences, Western Norway University of Applied Sciences, Bergen, Norway; Department of Paediatrics, Haukeland University Hospital, Bergen, Norway.
| | - J Tod Olin
- Department of Pediatrics, National Jewish Health, Denver, Colorado, USA
| | - Thomas Halvorsen
- Department of Paediatrics, Haukeland University Hospital, Bergen, Norway; Department of Clinical Science, Section for Paediatrics, University of Bergen, Bergen, Norway
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18
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Abstract
Exertional dyspnea is common in health and disease. Despite having known for centuries that breathlessness can arise from the larynx, exercise-induced laryngeal obstruction is a more prevalent condition than previously assumed. This article provides a brief overview of the history, epidemiology, and pathophysiology of exercise-induced laryngeal obstruction.
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19
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Mirza KK, Walsted ES, Backer V. Ergospirometry with concurrent fibre optic laryngoscopy: a randomised crossover study. Eur Clin Respir J 2017; 4:1399033. [PMID: 29201290 PMCID: PMC5700495 DOI: 10.1080/20018525.2017.1399033] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2017] [Accepted: 10/24/2017] [Indexed: 11/09/2022] Open
Abstract
Background: Patients suffering from exercise-induced laryngeal obstruction (EILO) are subjected to several exhausting tests. We aimed to assess the feasibility of using a single test to obtain diagnostic measurements for maximum oxygen uptake (VO2max) and exercise-induced laryngeal obstruction (EILO). Methods: Patients referred to the outpatient respiratory clinic at the University Hospital of Bispebjerg, Copenhagen with exercise-induced dyspnoea were evaluated for inclusion over 13 months. Eligible patients were aged 18–43 years, had a known EILO diagnosis (moderate or severe) and were inactive (self-reported activity) with less than 3 hours activity per week. In randomised order, all participants (n = 11) underwent three tests: a VO2max test with and without concurrent laryngoscopy. VO2max and EILO values from the two testing methods were compared. Findings: There was no difference in VO2max measured by ergospirometry with and without simultaneous continuous laryngoscopy during exercise (CLE) testing (mean difference −22 ml O2・min−1; 95% CI −125 to 81 ml O2・min−1; P = 0.647). EILO scores obtained during the CLE testing on the treadmill versus CLE testing on the ergometer bike revealed identical supraglottic scores in nine of the 11 participants (82%) with substantial agreement between the two types of test (x = 0.71). Glottic scores were identical in six of the 11 (55%), showing moderate agreement between test types (x = 0.38). Conclusions: Based on our findings in inactive individuals, ergospirometry with laryngoscopy is feasible and well tolerated, yielding measurements for maximal oxygen uptake comparable to those of standard bike ergospirometry. Likewise, measurements of supraglottic EILO are comparable to those of the standard treadmill CLE test.
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Affiliation(s)
- Kiran Kafila Mirza
- Respiratory Research Unit, Department of Respiratory Medicine, University Hospital Bispebjerg, Copenhagen, Denmark
| | - Emil Schwarz Walsted
- Respiratory Research Unit, Department of Respiratory Medicine, University Hospital Bispebjerg, Copenhagen, Denmark
| | - Vibeke Backer
- Respiratory Research Unit, Department of Respiratory Medicine, University Hospital Bispebjerg, Copenhagen, Denmark
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20
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Fretzayas A, Moustaki M, Loukou I, Douros K. Differentiating vocal cord dysfunction from asthma. J Asthma Allergy 2017; 10:277-283. [PMID: 29066919 PMCID: PMC5644529 DOI: 10.2147/jaa.s146007] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Vocal cord dysfunction (VCD)-associated symptoms are not rare in pediatric patients. Dyspnea, wheezing, stridor, chest pain or tightness and throat discomfort are the most commonly encountered symptoms. They may occur either at rest or more commonly during exercise in patients with VCD, as well as in asthmatic subjects. The phase of respiration (inspiration rather than expiration), the location of the wheezing origin, the rapid resolution of symptoms, and the timing occurring in relation to exercise, when VCD is exercise induced, raise the suspicion of VCD in patients who may have been characterized as merely asthmatics and, most importantly, had not responded to the appropriate treatment. The gold standard method for the diagnosis of VCD is fiberoptic laryngoscopy, which may also identify concomitant laryngeal abnormalities other than VCD. However, as VCD is an intermittent phenomenon, the procedure should be performed while the patient is symptomatic. For this reason, challenges that induce VCD symptoms should be performed, such as exercise tests. Recently, for the evaluation of patients with exercise-induced VCD, continuous laryngoscopy during exercise (such as treadmill, bicycle ergometer, swimming) was used. A definite diagnosis of VCD is of importance, especially for those patients who have been erroneously characterized as asthmatics, without adequate response to treatment. In these cases, another therapeutic approach is necessary, which will depend on whether they suffer solely from VCD or from both conditions.
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Affiliation(s)
- Andrew Fretzayas
- Third Department of Pediatrics, Athens University Medical School, "Attikon" University Hospital, Haidari, Greece.,Athens Medical Center, Department of Pediatrics, Marousi, Greece
| | - Maria Moustaki
- Department of Cystic Fibrosis, "Aghia Sofia", Children's Hospital, Athens, Greece
| | - Ioanna Loukou
- Department of Cystic Fibrosis, "Aghia Sofia", Children's Hospital, Athens, Greece
| | - Konstantinos Douros
- Respiratory Unit, Third Department of Pediatrics, Athens University Medical School, "Attikon" University Hospital, Haidari, Greece
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21
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Walsted ES, Hull JH, Hvedstrup J, Maat RC, Backer V. Validity and reliability of grade scoring in the diagnosis of exercise-induced laryngeal obstruction. ERJ Open Res 2017; 3:00070-2017. [PMID: 28765826 PMCID: PMC5532755 DOI: 10.1183/23120541.00070-2017] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Accepted: 06/12/2017] [Indexed: 11/05/2022] Open
Abstract
The current gold-standard method for diagnosing exercise-induced laryngeal obstruction (EILO) is continuous laryngoscopy during exercise (CLE), with severity classified by a visual grade scoring system. We evaluated the precision of this approach, by evaluating test-retest reliability of CLE and both inter- and intra-rater variability. In this prospective case-control study, subjects completed four consecutive treadmill CLE tests under identical conditions. Laryngoscopic video recordings were anonymised and graded by three expert raters. 2 months following initial scoring, videos were re-randomised and rating repeated to assess intra-rater agreement. 20 subjects (16 cases and four controls) completed four CLE tests. The time to exhaustion increased by 30 s (95% CI 0.02-57.8, p<0.05) in the second CLE compared with the first test, but remained identical in the subsequent tests. Only one-third of subjects retained their initial diagnosis in the subsequent three tests. Inter-rater agreement on grade scores (weighted Cohen's ϰ) was 0.16-0.45, while intra-rater agreement ranged from 0.30 to 0.67. The CLE test is key in the diagnostic assessment of patients with EILO. However, the widely adopted visual grade scoring system does not appear to be a robust means for reliably classifying severity of EILO.
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Affiliation(s)
- Emil Schwarz Walsted
- Respiratory Research Unit, Dept of Respiratory Medicine, Bispebjerg University Hospital, Copenhagen, Denmark.,Dept of Respiratory Medicine, Royal Brompton Hospital, London, UK
| | - James H Hull
- Dept of Respiratory Medicine, Royal Brompton Hospital, London, UK
| | - Jeppe Hvedstrup
- Respiratory Research Unit, Dept of Respiratory Medicine, Bispebjerg University Hospital, Copenhagen, Denmark
| | | | - Vibeke Backer
- Respiratory Research Unit, Dept of Respiratory Medicine, Bispebjerg University Hospital, Copenhagen, Denmark
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