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Exercise-induced laryngeal obstruction

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Exercise-induced laryngeal obstruction (EILO) is a transient, reversible narrowing of the larynx that occurs during high intensity exercise. This acts to impair airflow and cause shortness of breath, stridor and often discomfort in the throat and upper chest. EILO is a very common cause of breathing difficulties in young athletic individuals but is often misdiagnosed as asthma or exercise-induced bronchoconstriction.[1][2]

Causes

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EILO may arise because of a relative mechanical 'insufficiency' of the laryngeal structures that should act to maintain glottic patency. It has been proposed that a narrowing at the laryngeal inlet during the state of high airflow (e.g. when running fast), can act to cause a pressure drop across the larynx which then acts to 'pull' the laryngeal structures together. The Bernoulli principle states that increasing airflow through a tube creates increasing negative pressures within that tube.[3] Complex neuromuscular functioning is required to maintain laryngeal opening and to allow the larynx to achieve a great number of tasks (i.e. speaking, airway protection, swallowing).[4] It is thus also possible that EILO may arise as form a degree of neuromuscular failure.

A small heredity study indicated that an autosomal dominant model of inheritance with variable expressivity and reduced penetrance in males may be relevant; because in ten families studied, there was at least one affected person in every generation in which both parents were examined.[5]

Further work is needed to determine if structural deficiencies in the laryngeal tissue of individuals with EILO are present.[citation needed]

Mechanism

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EILO is typically caused by a narrowing of the supra-glottic structures of the larynx. In severe cases, these structures, also called arytenoids, can close over to almost completely close the laryngeal inlet.[citation needed]

In fewer cases, the glottic (i.e. vocal cord) structures close together and this is typically what happens during exercise-induced vocal-cord dysfunction.[citation needed]

EILO develops during intense exercise and closure develops as exercise becomes more intense.[6]

Closure of the voice box during exercise causes increased 'loading' on the breathing system and the respiratory muscles have to work much harder.[7]

Epidemiology

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The prevalence of EILO in adolescents and young adults appears to be in the range of 5–7% in northern Europe, with some indication that EILO may be more prevalent in highly trained athletes.[8][9][10]

Some, but not all studies report a higher female prevalence. Thus, in a study of 94 patients diagnosed using the CLE test, average age was ~15 years, and 68% were female.[11]

In athletic individuals EILO appears to be a highly prevalent cause of cough and wheeze and can co-exist with EIB. In one study, of almost 90 athletes, with unexplained respiratory symptoms, EILO was found to be present in approximately 30% of athletes, whilst EILO and EIB co-existed in one in ten.[12]

This condition can co-exist with other conditions, including severe asthma.[13]

Clinical features

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  • Key clinical features often include:[14]
    • Difficulty 'catching a breath'
    • Wheeze or whistling sound; typically when breathing in when exercising hard
    • Throat or upper chest discomfort
  • Symptoms often start to improve from the time of exercise cessation / reducing exercise intensity
  • No improvement with standard asthma medication (e.g. salbutamol, albuterol).

Diagnosis

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The current gold-standard means for diagnosing EILO is the continuous laryngoscopy during exercise test (CLE-test). This test involves the placement of a flexible laryngoscope via nostril, which is then secured in place and held with headgear. It allows continuous visualization of the laryngeal aperture during exercise. The CLE test can be used during indoor treadmill or cycle-ergometer exercise but also whilst rowing or swimming[15] or exercising outdoors.[16]

The examiner visually evaluates the relative change of the laryngeal inlet in the patient throughout the CLE-test. One common grading system uses 4 steps (0-3) on glottic and supraglottic level respectively. Grades 0-1 are considered normal, whereas grades 2-3 on either or both levels are consistent with EILO.[17] There is a need to identify other less-invasive means of making a secure diagnosis.

Treatment

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The current mainstay of treatment is therapy-based. Specialist breathing techniques, most commonly termed biphasic breathing techniques or EILOBI are recommended to reduce turbulent inspiratory airflow and thus reduce chance of laryngeal closure.[18]

Direct laryngeal visualisation during exercise to deliver biofeedback has been employed with success.[citation needed]

The place of inspiratory muscle training (IMT) is yet to be defined in EILO therapy.[citation needed]

Surgical treatment with supraglottopasty has also been utilised with success.[19]

Avoiding unnecessary treatment with asthma inhalers is important.[citation needed]

References

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  1. ^ Hall, Andrew; Thomas, Mike; Sandhu, Guri; Hull, James H (September 2016). "Exercise-induced laryngeal obstruction: a common and overlooked cause of exertional breathlessness". British Journal of General Practice. 66 (650): e683–e685. doi:10.3399/bjgp16X687001. PMC 5198683. PMID 27563141.
  2. ^ Halvorsen, Thomas; Walsted, Emil Schwarz; Bucca, Caterina; Bush, Andrew; Cantarella, Giovanna; Friedrich, Gerhard; Herth, Felix J.F.; Hull, James H.; Jung, Harald; Maat, Robert; Nordang, Leif; Remacle, Marc; Rasmussen, Niels; Wilson, Janet A.; Heimdal, John-Helge (September 2017). "Inducible laryngeal obstruction: an official joint European Respiratory Society and European Laryngological Society statement". European Respiratory Journal. 50 (3): 1602221. doi:10.1183/13993003.02221-2016. hdl:10044/1/54549. PMID 28889105.
  3. ^ Røksund, Ola Drange; Heimdal, John-Helge; Olofsson, Jan; Maat, Robert Christiaan; Halvorsen, Thomas (September 2015). "Larynx during exercise: the unexplored bottleneck of the airways". European Archives of Oto-Rhino-Laryngology. 272 (9): 2101–2109. doi:10.1007/s00405-014-3159-3. PMC 4526593. PMID 25033930.
  4. ^ Hull, James H.; Backer, Vibeke; Gibson, Peter G.; Fowler, Stephen J. (1 November 2016). "Laryngeal Dysfunction: Assessment and Management for the Clinician". American Journal of Respiratory and Critical Care Medicine. 194 (9): 1062–1072. doi:10.1164/rccm.201606-1249CI. PMID 27575803.
  5. ^ Walsted, Emil Schwarz; Hvedstrup, Jeppe; Eiberg, Hans; Backer, Vibeke (August 2017). "Heredity of supraglottic exercise-induced laryngeal obstruction". European Respiratory Journal. 50 (2): 1700423. doi:10.1183/13993003.00423-2017. PMID 28818875.
  6. ^ Olin, J. Tod; Clary, Matthew S.; Fan, Elizabeth M.; Johnston, Kristina L.; State, Claire M.; Strand, Matthew; Christopher, Kent L. (October 2016). "Continuous laryngoscopy quantitates laryngeal behaviour in exercise and recovery". European Respiratory Journal. 48 (4): 1192–1200. doi:10.1183/13993003.00160-2016. PMID 27418554.
  7. ^ Walsted, Emil S.; Faisal, Azmy; Jolley, Caroline J.; Swanton, Laura L.; Pavitt, Matthew J.; Luo, Yuan-Ming; Backer, Vibeke; Polkey, Michael I.; Hull, James H. (1 February 2018). "Increased respiratory neural drive and work of breathing in exercise-induced laryngeal obstruction". Journal of Applied Physiology. 124 (2): 356–363. doi:10.1152/japplphysiol.00691.2017. PMC 5867370. PMID 29097629.
  8. ^ Johansson, Henrik; Norlander, Katarina; Berglund, Lars; Janson, Christer; Malinovschi, Andrei; Nordvall, Lennart; Nordang, Leif; Emtner, Margareta (January 2015). "Prevalence of exercise-induced bronchoconstriction and exercise-induced laryngeal obstruction in a general adolescent population". Thorax. 70 (1): 57–63. doi:10.1136/thoraxjnl-2014-205738. PMID 25380758.
  9. ^ Christensen, Pernille M.; Thomsen, S. F.; Rasmussen, N.; Backer, V. (September 2011). "Exercise-induced laryngeal obstructions: prevalence and symptoms in the general public". European Archives of Oto-Rhino-Laryngology. 268 (9): 1313–1319. doi:10.1007/s00405-011-1612-0. PMID 21528411. S2CID 23253671.
  10. ^ Ersson, Karin; Mallmin, Elisabet; Malinovschi, Andrei; Norlander, Katarina; Johansson, Henrik; Nordang, Leif (December 2020). "Prevalence of exercise‐induced bronchoconstriction and laryngeal obstruction in adolescent athletes". Pediatric Pulmonology. 55 (12): 3509–3516. doi:10.1002/ppul.25104. ISSN 8755-6863. PMC 7702091. PMID 33002318.
  11. ^ Maat, Robert Christiaan; Hilland, Magnus; Røksund, Ola Drange; Halvorsen, Thomas; Olofsson, Jan; Aarstad, Hans Jørgen; Heimdal, John-Helge (October 2011). "Exercise-induced laryngeal obstruction: natural history and effect of surgical treatment". European Archives of Oto-Rhino-Laryngology. 268 (10): 1485–1492. doi:10.1007/s00405-011-1656-1. PMC 3166603. PMID 21643933.
  12. ^ Nielsen, Emil Walsted; Hull, James H.; Backer, Vibeke (November 2013). "High Prevalence of Exercise-Induced Laryngeal Obstruction in Athletes". Medicine & Science in Sports & Exercise. 45 (11): 2030–2035. doi:10.1249/MSS.0b013e318298b19a. PMID 23657163. S2CID 6603638.
  13. ^ Hull, James H.; Walsted, Emil S.; Pavitt, Matt J.; Menzies-Gow, Andrew; Backer, Vibeke; Sandhu, Guri (15 February 2019). "High Prevalence of Laryngeal Obstruction during Exercise in Severe Asthma". American Journal of Respiratory and Critical Care Medicine. 199 (4): 538–542. doi:10.1164/rccm.201809-1734LE. PMC 6376624. PMID 30570393.
  14. ^ Griffin, Steffan Arthur; Walsted, Emil S; Hull, James H (September 2018). "Breathless athlete: exercise-induced laryngeal obstruction". British Journal of Sports Medicine. 52 (18): 1211–1212. doi:10.1136/bjsports-2018-099159. PMID 29669719. S2CID 4930495.
  15. ^ Walsted, Emil S.; Swanton, Laura L.; van van Someren, Ken; Morris, Tessa E.; Furber, Matthew; Backer, Vibeke; Hull, James H. (October 2017). "Laryngoscopy during swimming: A novel diagnostic technique to characterize swimming-induced laryngeal obstruction: Laryngoscopy During Swimming". The Laryngoscope. 127 (10): 2298–2301. doi:10.1002/lary.26532. PMID 28236311. S2CID 45634351.
  16. ^ Hull, James H.; Walsted, Emil S.; Orton, Christopher M.; Williams, Parris; Ward, Simon; Pavitt, Mathew J. (February 2019). "Feasibility of portable continuous laryngoscopy during exercise testing". ERJ Open Research. 5 (1). doi:10.1183/23120541.00219-2018. PMC 6360209. PMID 30740460.
  17. ^ Røksund, Ola Drange; Maat, Robert Christiaan; Heimdal, John Helge; Olofsson, Jan; Skadberg, Britt Torunn; Halvorsen, Thomas (1 December 2009). "Exercise induced dyspnea in the young. Larynx as the bottleneck of the airways". Respiratory Medicine. 103 (12): 1911–1918. doi:10.1016/j.rmed.2009.05.024. hdl:1956/5337. PMID 19782550.
  18. ^ Johnston, Kristina L.; Bradford, Hannah; Hodges, Heather; Moore, Camille M.; Nauman, Emily; Olin, J. Tod (November 2018). "The Olin EILOBI Breathing Techniques: Description and Initial Case Series of Novel Respiratory Retraining Strategies for Athletes with Exercise-Induced Laryngeal Obstruction". Journal of Voice. 32 (6): 698–704. doi:10.1016/j.jvoice.2017.08.020. PMID 29050661. S2CID 36324540.
  19. ^ Heimdal, John-Helge; Maat, Robert; Nordang, Leif (May 2018). "Surgical Intervention for Exercise-Induced Laryngeal Obstruction". Immunology and Allergy Clinics of North America. 38 (2): 317–324. doi:10.1016/j.iac.2018.01.005. PMID 29631739.

Further reading

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