Inducible Laryngeal Obstruction Research Articles

Exploring Factors Impacting Engagement in Speech Pathology Intervention for Inducible Laryngeal Obstruction

Speech pathology is the first-line treatment for inducible laryngeal obstruction (ILO) and involves behavioral techniques to address symptoms and modify maladaptive laryngeal postures. Benefit from speech pathology is reliant on patients engaging in treatment sessions, regular home practice, and generalizing techniques to everyday activities. There is limited research exploring engagement in speech pathology treatment for ILO, particularly from the patient perspective. This study aimed to explore the experiences of living with ILO and how this experience may impact the way patients engage in speech pathology treatment. Qualitative study. Semistructured interviews were completed with seven participants exploring their experiences living with ILO, their diagnostic process and their experiences with speech pathology treatment. Data were analyzed using reflexive thematic analysis to determine shared meanings across participants and themes were developed. Three major themes were identified - Life with ILO, Challenges of Speech Pathology Treatment, and What Matters to Me. Patients' reports of living with ILO and interacting with speech pathology suggested that these experiences impacted their readiness to start treatment and persist through the challenges of the treatment. Engagement appeared to be positively associated with significant ILO symptom burden and life impact, confidence in the diagnostic process, recommendation for speech pathology treatment, a tailored intervention by a patient-perceived expert in the field and working in a partnership with the speech pathologist to develop a sense of agency. Patients indicated their engagement was negatively influenced by competing time demands, social embarrassment when using symptom relief techniques and laryngeal exercises, and a low ILO symptom burden and life impact. The reasons behind engagement in speech pathology treatment for ILO appear to be a complex interaction between previous experiences of living with ILO including the diagnostic process and the experience of speech pathology treatment. A patient-centered approach to therapy may help to maximize engagement by exploring readiness and expectations for treatment. The greater understanding of the patient experience provided through this study may allow speech pathologists to devise meaningful ways to maximize engagement in treatment for people with ILO.

Drug Allergy Mimics

When approaching a case of apparent drug allergy, the consulting clinician should consider a broad differential diagnosis. This article presents a series of cases that could be commonly referred to an Allergist for assessment as "drug allergy," however, where a real diagnosis exists that mandates a different diagnostic and treatment strategy. Including a case of Inducible Laryngeal Obstruction, Multiple Drug Intolerance Syndrome, viral rash, seizure due to metastatic malignancy, and Hemophagocytic lymphohistiocytosis (HLH) initially diagnosed as drug reaction and eosinophilia with systemic symptoms (DRESS). The initial misdiagnoses of these patients delayed or interfered with their medical care, emphasizing the importance of accurate diagnoses for the benefit of our patients.

Is trans-laryngeal ultrasound (TLUS) an accurate and acceptable tool in the assessment of inducible laryngeal obstruction? A protocol for the ILOTUS: A cross-sectional, two-stage feasibility study

BACKGROUND: Inducible laryngeal obstruction (ILO) describes an inappropriate narrowing of the larynx during breathing in. ILO can lead to several respiratory symptoms and be misidentified and treated as asthma, with associated patient morbidity and healthcare cost. ILO is also known as vocal cord dysfunction, or paradoxical vocal fold movement. The current reference assessment tool for diagnosing ILO is a video-laryngoscopy. However, timely access to specialist diagnostic laryngoscopy services may be challenging, and laryngoscopy may be poorly tolerated. AIMS: The aim of this cross-sectional, two-stage feasibility study is to determine whether abnormal vocal fold movements associated with ILO can be adequately visualised using trans-laryngeal ultrasound (TLUS) namely, the ILOTUS study: (ILO assessment via trans- laryngeal ultrasound). The second aim is to compare TLUS with a reference standard diagnostic tool to ascertain whether it may serve as a less invasive screening tool to assess ILO. Participants’ opinions about the acceptability of TLUS will also be gathered and compared with responses to a validated symptom score questionnaire. METHODS: In stage one, healthy volunteers (n = 30) will undergo TLUS to assess whether the vocal folds can be visualised,and whether narrowing of the vocal folds can be seen when they mimic ILO. Stage 2 will be conducted with a patient population(n = 30) referred to a tertiary airways service for breathlessness assessment. Participants in stage 2 will undergo the reference standard laryngoscopy as well as simultaneous TLUS. The level of agreement between TLUS and laryngoscopy will be evaluated, as well as comparison of symptom scores. DISCUSSION: This study will help inform future studies of the utility of TLUS in the assessment of ILO. This will be valuable for understanding whether TLUS could be offered as a non-invasive option for patients in the assessment of ILO if they are not able to tolerate or access laryngoscopy diagnostic services. It is not intended that TLUS will replace the current reference standard of video-laryngoscopy but may have potential as an early screening tool if found to be non-inferior.

Protocol for a scoping review to map health outcomes in individuals with inducible laryngeal obstruction.

Inducible laryngeal obstruction causes narrowing of the laryngeal aperture in response to external triggers. Outcomes are measured in inducible laryngeal obstruction to monitor changes in health status over time. This study is a scoping review based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology. The review will be guided by the following research question: 'What health outcomes are measured in studies including people with inducible laryngeal obstruction?' The research question was validated using the Population-Concept-Context framework according to the methodology for Joanna Briggs Institution Scoping Reviews. Relevant peer-reviewed studies and grey literature conducted over the last 40 years will be identified from electronic databases including AMED, CINAHL, Embase, EMCARE, MEDLINE, OVID, PubMed and PsycINFO. The search strings 'inducible laryngeal obstruction', 'ILO', 'vocal cord dysfunction', 'VCD', 'paradoxical vocal fold motion', 'PVFM', 'outcome', 'measure', 'measurement instrument', 'assessment', 'scale', 'questionnaire' will be combined using Boolean logic. An independent reviewer will conduct title screening; two independent reviewers will conduct abstract and full article screening, followed by data extraction by two reviewers. Analyses will be conducted appropriate to the findings. The review will document evidence of health outcomes measured in inducible laryngeal obstruction, identifying measurement characteristics and potential utility. Collating studies may identify gaps in coverage, the need for novel tools, and for standardisation for clinical and research purposes. What is already known on the subject Inducible laryngeal obstruction causes narrowing of the laryngeal aperture in response to external triggers. Outcomes are measured in inducible laryngeal obstruction to monitor changes in health status over time. Currently, there are no standardised outcome measures for measuring the effects of interventions in inducible laryngeal obstruction (ILO). What this paper adds to existing knowledge Assessment of health can be measured in a variety of ways. Physiological, radiological and biochemical measurements of impairment are more common historically but there are a lot of outcomes of other factors now including subjective measures of functional status and health-related quality of life, with data collected directly from patients. This study will allow us to scope the literature to see the health outcomes being measured in ILO to attempt to standardise and develop future health outcomes. What are the potential or actual clinical implications of this work? The review will document evidence of health outcomes measured in inducible laryngeal obstruction, identifying measurement characteristics and potential utility. Collating studies may identify gaps in coverage, the need for novel tools and for standardisation for clinical and research purposes.

Group Singing-Related Technique Workshops for People with Inducible Laryngeal Obstruction: A Feasibility Study

Inducible laryngeal obstruction (ILO) is an upper-airway disorder involving a heightened sensitivity of the larynx, obstructing airflow and potentially leading to breathing difficulties. Speaking can trigger, and be affected by, ILO symptoms. This research explored the feasibility of singing-related workshops for people with ILO. The aim was to increase participants’ vocal confidence by combining relaxation with improved control, tone, and projection. Five participants consented to participate in the research. The workshops were led by a voice teacher (VT) and a speech and language therapist (SLT), focusing on posture, breathing techniques, and singing techniques. Ten weekly workshops took place online, with the final session being hybrid where most participants attended in person. Data collection included weekly response forms with Likert scales to rate speaking and singing confidence and feedback on the workshops; interviews with VT and SLT; workshop observations; and a participant reflection questionnaire following the program. Participants reported a significant improvement in speaking and singing confidence as the workshops progressed. Thematic analysis revealed four themes: improvements in confidence, specifically in speaking and singing; the value of social support and meeting others with the condition; specific techniques and approaches that were beneficial; and benefits and disadvantages of the online format. This research demonstrates the feasibility of group singing workshops for people with ILO who do not have a background in singing, using an online format. It confirms the potential benefits of using singing-related techniques for this condition, supporting confidence in speaking and singing. Further research would be useful to extend the findings from this initial project and to provide a firm basis for introducing further programs using singing-related techniques for people with a range of upper-airway disorders. Future developments could include introducing these techniques in clinical settings and using them alongside (or as part of) speech and language therapy.

Obstruction laryngée induite

Inductible laryngeal obstruction (i.e. by an external stimulus) is the consensual terminology to describe the paroxysmal and episodic closure of the larynx at the origin of respiratory problems with sub-categorizations related to the inducers of the crisis, and laryngoscopic results regarding the modalities of obstruction. This new framework allowed the revision of the results published under the different previous names and improved knowledge on diagnostic and therapeutic modalities. Thus, an inducible laryngeal obstruction refers to an inappropriate, transient and reversible obstruction of the larynx in response to external triggers. An important cause of a variety of respiratory symptoms, it can mimic asthma. However, despite recent progress, the pathophysiological mechanism remains unknown and validated diagnostic and treatment algorithms are not yet established.

Exertional Dyspnea; Just an Untrained Child? Two Case Reports Analyzing the Role of Lung Function Testing

Background: Dyspnea is a common symptom that afflicts many patients with pulmonary disease and may be the primary manifestation of not only lung disease but also myocardial dysfunction, anemia, neuromuscular disorders, obesity, etc. Dyspnea can be induced by physical activity, which is referred to as exercise-induced dyspnea (EID). It can be caused by various etiologies, sometimes concomitant. In pediatrics, the three most common causes of exertional dyspnea are exercise-induced bronchoconstriction, inducible laryngeal obstruction, and being physically untrained Case presentation: We report two cases of adolescents who developed EID and their management approach. The first patient had an inducible laryngeal obstruction (EILO), while the second had an exercise-induced bronchoconstriction (EIB). Discussion: The diagnosis of EIB is based on clinical symptoms (e.g., exercise-related symptoms of dyspnea, cough, or wheezing) and lung function testing (LFT). This test shows a reversible airflow limitation in response to exercise. A decrease in FEV1 ≥ 10% is considered positive. A major goal is to ensure that patients with EIB continue physical activity. Therapy is based on non-pharmacologic and pharmacologic measures. Conclusion: Our aim is to add our experience to the available knowledge on the diagnosis of EID. In conclusion, when faced with a child with exertional dyspnea, before declaring that he is not trained, it is always necessary to collect an accurate medical history, examination and carry out LFT, excluding pathologies of the upper and lower respiratory tract, such as EILO and EIB.

Characterization of adolescents with functional respiratory disorders and prior history of SARS-CoV-2

BackgroundThe SARS-CoV-2 pandemic has caused significant pulmonary morbidity and mortality in the adult population. Children and adolescents typically show milder symptoms; however, a relevant proportion of them report persistent pulmonary symptoms even after mild SARS-CoV-2 infection. Functional respiratory disorders may be relevant differential diagnoses of persistent dyspnea. This study aims at characterizing functional respiratory disorders that may arise after SARS-CoV-2 infection regarding their clinical presentation and pulmonary function tests as well as gaining insights into the clinical course after initiation of appropriate therapy.MethodsThis study retrospectively identified all patients referred to an outpatient clinic for pediatric pulmonology with functional respiratory disorders manifesting after proven SARS-CoV-2 infection between January 1, 2022, and October 31, 2022. Clinical history, thorough clinical examination regarding breathing patterns, and pulmonary function tests (PFTs) were taken into consideration to diagnose functional respiratory disorders.ResultsTwenty-five patients (44% female) with mean (m) age = 12.73 years (SD ± 1.86) who showed distinctive features of functional respiratory disorders after SARS-CoV-2 infection (onset at m = 4.15 (± 4.24) weeks after infection) were identified. Eleven patients showed thoracic dominant breathing with insufficient ventilation, and 4 patients mainly had symptoms of inducible laryngeal obstruction. The rest (n = 10) showed overlap of these two etiologies. Most patients had a flattened inspiratory curve on spirometry and slightly elevated residual volume on body plethysmography, but values of PFTs were normal before and after standardized treadmill exercise testing. Patients were educated about the benign nature of the condition and were offered rebreathing training. All patients with follow-up (n = 5) showed normalization of the breathing pattern within 3 months.ConclusionsFunctional respiratory disorders are important differential diagnoses in persisting post-SARS-CoV-2 dyspnea in adolescents. A combination of clinical history, detailed examination of breathing patterns, and pulmonary function tests are helpful to correctly diagnose these conditions. Reassurance and rebreathing training are the mainstay of the therapy. The clinical course is favorable.

Multidisciplinary management of inducible laryngeal obstruction and breathing pattern disorder.

Inducible laryngeal obstruction and breathing pattern disorder are common causes of breathlessness.Inducible laryngeal obstruction is an inappropriate, transient, reversible narrowing of the laryngeal area that causes breathlessness and laryngeal symptoms.Breathing pattern disorder is an alteration in the normal biomechanical patterns of breathing that results in intermittent or chronic symptoms, which may be respiratory and/or non-respiratory.People with inducible laryngeal obstruction or breathing pattern disorder often have other comorbidities that will also need addressing.Multidisciplinary assessment and treatment is essential for comprehensive workup and holistic care.Timely assessment and diagnosis can prevent unnecessary medication use and hospital admissions and facilitate effective management of the condition using reassurance, advice, education, breathing retraining and vocal exercises.

A masquerade of recurrent anaphylaxis.

Background: We present a case of a 37 year old man with a history of human immunodeficiency virus, latent syphilis, anxiety, posttraumatic stress disorder. attention deficit/hyperactivity disorder, multiple drug intolerance syndrome who presented with concerns of recurrent episodes of rash and respiratory symptoms with questionable "anaphylaxis" episodes without clear etiology or known trigger. Methods: To evaluate some of the potential causes of recurrent anaphylaxis in our patient. Further evaluation through laboratory analysis and ultimately direct visualization of the patient's vocal cords by laryngoscopy assisted in the final diagnosis. Results: Inappropriate adduction of the vocal cords was observed during an acute reaction. Conclusion: The patient's presentation was consistent with inducible laryngeal obstruction and highlights the importance of confirming a suspected diagnosis of anaphylaxis and keeping a broad differential when establishing an etiology.

Inducible Laryngeal Obstruction (ILO) Coexisting with COPD can Fatally Influence the Course of COPD Exacerbation

Inducible Laryngeal Obstruction (ILO) Coexisting with COPD can Fatally Influence the Course of COPD Exacerbation

Indications and Short-Term Outcomes for In-Office Therapeutic Superior Laryngeal Nerve Block.

Superior laryngeal nerve (SLN) block consists of injection of steroid and anesthetic at the internal branch of the SLN entry site. Prior case series have demonstrated beneficial effects on neurogenic cough. SLN blocks have also recently shown benefit for paralaryngeal pain. We describe short-term outcomes for multiple symptoms of irritable larynx syndrome (ILS) including neurogenic cough, dysphonia related to laryngeal hypersensitivity, inducible laryngeal obstruction (ILO), paralaryngeal pain, and isolated globus. Retrospective review from 2 institutions of patients undergoing a single SLN block for the indications listed. Variables include age, sex, indication(s), known vagus neuropathy, and patient-reported outcomes at short-term follow-up. A total of 209 patients were included (59 males, 150 females; age: 58 ± 13 years). Twenty-six patients (12%) had a history of a vagus nerve injury. Indications included neurogenic cough (n = 149), dysphonia related to laryngeal hypersensitivity (n = 66), paralaryngeal pain (n = 50), ILO (n = 23), and isolated globus (n = 3). Some patients had multiple indications. Significant improvements in patient-reported measures occurred after a single SLN block within 2 to 4 weeks for neurogenic cough (cough severity index; 25.2 ± 11.2 to 19.0 ± 12.8; P < .001), dysphonia (voice handicap index-10; 22.1 ± 12.2-18.0 ± 13.3; P = .005), and ILO (dyspnea index; 21.0 ± 14.9-14.7 ± 15.7; P = .017). Subjective pain improved in 23 of 39 patients with paralaryngeal pain. There was no observed improvement for isolated globus. Presence of known vagal neuropathy or therapy around the time of SLN block did not affect outcome. SLN block can be an effective component of treatment for a variety of ILS symptoms. Patients may experience some improvement after 1 injection. Symptoms of irritable larynx syndrome, such as neurogenic cough, paralaryngeal pain, inducible laryngeal obstruction, and dysphonia related to laryngeal hypersensitivity can be challenging to manage. In-office Superior Laryngeal Nerve blocks can serve as a quick, well tolerated, adjunctive treatment with positive short-term outcomes. 4.

Experiences of Diagnosis, Symptoms, and Use of Reliever Inhalers in Patients With Asthma and Concurrent Inducible Laryngeal Obstruction or Breathing Pattern Disorder: Qualitative Analysis of a UK Asthma Online Community.

Breathing pattern disorders (BPDs) and inducible laryngeal obstruction (ILO) cause similar symptoms to asthma, including dyspnea and chest tightness, with an estimated prevalence of up to one-fifth of patients with asthma. Both conditions can be comorbid with asthma, and there is evidence that they are misdiagnosed and mistreated as asthma. This study aims to explore whether the symptoms of ILO and BPD were topics of discussion in a UK asthma online health community and patient experiences of diagnosis and treatment, in particular their use of reliever inhalers. A qualitative thematic analysis was performed with posts from an asthma community between 2018 and 2022. A list of key ILO or BPD symptoms was created from the literature. Posts were identified using the search terms "blue inhaler" and "breath" and included if describing key symptoms. Discussion threads of included posts were also analyzed. The search retrieved a total of 1127 relevant posts: 1069 written by 302 users and 58 posted anonymously. All participants were adults, except 2 who were parents writing about their children. Sex and age were only available for 1.66% (5/302; 3 females and 2 males) and 9.93% (30/302) of participants (27 to 73 years old), respectively. The average number of posts written by each participant was 3.54 (range 1-63). Seven participants wrote >20 posts each. Participants experiencing undiagnosed ILO or BPD symptoms, whether or not comorbid with asthma, expressed frustration with the "one-size-fits-all" approach to diagnosis, as many felt that their asthma diagnosis did not fully explain symptoms. Some suspected or were formally diagnosed with BPD or ILO, the latter reporting relief on receiving a diagnosis and appropriate management. Participants showed awareness of their inappropriate salbutamol use or overuse due to lack of effect on symptoms. BPD and ILO symptoms were frequently comorbid with asthma. The asthma online community was a valuable resource: engagement with peers not only brought comfort but also prompted action with some going back to their clinicians and reaching a diagnosis and appropriate management. Undiagnosed ILO and BPD symptoms and lack of effects of asthma treatment were topics of discussion in an asthma online community, caused distress and frustration in participants, and affected their relationship with health care professionals, showing that patients experiencing BPD and ILO have unmet needs. Clinicians' education on BPD and ILO diagnosis and management, as well as increased access to appropriate management options, such as respiratory physiotherapy and speech and language therapy, are warranted particularly in primary care. Qualitative evidence that engagement with the online community resulted in patients taking action going back to their clinicians and reaching a diagnosis of ILO and BPD prompts future research on online peer support from an established online health community as a self-management resource for patients.

Applying behaviour change theory to speech and language therapy intervention for inducible laryngeal obstruction.

Speech and language therapists (SLTs) provide interventions for inducible laryngeal obstruction (ILO) despite a current lack of evidence to inform intervention delivery. This study is the first step to develop an evidence-based intervention for ILO, using behaviour change theory and the Behaviour Change Technique Taxonomy version 1 (BCTTv1). Outcomes will inform the early development stage of a complex speech and language therapy intervention for ILO, enabling more precise reporting of ILO intervention studies, as per CONSORT guidelines. (1) To identify whether the BCTTv1 is a useful tool for characterising speech and language therapy interventions for ILO, based on existing literature, current practice and patient interviews. (2) To identify key behaviour change techniques (BCT) used within existing complex speech and language therapy interventions for ILO METHODS AND PROCEDURES: A five-phase study was conducted: (1) a systematic literature search of six electronic databases (Medline, EMBASE, CINAHL (EBSCO), Scopus, Trip, Web of Science) and grey literature between 2008 and 2020; (2) observations of six speech and language therapy intervention sessions; (3) a semi-structured interview with an SLT to validate the observed BCTTs; (4) consensus from four national expert SLTs regarding application of synthesised BCTT data to their own experiences of ILO interventions; and (5) patient engagement to review and comment on findings. Forty-seven BCTs in total were coded across all three sources. Thirty-two BCTs were identified in clinical observations; 31 in interviews with SLTs and 18 in the literature. Only six BCT were identified in all three sources. Expert SLTs confirmed clinical application and relevance. Patients reported finding the concept of BCT challenging but highlighted the value of psychoeducation to support their understanding of symptoms and in turn to understand the rationale behind speech and language therapy intervention recommendations. This study indicates that the BCTTv1 is a suitable framework to identify and describe intervention components used within speech and language therapy interventions for ILO. A practice-research gap exists, reinforcing that existing literature does not capture the complexity of speech and language therapy intervention for ILO. Further research is needed to develop our understanding of the BCTs that support optimal behaviour change for this patient group. What is already known on the subject There is growing recognition for the value of speech and language therapists (SLTs) in delivering complex interventions for patients with inducible laryngeal obstruction (ILO), including evidence to suggest that their intervention can improve quality of life for patients and reduce excessive healthcare use. There are, however, no randomised controlled trials in this field; thus it is unclear what constitutes the most effective intervention. What this study adds This study demonstrates the complexity of speech and language therapy interventions for ILO and highlights the practice-research gap. It identifies a range of behaviour change techniques that are used in existing practice and captures patient views relating to the components identified within this study. What are the clinical implications of this work? Findings highlight the value of providing education about factors that might be driving ILO symptoms and in turn the importance of sharing with patients the rationale for treatment recommendations that necessitate a change in their behaviours. Identified behaviour change techniques can be used when developing and implementing SLT interventions for ILO.

Letter from Norway

Letter from Norway

Management of difficult-to-treat asthma in adolescence and young adults.

The period of adolescence and young adulthood (AYA) has been proposed to extend from 11 to 25 years of age as patients in this age group face similar challenges. AYA is a time of fast and great physiological and psychological growth, in which an individual transitions from a young dependent child to a mature independent adult. Behaviour patterns during adolescence, such as risk taking and desire for privacy, can challenge parents or healthcare professionals' (HCPs') ability to help adolescents to manage their asthma. Asthma itself tends to remit, become milder or worsen into a severe variant during adolescence. The pre-pubertal male predominance of asthma switches to a female predominance in late teen years. ∼10% of AYA with asthma have "difficult-to-treat asthma (DTA)", characterised by poor asthma control despite treatment with inhaled corticosteroids (ICS) and other controller medications. DTA management in AYA requires a multidisciplinary team approach and systematic assessment that can address the key questions of objective confirmation of diagnosis, severity assessment, phenotyping, comorbidities, asthma mimickers or other drivers of poor control such as non-adherence to treatment. A key task for HCPs is to establish the magnitude of the severe asthma component versus other non-asthma drivers of symptoms (e.g. inducible laryngeal obstruction or breathing pattern disorder). Severe asthma is a subset of DTA and is determined once asthma diagnosis and its severity have been confirmed and adherence to controller (ICS) treatment has been assured. Severe asthma is a heterogeneous disease and appropriate phenotyping is necessary for the management of treatable traits and consideration for biologic therapies. Finally, an important part of successful management of DTA in the AYA group is the provision of an effective transition of asthma care from paediatric to adult asthma services through setting up a well-designed asthma transition pathway tailored to the individual patient needs.

Severe asthma, more than that?

I was recently invited to write about the development of asthma management in the past decade. Biologic therapy came to my mind, and I was fascinated by the concept that asthma remission can potentially be achieved with this treatment (https://erj.ersjournals.com/content/early/2022/03/17/13993003.02583-2021). At the same time, I reflected on the management of one of my patients with severe asthma treated with biologics and the importance of looking for and managing comorbidities when treating patients with severe asthma. She was a young lady, and it was after more than a year of treatment with various agents for severe asthma, including high-dose inhaled corticosteroids, long-acting beta-agonist, anti-muscarinic agent, montelukast, azithromycin, systemic steroid and biologics (two biologics, started with one and then changed to the other with lack of effect) that we made the diagnosis of inducible laryngeal obstruction (ILO) (https://erj.ersjournals.com/content/50/3/1602221) that was causing the recurrent ‘asthma exacerbations’ and ICU admissions. Correct diagnosis is crucial for the treatment of asthma. However, having a confirmed diagnosis of asthma does not mean that it is the sole cause of respiratory symptoms/asthma exacerbations. This lady had features typical of asthma, including positive bronchodilator reversibility and her lung function varied with time with lower FEV1 at times of poor control or attacks. She also had Type-2 high asthma with high eosinophil blood count and exhaled nitric oxide levels. At the start of the illness, the patient improved with systemic steroid during hospitalisations. We did our usual workup for assessing comorbidities, such as looking for rhinitis and gastroesophageal reflux disease and excluded eosinophilic granulomatosis with polyangiitis. However, the young lady subsequently had more ‘asthma attacks’, and those episodes required ICU care, but no intubation was ever needed. Given the recurrent ICU admissions despite optimal pharmacotherapy for asthma, we have performed extensive investigations to exclude other diseases, including CT thorax, blood tests, echocardiogram and sleep study. During one of the ICU admissions, the patient was noted to have a low tidal and a high respiratory rate while on non-invasive pressure ventilation (NIV). Arterial blood gas taken during the ‘attacks’ showed respiratory acidosis with elevated pCO2 and normal alveolar-arterial gradient. The ‘attacks’ did not improve with asthma medications but responded to oxygen supplementation and NIV. We suspected ILO and were able to prove that by laryngoscopy. The patient had several ‘attacks’ of breathlessness afterwards, which were improved by benzodiazepines. We have thus stopped the unnecessary asthma medications for this patient, including biologics. The ILO was managed by speech therapist, psychologist, psychiatrist and ENT surgeon. Not every patient needs extensive investigations to search for comorbidities, but how far we need to go for patients with recurrent ‘asthma attacks’ would need clinical judgement and a personalized approach. Also, we have to think about ILO earlier in patients with severe asthma not responding well to therapy. We currently have potent medications, including biologics, for treating severe asthma, but we must ensure that these are given to the right patient. None declared.

Inducible laryngeal obstruction: detection and management

Inducible laryngeal obstruction (ILO) is a phenomenon of paradoxical upper airway closure during breathing causing respiratory distress and a noisy breathing. It most often appears during maximal exertion but can also be induced by inhalation of irritants, pharyngolaryngeal reflux or stressful situations. It can sometimes be confused with an acute asthma attack. The gold standard investigation is a videolaryngoscopy during ergometry which can confirm the diagnosis, allowing appropriate treatment. The aim of this article is to describe the pathophysiology of ILO and to discuss paraclinical examinations and treatment options.

A CASE OF INDUCIBLE LARYNGEAL OBSTRUCTION UNSUCCESSFULLY TREATED AS SEVERE ASTHMA WAS WELL CONTROLLED AFTER APPROPRIATE DIAGNOSIS AND INSTRUCTION OF THERAPEUTIC BREATHING MANEUVERS

Inducible laryngeal obstruction (ILO) refers to respiratory disorders caused by airflow limitation in the larynx, including vocal cord dysfunction, and may sometimes be misdiagnosed as bronchial asthma (BA). Here, we report the case of an 11-year-old boy diagnosed with BA in infancy. He was referred to our Allergy Center and was taking a high dose of inhaled corticosteroids (ICS) due to frequent coughing from the age of 10 years and persistent coughing following COVID-19 infection at the age of 11. However, the patient continued to experience frequent coughing attacks and repeated visits to the emergency department after inhalation of β2-stimulants failed to improve his cough. We admitted him to the allergy center for examinations to assess the BA severity. In the airway hypersensitiveness test, saline inhalation performed prior to methacholine inhalation caused expiratory stridor and respiratory distress in the larynx, which worsened with β2-stimulant inhalation. Based on these results, we ruled out BA and diagnosed ILO. We instructed him on breathing maneuvers, and he was able to respond appropriately when symptoms appeared. We then started reducing his ICS dose.

Paroxysmal dyspnoea in asthma: Wheeze, ILO or dysfunctional breathing?

Paroxysms of dyspnoea in the general population are commonly reported and are frequently assumed to be asthma-related, especially if this diagnostic label has been previously applied. Often, this is not the case. Inducible Laryngeal Obstruction (ILO) and Dysfunctional Breathing (DB) are common comorbid conditions that go unrecognised in many difficult-to-treat asthmatics. On average, these patients have a delay in diagnosis of almost 5 years. This delay, along with ineffective, inappropriate escalation of asthma therapy, frequent hospital presentations for uncontrolled symptoms, and even intensive care admissions, magnifies patient morbidity and poor quality of life. ILO and DB have similar presentations and triggers to asthma. Differentiating between them can be challenging, especially in centres that do not have access to multidisciplinary subspecialty asthma services. Objectively confirming the diagnosis can likewise be challenging as symptoms fluctuate, and gold-standard investigations require extensive experience. This mini-review will summarise the clinical features of ILO and DB, with particular focus in the context of individuals treated for asthma. This narrative review will define each condition, highlight poignant aspects of the history and describe elements of the diagnostic pathway to gain objective confirmation.