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

Abstract

Purpose Exercise‐induced bronchoconstriction (EIB) and exercise‐induced laryngeal obstruction (EILO) are the 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 Exercise‐induced laryngeal obstruction 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 dyspnea 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.

A longitudinal follow-up of continuous laryngoscopy during exercise test scores in athletes irrespective of laryngeal obstruction, respiratory symptoms, and intervention

“…However, the high prevalence of EILO in our study population, indicates that objective testing for both asthma and EILO is important in athletes with exercise-induced symptoms. Also in Norway many athletes diagnosed with EILO use asthma medication and many without objective evidence of variable broncho-obstruction according to retrospective reviews [ 42 ].…”

Economic Burden of Induced Laryngeal Obstruction in Adolescents and Children

“…23 In pediatric patients, identifying ILO and distinguishing between ILO and asthma symptoms can be challenging. [25][26][27][28][29][30] Both ILO and asthma are relatively common in children, and the conditions may co-occur. 31 Accurately triaging patients to appropriate specialists can, therefore, be challenging.…”

Prevalence and characterisation of exercise-induced laryngeal obstruction in patients with exercise-induced dyspnoea

“…10 However, studies describing exercise-induced laryngeal obstruction patients are heterogeneous, and report variable prevalence, test methods and definitions of exercise-induced laryngeal obstruction (Table 1). [2][3][4]6,[8][9][10][11][12][13][14][15][16][17][18] The 'gold standard' in diagnosing exercise-induced laryngeal obstruction is the visualisation of the larynx during strenuous exercise. The continuous laryngoscopy exercise test has been validated for this purpose.…”

“…The prevalence of exercise-induced laryngeal obstruction has mainly been investigated in younger populations 3 , 4 , 6 and groups of athletes. 8 , 9 Recently, a multinational study, conducted in Denmark, the UK and the USA, of 1007 patients aged 8–76 years referred on suspicion of exercise-induced laryngeal obstruction, reported an exercise-induced laryngeal obstruction prevalence of 58 per cent. 10 However, studies describing exercise-induced laryngeal obstruction patients are heterogeneous, and report variable prevalence, test methods and definitions of exercise-induced laryngeal obstruction ( Table 1 ).…”