BREATHING CESSATION IN CHILD WITH ASTHMA AND INDUCIBLE LARYNGEAL OBSTRUCTION: WHEN TWO DIAGNOSES AREN'T ENOUGH

Abstract

Introduction It is important to consider the differential of breathing cessation in a patient with established diagnoses, such as asthma and inducible laryngeal obstruction (ILO). Uncommon etiologies may masquerade as asthma or ILO exacerbations. Case Description A 5-year-old boy with history of asthma was referred for evaluation of recurrent respiratory episodes presumed to be from ILO. These episodes were characterized by complete absence of airflow, lasting 5-60 seconds with spontaneous resolution, occurring up to 20 times a day, every 3-4 days, during the day and at night, which would wake him up from sleep. Institution of pursed lip breathing was ineffective. Continuous laryngoscopy during exercise demonstrated moderate-to-severe ILO although characteristic field symptoms weren't reproduced. During 24-hour impedance probe study, he had several episodes of breathing cessation, perioral cyanosis, oxygen desaturation to the mid-60s and full-body limpness, resolving spontaneously after 45-60 seconds. Further evaluation included an electroencephalogram during an episode with no seizure activity, normal brain MRI, and normal rigid bronchoscopy. Impedance study demonstrated 100% correlation with reflux and breathing cessation, and he was diagnosed with reflux laryngospasm. A proton pump inhibitor (PPI) and promotility agent provided no relief. After Nissen fundoplication with post-surgical use of PPI and H2 blocker, there were no further respiratory events. Discussion In cases of apnea during wakefulness and sleep, it is important to consider etiologies such as seizure disorders, sleep disorders and reflux laryngospasm. Patients with gastroesophageal reflux can develop laryngospasm, a rare cause of abrupt absence of airflow caused by prolonged forceful apposition of the vocal cords.