Eucapnic Voluntary Hyperventilation Research Articles

Activation of epithelial and inflammatory pathways in adolescent elite athletes exposed to intense exercise and air pollution

RationaleParticipation in high-intensity exercise in early life might act as stressor to the airway barrier.ObjectivesTo investigate the effect of intense exercise and associated exposure to air pollution on the airway...

High Prevalence of Exercise-induced Laryngeal Obstruction in a Cohort of Elite Cross-country Skiers.

ABSTRACTIntroductionExercise-induced laryngeal obstruction (EILO) is a differential diagnosis for asthma and prevalent in athletes referred for exercise-induced dyspnea. The aim of this study was to estimate the prevalence of EILO in elite cross-country skiers, known for a high prevalence of asthma.MethodElite cross-country skiers were invited for screening of EILO. Screening consisted of clinical assessment, questionnaires, skin prick test, spirometry, eucapnic voluntary hyperventilation test, and continuous laryngoscopy during exercise test. Current asthma was defined as physician-diagnosed asthma and use of asthma medication during the last 12 months. EILO was defined as ≥2 points at the supraglottic or glottic level during exercise at maximal effort, using a visual grade score system.ResultA total of 89 (51% female) cross-country skiers completed the study. EILO was identified in 27% of the skiers, 83% of whom were female. All skiers with EILO had supraglottic EILO, and there was no glottic EILO. Current asthma was present in 34 (38%) of the skiers, 10 (29%) of whom had concomitant EILO. In the skiers with EILO, a higher proportion reported wheeze or shortness of breath after exercise, compared with skiers without EILO. In skiers with EILO and current asthma, compared with skiers with asthma only, a higher proportion reported wheeze or shortness of breath after exercise. Asthma medication usage did not differ between these groups.ConclusionEILO is common in elite cross-country skiers, especially females. Asthma and EILO may coexist, and the prevalence of respiratory symptoms is higher in skiers with both. Testing for EILO should be considered in cross-country skiers with respiratory symptoms.

Eucapnic voluntary hyperventilation test decreases exhaled nitric oxide level in children.

Exhaled nitric oxide (FeNO) measurements and eucapnic voluntary hyperventilation (EVH) tests have been used as diagnostic tools for asthma. Data on the impact of hyperventilation on the level of FeNO are limited. We aimed to evaluate whether EVH tests affect the level of FeNO in children aged 10-16years. A total of 234 children aged 10-16years had a 6-min EVH test performed. In total, FeNO values for 153 of 234 children were measured before the test and within 15min after the test. According to a baseline FeNO level of 20ppb, children were divided into two groups: those with low values (FeNO<20ppb) and those with high values (FeNO≥20ppb). The median age of the children was 13.4years (interquartile range 12.3-15.3years); 58% were boys and 42% were girls. Of these children, 51% were sensitized to aeroallergens. In 101 of 153 children (66%), the FeNO values decreased after the EVH test. In children with low and high baseline levels, the median level of FeNO decreased after the EVH test: 10.5ppb before versus 9.5ppb after (p<.011), and 31.0ppb before versus 28.0ppb after (p<.011), respectively. The decrease in FeNO after EVH test was not associated with induced bronchoconstriction expressed as a change in FEV1 (Rs =.19). The EVH test decreases FeNO levels. Therefore, FeNO should be measured before an EVH test is performed.

Cut-off values to evaluate exercise-induced asthma in eucapnic voluntary hyperventilation test for children.

Background and AimThe eucapnic voluntary hyperventilation (EVH) testing is a diagnostic tool for diagnostics of exercise‐induced bronchoconstriction; while the testing has become more common among children, data on the test's feasibility among children remain limited. Our aim was to investigate EVH testing feasibility among children, diagnostic testing cut‐off values, and which factors affect testing outcomes.MethodsWe recruited 134 patients aged 10–16 years with a history of exercise‐induced dyspnoea and 100 healthy control children to undergo 6‐min EVH testing. Testing feasibility was assessed by the children's ability to achieve ≥70% of the target minute ventilation of 30 times forced expiratory volume in 1 s (FEV1). Bronchoconstriction was assessed as a minimum of 8%, 10%, 12%, 15% or 20% fall in FEV1. Patient characteristics were correlated with EVH outcomes.ResultsOverall, 98% of the children reached ≥70%, 88% reached ≥80%, 79% reached ≥90% and 62% reached ≥100% of target ventilation in EVH testing; of children with a history of exercise‐induced dyspnoea, the decline percentages were as follows: 24% (≥8% fall), 17% (≥10% fall), 10% (≥12% fall), 6% (≥15% fall) and 5% (≥20% fall) in FEV1, compared to 11%, 4%, 3%, 1% and 0% among the healthy controls, respectively. Healthy controls and boys performed testing at higher ventilation rates (p < .05).ConclusionEucapnic voluntary hyperventilation testing is feasible among children aged 10–16 years and has diagnostic value in evaluating exercise‐induced dyspnoea among children. A minimum 10% fall in FEV1 is a good diagnostic cut‐off value. Disease status appears to be important covariates.

EUCAPNIC VOLUNTARY HYPERVENTILATION FOR THE DIAGNOSIS OF EXERCISE-INDUCED BRONCHOSPASM IN A COMMUNITY SETTING

SESSION TITLE: Wednesday Abstract Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM PURPOSE: Exercise-induced bronchospasm (EIB) is a common and well-known condition affecting 5% to 20% of the general population and up to 90% of patients with symptomatic asthma. EIB tends to be treated in a community setting based on symptoms without objective findings of bronchospasm. Eucapnic voluntary hyperventilation (EVH) has been established as a sensitive test to diagnose EIB in elite athletes enrolled in research settings or in University based academic medical centers. However, clinical utility of EVH in a community practice setting has not yet been fully demonstrated. We evaluated the feasibility and performance of EVH as a diagnostic test for EIB in a community based pulmonary clinic. METHODS: Retrospective analysis of 22 EVH tests performed for evaluation of EIB symptoms. All tests were done in the pulmonary clinic at The Oregon Clinic using a standard protocol (Anderson SD, Br J Sport Med 2001). Patients underwent baseline spirometry followed by breathing a gas mixture of 5% CO2, 74% N, and 21% O2 at a target minute ventilation (35 x FEV1) for 6 minutes. Spirometry was performed at 3, 5, 10, 15, and 20 minutes. An EVH test was considered sufficient if maximum voluntary ventilation per minute (MVV) >60%. A positive test was defined as >10% decrease in any post-EVH FEV1. RESULTS: 22 patients completed EVH with 21/22 (95.4%) able to achieve MVV >60%. Mean age was 37 years, with a range of 15-71. 59% of patients were female. 4/21 (19%) of patients had a positive test for EIB. Abnormal inspiratory flow volume loops were found in 11 (50%) of patients, suggestive of vocal cord dysfunction (VCD). Videolaryngoscopy (VLS) was subsequently performed on 9 of these 11 patients, with 100% (9/9) (+) for exercise induced VCD (EIVCD) .One patient had a (+) EVH for EIB and an abnormal flow volume loop with a subsequent (+) VLS for EIVCD. CONCLUSIONS: Eucapnic Voluntary Hyperventilation has, to this point, largely been used in research and University academic medical centers to diagnose EIB. Our data suggests that EVH can be utilized successfully in a community based practice setting with the majority of athlete and non-athlete patients able to complete the test with sufficient MVV. Only 19% of patients presenting with symptoms consistent with EIB, were objectively diagnosed with EIB via EVH. This suggests EIB may be over diagnosed in the community setting based on symptoms alone. 50% of the patients evaluated with an EVH test had abnormal flow volume loops with 80% of these patients (+) for EIVCD via VLS testing. CLINICAL IMPLICATIONS: Thus, our data suggests that EVH is an acceptable diagnostic modality for EIB in a community setting, and may be useful in diagnosing alternative conditions such as EIVCD causing similar symptoms. DISCLOSURES: No relevant relationships by Crystal Clark, source=Web Response No relevant relationships by Jordan Lauw, source=Web Response No relevant relationships by John Mastronarde, source=Web Response No relevant relationships by Brandon Temte, source=Web Response No relevant relationships by Jason Wells, source=Web Response

Comparison of impulse oscillometry and spirometry for detection of airway hyperresponsiveness to methacholine, mannitol, and eucapnic voluntary hyperventilation in children.

Forced expiratory maneuvers are usually difficult in young children. Impulse oscillometry (IOS) requires no active cooperation, is noninvasive, rapid, and easy to perform. This study aimed to compare IOS indexes and forced expiratory volume in 1 second (FEV1) in children for the assessment of bronchial hyperreactivity to methacholine, mannitol, and eucapnic voluntary hyperventilation (EVH). Children aged 3-14 years (mean 10.0 ± 3.1) with symptoms suggestive of asthma were recruited. IOS measurements were taken before spirometry. Methacholine, mannitol, and EVH tests were performed without a specific order. We included 190 children, whose mean age was 10.0 ± 3.1 years. Changes in FEV1 correlated significantly with variation in IOS indexes (P < .05). The indexes with the greatest discriminative capacity were Z5, R5, and X5. Optimal cut-offs were: for methacholine tests, ≧22% in R5, ≧82% for reactance area (AX), and ≦41% for X5; for the mannitol test, ≧18% in R5, ≧40% in AX, and ≦21% for X5. In the EVH test, ≧23% for R5, ≧40% for AX, and a fall of 29% for X5. When using the optimal cut-off points obtained from IOS, the mean number of steps and doses required for methacholine and mannitol tests to induce significant bronchoconstriction were significantly lower compared with spirometry ( P < .05). The effectiveness of R5, X5, and AX indexes were comparable to FEV1 in assessing bronchial obstruction during bronchial challenge testing. Therefore, IOS may be useful in assessing bronchial obstruction in children who cannot reliably perform spirometric maneuvers during bronchial challenge testing.

Utility of Exhaled Breath Condensate for Determination of Airway Inflammation After Eucapnic Voluntary Hyperventilation

Utility of Exhaled Breath Condensate for Determination of Airway Inflammation After Eucapnic Voluntary Hyperventilation

A Meta-analysis of Diagnostic Test Agreement Between Eucapnic Voluntary Hyperventilation and Cardiopulmonary Exercise Tests for Exercise-Induced Bronchoconstriction.

Exercise-induced bronchoconstriction (EIB) is very common in athletes. Cardiopulmonary exercise tests (CPET) have traditionally been used for the diagnosis of EIB. However, alternative indirect bronchoprovocation tests have recently been used as surrogate tests. One of these is the eucapnic voluntary hyperventilation (EVH). This meta-analysis studied the agreement between the two tests. An extensive search in PubMed and Medline was conducted for studies where participants underwent both CPET and EVH with measurement of forced expiratory volume in 1-second (FEV1). After extracting data using two-by-two contingency tables, pooled positive and negative agreements were first calculated between the two tests, with EVH benchmarked against CPET, and then, pooled positive and negative agreements were calculated with CPET benchmarked against EVH. The pooled positive and negative agreements between EVH and CPET (with CPET as the reference) were 0.62 [(95% confidence interval 0.54-0.70), I2 77%] and 0.61 [(0.56-0.65)), I2 81%]. The pooled positive and negative agreements between CPET and EVH (with EVH as the reference) were 0.36 [(0.30-0.42), I2 93%] and 0.82 [(0.77-0.86), I2 78%]. The average of positive test results with EVH across all studies was greater than that of CPETs (58.84% vs. 39.51%). Results of this meta-analysis show poor positive agreement between the two tests but high negative agreement (specifically using EVH as reference), suggesting that either test can be used for correctly identifying those without EIB. Results also suggest that the chances of a test resulting positive are higher with EVH than with CPET.

Exercise-induced bronchospasm in children and adolescents with allergic rhinitis by treadmill and hyperventilation challenges.

Respiratory complaints after exercise are common in patients with rhinitis. Exercise-induced bronchospasm (EIB) may be one of the causes. To evaluate EIB prevalence in a group of children and adolescents with allergic rhinitis, to compare the treadmill running (TR) and eucapnic voluntary hyperventilation (EVH) challenge methods as diagnostic tools and to assess the association between respiratory complaints on exercise and EIB. Patients aged between 10 and 20 years were studied at the Pulmonology Department of the Hospital das Clínicas -UFPE- Recife, Brazil. The severity of symptoms of rhinitis and exercise-related respiratory complaints in the past year were evaluated. Challenges were performed in random sequence, no more than 72 h apart and followed international guidelines. Forced expiratory volume in the first second (FEV1) was determined before and 3, 5, 7, 10, 15 and 30 min after each challenge. A >10% reduction in FEV1 from baseline at two points after the challenge was considered sufficient to diagnose EIB. Of the thirty-five subjects evaluated, thirteen (37%) showed EIB, six by both methods, three only after TR and four only after EVH (Coens' Kappa = 0.489). There was no association between respiratory complaints after exercise and EIB (p = 0.74). A high prevalence of EIB was found in this population but only moderate agreement between the challenges used to diagnose EIB. Caution should be adopted when comparing these methods or interpreting their results interchangeably. There was no association between reported respiratory symptoms after exercise and EIB.

P205 Experience with a simplified eucapnic voluntary hyperventilation (evh) device for diagnosis of exercise-induced bronchospasm

P205 Experience with a simplified eucapnic voluntary hyperventilation (evh) device for diagnosis of exercise-induced bronchospasm

Eucapnic voluntary hyperventilation test in children.

In children, exercise-induced dyspnea is a common symptom that can be due to dysfunctional breathing. EVH test has bee used especially in elite athletes as bronchoprovocation test. Currently, there are only few studies on the EVH test. New research methods are required alongside the traditionally used tests especially due to dysfunctional breathing disorder. The purpose of the "pilot study" was to study the usability of the EVH test with real time biofeedback in children of 10-16years of age in the diagnostics of exercise-induced dyspnea. Six 10-16-year-old teenagers with history of exercise-induced dyspnea and three healthy control subjects were selected for the study. A 6-minute EVH test with realtime biofeedback was performed on the patients and the diagnosis was confirmed on the basis of clinical findings and spirometry follow-up either as normal, asthma or dysfunctional breathing. The study was successful in the patients. In the spirometry follow-up, three patients had bronchoconstriction (FEV1 decline over 10%), dysfunctional breathing condition was observed in three patients and three control patients experienced no symptoms. Only two DFB-patients didn't reach the target level of minute ventilation due to a clinical symptom (inspiratory stridor). The EVH test was successful in the 10-16-year-old children having participated in the study and the test was well tolerated. Through the study, it was possible to provoke both dysfunctional breathing disorder and bronchoconstriction in the symptomatic patients. Based on the pilot study, EVH test seems to be usable in the diagnostics of pediatric exercise-induced dyspnea but larger studies are warranted to confirm our preliminary findings.

Vitamin D deficiency and exercise-induced laryngospasm in young competitive rowers.

Exercise-induced dyspnea is common among adolescents and young adults and often originates from exercise-induced bronchoconstriction (EIB). Sometimes, dyspnea corresponds to exercise-induced laryngospasm (EILO), which is a paradoxical decrease in supraglottic/glottic area. Vitamin D deficiency, which occurs frequently at northern latitudes, might favor laryngospasm by impairing calcium transport and slowing striate muscle relaxation. The aim of this study was to evaluate whether vitamin D status has an influence on bronchial and laryngeal responses to exercise in young, healthy athletes. EIB and EILO were investigated during winter in 37 healthy competitive rowers (24 males; age range 13-25 years), using the eucapnic voluntary hyperventilation test (EVH). EIB was diagnosed when forced expiratory volume in the first second decreased by 10%, EILO when maximum mid-inspiratory flow (MIF50) decreased by 20%. Most athletes (86.5%) had vitamin D deficiency (below 30 ng/mL), 29 mild-moderate (78.4%) and 3 severe (8.1%). EVH showed EIB in 10 subjects (27%), EILO in 16 (43.2%), and combined EIB and EILO in 6 (16.2%). Athletes with EILO had lower vitamin D (19.1 ng/mL vs. 27.0 ng/mL, p < 0.001) and higher parathyroid hormone (30.5 pg/mL vs. 19.2 pg/mL, p = 0.006) levels. The degree of laryngoconstriction (post-EVH MIF50 as a percentage of pre-EVH MIF50) was related directly with vitamin D levels (r = 0.51; p = 0.001) and inversely with parathyroid hormone levels (r = -0.53; p = 0.001). We conclude that vitamin D deficiency is common during winter in young athletes living above the 40th parallel north and favors laryngospasm during exercise, probably by disturbing calcium homeostasis. This effect may negatively influence athletic performance.

Feasibility to apply eucapnic voluntary hyperventilation in young elite athletes

Introduction: Exercise-induced bronchoconstriction (EIB) is more common in athletes compared to the general population. The eucapnic voluntary hyperventilation test is used to detect EIB in adult athletes. It is however unclear whether this technique is also applicable to young athletes.MethodsYoung athletes (basketball (n = 13), football (n = 19), swimming (n = 12)) were recruited at the start of their elite sports career (12–14 years). Eight age-matched controls were also recruited. Eucapnic voluntary hyperventilation test was performed according to ATS guidelines in all subjects. A second (after 1 year, n = 32) and third (after 2 years, n = 39) measurement was performed in a subgroup of athletes and controls.ResultsAt time of first evaluation, 3/13 basketball players, 4/19 football players, 5/11 swimmers and 1/8 controls met criteria for EIB (fall in FEV1≥10% after EVH). A ventilation rate of >85% of the maximal voluntary ventilation (MVV) is recommended by current guidelines (for adults) but was only achieved by a low number of individuals (first occasion: 27%, third occasion: 45%) However, MVV in young athletes corresponds to 30 times FEV1, which is equivalent to 85% of MVV in adults. A threshold of 70% of MVV (21 times FEV1) is feasible in the majority of young athletes.ConclusionEIB is present in a substantial number of individuals at the age of 12–14 years, especially in swimmers. This underscores the importance of screening for EIB at this age. EVH is feasible in young elite athletes, however target ventilation needs to be adjusted accordingly.

Eucapnic voluntary hyperpnoea and exercise-induced vocal cord dysfunction

IntroductionExercise-induced bronchoconstriction (EIB) is a common condition in endurance athletes. Exercise-induced vocal cord dysfunction (EIVCD) is a frequent confounder of EIB. The diagnosis of EIVCD may be challenging and can...

Exercise-induced bronchoconstriction diagnosis in asthmatic children: comparison of treadmill running and eucapnic voluntary hyperventilation challenges

BackgroundExercise-induced bronchoconstriction (EIB) occurs in up to 90% of young people with asthma and can be diagnosed using serial measurements of forced expiratory volume in 1 second (FEV1) after standardized exercise, usually treadmill running (TR). Eucapnic voluntary hyperventilation (EVH) is a guideline-recommended alternative challenge for EIB diagnosis. The 2 methods have not been compared for EIB diagnosis in this population. ObjectiveTo compare 2 methods of EIB diagnosis in children and adolescents with asthma. MethodsThirty-four children 8 to 18 years of age attending the allergy clinic of the Hospital das Clínicas (Recife, Brazil) from September through December 2013 were examined. All underwent a basal FEV1 determination followed by TR for 8 minutes or EVH for 6 minutes on consecutive days. The first challenge was chosen at random. Serial FEV1 determinations were obtained at 3, 5, 7, 10, 15, and 30 minutes after the challenge and the test result was considered positive if at least 2 consecutive FEV1 measurements decreased at least 10% below the basal value. ResultsThirteen patients responded to the 2 challenges, 6 only after TR and 4 exclusively after EVH (agreement 71%, κ = 0.41). The 95% limits of agreement of FEV1 decreasing after the challenges were widely spread (mean 0.1%, limits 19.8% to −19.6%). ConclusionThe 2 tests cannot be used interchangeably and the reproducibility of the FEV1 response to the EVH challenge has to be properly evaluated to better understand its role in EIB diagnosis.

Eucapnic Voluntary Hyperventilation to Detect Exercise-Induced Bronchoconstriction in Cystic Fibrosis.

Exercise-induced bronchoconstriction (EIB) has not been well studied in cystic fibrosis (CF), and eucapnic voluntary hyperventilation (EVH) testing has not been used as an objective assessment of EIB in CF to date. A prospective cohort pilot study was completed where standard EVH testing was completed by 10 CF patients with forced expiratory volume in 1 s (FEV1) ≥70% of predicted. All patients also completed a cardiopulmonary exercise test (CPET) with pre- and post-CPET spirometry as a comparative method of detecting EIB. No adverse events occurred with EVH testing. A total of 20% (2/10) patients were diagnosed with EIB by means of EVH. Both patients had clinical symptoms consistent with EIB. No patient had a CPET-based exercise challenge consistent with EIB. EVH testing was safe and effective in the objective assessment for EIB in patients with CF who had well-preserved lung function. It may be a more sensitive method of detecting EIB then exercise challenge.

Damage-associated molecular pattern and innate cytokine release in the airways of competitive swimmers.

Daily intensive exercise by elite athletes can result in exercise-induced asthma especially in elite swimmers and this may be linked to epithelial damage. To study airway epithelial damage and release of damage-associated molecular patterns (DAMPs) after intensive exercise in elite athletes and controls. We recruited competitive swimmers (n=26), competitive indoor athletes (n=13) and controls (n=15) without any history of asthma. Lung function was measured before, immediately after and 24h after a 90-min intensive exercise protocol. Sputum induction was performed at baseline and 24h after exercise. Exercise-induced bronchoconstriction (EIB) was assessed by the eucapnic voluntary hyperventilation test. Baseline sputum uric acid, high mobility group box-1, CXCL8 mRNA, sputum neutrophils and serum Clara cell protein-16 (CC-16) were significantly higher in competitive swimmers compared with controls. Intensive swimming for 90min resulted in an increase of sputum IL-1β, IL-6 and TNF mRNA in competitive swimmers, and of sputum IL-6 mRNA and sputum neutrophils in controls. Although all participants were asymptomatic, seven competitive swimmers, one indoor athlete and one control met the criteria for EIB. Our findings show that the intensive training combined with exposure to by-products of chlorination induces airway epithelial damage in competitive swimmers. This is associated with increased damage-associated molecular patterns, innate cytokine release and neutrophilic airway inflammation.

The Simplified Method For Eucapnic Voluntary Hyperventilation (EVH) May Be Useful To Discriminate Between Hyperventilation and Gastroesophageal Reflux Disease (GERD) Induced Bronchospasm

The Simplified Method For Eucapnic Voluntary Hyperventilation (EVH) May Be Useful To Discriminate Between Hyperventilation and Gastroesophageal Reflux Disease (GERD) Induced Bronchospasm

Exhaled Breath Temperature in Asthmatics and Controls after Eucapnic Voluntary Hyperventilation and a Methacholine Challenge Test

Background: It has been suggested that exhaled breath temperature (EBT) is increased in asthmatic subjects. Objectives: Our aim was to investigate EBT in asthmatics compared to healthy controls before and after eucapnic voluntary hyperventilation (EVH) and a methacholine challenge test (MCT). Methods: A total of 26 asthmatics and 29 healthy controls were included. Forced expiratory volume in 1 s (FEV₁), EBT and oral, axillary and auricular temperatures were measured before and after EVH and MCT. Results: FEV₁ % predicted (%p) was significantly lower in asthmatic subjects compared to healthy controls at all time points. EBT was significantly increased in all subjects 15-30 min after EVH and 5-45 min after MCT. Oral temperature displayed a similar pattern of increase, in contrast to axillary and auricular temperature, and correlated with EBT before and after both of the challenge tests. EBT after 5 min correlated with the largest drop in FEV₁%p after EVH in asthmatic subjects. No significant differences or changes in EBT were found when comparing asthmatics to healthy controls before or after any of the tests. Conclusions: EBT is increased after both EVH and MCT, possibly reflecting a vascular response. This is related to both the fall in FEV₁ and to oral temperature, suggesting an effect on the whole respiratory tract including the oral cavity. No differences in EBT are seen between asthmatics and healthy controls, indicating that the increase in EBT is mainly physiological rather than pathophysiological.

A RANDOMISED PLACEBO CONTROLLED TRIAL TO COMPARE THE EFFECTS OF TWO DOSAGES OF OMEGA-3 PUFA ON EXERCISE-INDUCED BRONCHOCONSTRICTION (EIB)

Treatment of EIB often involves drug interventions, but long-term use may cause systemic side effects (Dahl, Respir Med 2006;8:1307–1317). Supplementing the diet of EIB sufferers with fish oil rich in...