Treatment of Exercise-induced Laryngeal Obstruction : Exploring modalities in short and long term

Background: Exercise-induced laryngeal obstruction (EILO) is an umbrella term describing inappropriate and transient closure of laryngeal structures during exercise, causing breathlessness and/or noisy respiration (stridor). EILO is a relatively prevalent entity, affecting adolescents or young adults in all activity levels. The condition has been reported to have a considerable functional impact, particularly as a limitation of physical activity in an effort to minimize the occurrence and severity of inspiratory symptoms. Objective visualization of the laryngeal obstruction and determining the level of obstruction within the larynx (supraglottic and/or glottic) during ongoing exercise is considered gold-standard for diagnosing EILO and seems of importance for subsequent treatment planning. Treatment options are based on weak evidence, with evaluation of different modalities mainly based on subjective outcomes. Information about the diagnosis and breathing advice (IBA) seems to be fundamental elements. Small studies and case reports suggests effect from speech therapy, biofeedback, inspiratory muscle training (IMT) and surgical supraglottoplasty. Robust treatment algorithms and follow-up streams are yet to be established. Aims: The overall aim of the thesis was to explore improvement of symptoms and laryngeal obstruction in EILO patients treated with IMT and supraglottoplasty in short- and long term. Study #I: To investigate laryngeal response pattern(s) during inspiratory muscle training (IMT) in healthy subjects using laryngoscopic evaluation and imaging. Study #II: To expand our knowledge and to explore possible effects from inspiratory muscle training in patients diagnosed with EILO. Study #III: To investigate the efficacy and safety of laser supraglottoplasty for patients with supraglottic EILO, using continuous laryngoscopy exercise (CLE) tests before and after surgery. Study #IV: To assess changes of self-reported symptoms and laryngeal outcomes shortly after IMT, and to compare self-reported symptoms with a control group 4-6 years later. Methods: Study design: An explorative approach with combined descriptive and quasi-experimental observational design. Study #I: cross-sectional study, Study #II: prospective pre-post study Study #III: retrospective pre-post study. Study #IV: follow-up study. Subjects and study procedures: Study #I: Twenty healthy volunteers examined with laryngoscopy during inspiratory muscle training (IMT). The laryngeal movements were retrospectively assessed from video files. Study# II and #III: EILO patients examined with continuous laryngoscopy exercise (CLE)-test before and after a treatment; six-week training program with IMT or supraglottoplasty. Outcome data were self-reported symptom scores and laryngeal obstruction (by CLE-scores from video recordings). Study #IV: Two groups were retrospectively identified from the EILO-register; one group receiving IBA only at diagnosis, and the other additionally receiving six weeks of IMT (IBA+IMT). Laryngeal outcome was assessed shortly after IMT, and the two groups’ self-reported symptoms were compared with a new questionnaire 4-6 years later. Results: Study #I: IMT facilitated laryngeal abduction in the investigated healthy subjects and application of medium intensity resistance seemed superior to higher resistance in opening of the laryngeal aperture. Study #II: IMT was safe and the perceived symptoms and laryngeal obstruction improved in subgroups of EILO after IMT, with improvement mainly observed at the glottic level. Study #III: Supraglottoplasty improved symptoms and reduced laryngeal obstruction in the investigated patients with predominantly supraglottic EILO and appeared safe in highly selected severe cases. Notably, supraglottoplasty might improve also glottic obstruction in patients with combined supraglottic and glottic obstruction. Study #IV: The response rate after 4-6 years was 40 % in the IBA-group and 55% in IBA+IMT-group. After 2-4 weeks, 23/32 in the IBA+IMT-group reported symptom improvements, associated mainly with glottic changes, contrasting unchanged laryngeal scores in 9/32 without symptom improvements. After 4-6 years, self-reported exercise-related symptoms and activity had decreased to similar levels in both groups. Full symptom resolution was reported by 8/55. Conclusion: Self-reported symptoms and laryngeal obstruction as observed and rated in CLE-tests can improve in EILO patients treated with IBA, IMT or supraglottoplasty. Heterogeneous responses to treatment were observed and substantiates that EILO is a heterogeneous condition, thus it is unlikely that one mode of treatment will work in all. Individual treatment and follow-up based on laryngeal findings seems essential. Future controlled studies with longer follow-up time are needed to establish effects from the treatment modalities applied in EILO patients. This work provides hypotheses that may serve as a basis in doing so.Doktorgradsavhandlin

Då Lisa gjekk til skulen - igjen! : om kombinasjonsstudenten på desentralisert og delvis nettbasert førskule- og allmennlærarutdanning ved Høgskulen i Sogn og Fjordane.

Rapporten er ei internevaluering av desentralisert og delvis nettbasert førskule- og almennlærarutdanning ved HSF, avdeling for lærarutdanning og idrett. Evalueringa følgjer studentar i første året, og systematiserer røynsler studentar og tilsette har med studietilbodet. Datainnsamlinga er basert på kvalitativ metode. Vi intervjuar eit utval studentar, lærarar og administrativt tilsette, vi observerer studentar i arbeid i lokalgrupper og nyttar tekstar frå dagbøker skrivne av studentar på gitte tidspunkt

Hvordan kan samtale om seksualitet inngå som en integrert del av sykepleien til pasienter som har gjennomgått gynekologisk kreft?

Sammendrag Bakgrunn Om lag 1500 kvinner blir diagnostisert med gynekologisk kreft hvert år i Norge. Flere lever med plager og senkomplikasjoner som følge av gynekologisk kreft og behandlingen av den. Pasienter ønsker et større fokus rundt emnet og etterlyser informasjon om kreft og behandlingens påvirkning på den seksuelle helsen. Helsepersonell har et lovpålagt ansvar å ivareta pasientenes helhetlige behov, men til tross for denne plikten viser det seg at dette sjeldent blir gjort. I denne studien ønsker vi å undersøke hva som gjør at sykepleierne ikke tar opp temaet i møtet med pasienter med gynekologisk kreft. Hensikt Hensikten med oppgaven er å få en dypere forståelse for dagens praksis når det gjelder samtalen om seksualitet i møte med pasienter med gynekologisk kreft. Vi ønsker med dette å få frem hva som må til for at pasienten skal oppleve å bli møtt av sykepleiere som ivaretar denne funksjonen. Metode For å besvare vår oppgave har vi benyttet oss av litteraturstudie som metode. Resultatene fra de valgte forskningsartiklene, relevant faglitteratur og egne refleksjoner utgjør grunnlaget for besvarelsen i vår bacheloroppgave. Resultater Resultatene fra de utvalgte studiene viser at sykepleierne er usikre på hvem som har ansvaret for å snakke med pasienter om seksuelle problemer. De trekker frem mangel på ansvarsavklaring, dårlig tilrettelagte fasiliteter for å kunne gjennomføre samtalen uforstyrret, og mangel på tid. I tillegg rapporteres det om mangel på kunnskap, utdanning og erfaring som gjør sykepleierne usikre. Vi mener derfor at sykepleierne har behov for bedre rutiner, økt kunnskap, trygghet og bevisstgjøring for egne holdninger og tanker i møte med pasientgruppen

Pulmonal tularemi

publishedVersio

Exercise related respiratory problems in the young—Is it exercise-induced bronchoconstriction or laryngeal obstruction?

Complaints of breathlessness during heavy exercise is common in children and adolescents, and represent expressions of a subjective feeling that may be difficult to verify and to link with specific diagnoses through objective tests. Exercise-induced asthma and exercise-induced laryngeal obstruction are two common medical causes of breathing difficulities in children and adolescents that can be challenging to distinguish between, based only on the complaints presented by patients. However, by applying a systematic clinical approach that includes rational use of tests, both conditions can usually be diagnosed reliably. In this invited mini-review, we suggest an approach we find feasible in our everyday clinical work.publishedVersio

Clinical responses following inspiratory muscle training in exercise-induced laryngeal obstruction

Purpose Exercise-induced laryngeal obstruction (EILO) is relatively common in young people. Treatment rests on poor evidence; however, inspiratory muscle training (IMT) has been proposed a promising strategy. We aimed to assess laryngeal outcomes shortly after IMT, and to compare self-reported symptoms with a control group 4–6 years later. Methods Two groups were retrospectively identified from the EILO-register at Haukeland University Hospital, Norway; one group had received only information and breathing advice (IBA), and another additionally IMT (IBA + IMT). At diagnosis, all participants performed continuous laryngoscopy during exercise (CLE), with findings split by glottic and supraglottic scores, and completed a questionnaire mapping exercise-related symptoms. After 2–4 weeks, the IBA + IMT-group was re-evaluated with CLE-test. After 4–6 years, both groups were re-assessed with a questionnaire. Results We identified 116 eligible patients from the EILO-register. Response rates after 4–6 years were 23/58 (40%) and 32/58 (55%) in the IBA and IBA + IMT-group, respectively. At diagnosis, both groups rated symptoms similarly, but laryngeal scores were higher in the IBA + IMT-group (P = 0.003). After 2–4 weeks, 23/32 in the IBA + IMT-group reported symptom improvements, associated with a decrease of mainly glottic scores (1.7–0.3; P < 0.001), contrasting unchanged scores in the 9/32 without symptom improvements. After 4–6 years, exercise-related symptoms and activity levels had decreased to similar levels in both groups, with no added benefit from IMT; however, full symptom resolution was reported by only 8/55 participants. Conclusion Self-reported EILO symptoms had improved after 4–6 years, irrespective of initial treatment. Full symptom resolution was rare, suggesting individual follow-up should be offered.publishedVersio

Exercise-induced Laryngeal Obstruction: Protocol for a Randomized Controlled Treatment Trial

Background: Exercise-induced laryngeal obstruction (EILO) is a common cause of exertional breathing problems in young individuals, caused by paradoxical inspiratory adduction of laryngeal structures, and diagnosed by continuous visualization of the larynx during high-intensity exercise. Empirical data suggest that EILO consists of different subtypes, possibly requiring different therapeutic approaches. Currently applied treatments do not rest on randomized controlled trials, and international guidelines based on good evidence can therefore not be established. This study aims to provide evidence-based information on treatment schemes commonly applied in patients with EILO. Methods and Analysis: Consenting patients consecutively diagnosed with EILO at Haukeland University Hospital will be randomized into four non-invasive treatment arms, based on promising reports from non-randomized studies: (A) standardized information and breathing advice only (IBA), (B) IBA plus inspiratory muscle training, (C) IBA plus speech therapy, and (D) IBA plus inspiratory muscle training and speech therapy. Differential effects in predefined EILO subtypes will be addressed. Patients failing the non-invasive approach and otherwise qualifying for surgical treatment by current department policy will be considered for randomization into (E) standard or (F) minimally invasive laser supraglottoplasty or (G) no surgery. Power calculations are based on the main outcomes, laryngeal adduction during peak exercise, rated by a validated scoring system before and after the interventions. Ethics and Dissemination: The study will assess approaches to EILO treatments that despite widespread use, are insufficiently tested in structured, verifiable, randomized, controlled studies, and is therefore considered ethically sound. The study will provide knowledge listed as a priority in a recent statement issued by the European Respiratory Society, requested by clinicians and researchers engaged in this area, and relevant to 5–7% of young people. Dissemination will occur in peer-reviewed journals, at relevant media platforms and conferences, and by engaging with patient organizations and the healthcare bureaucracy.publishedVersio

Treatment of Exercise-induced Laryngeal Obstruction : Exploring modalities in short and long term

Background: Exercise-induced laryngeal obstruction (EILO) is an umbrella term describing inappropriate and transient closure of laryngeal structures during exercise, causing breathlessness and/or noisy respiration (stridor). EILO is a relatively prevalent entity, affecting adolescents or young adults in all activity levels. The condition has been reported to have a considerable functional impact, particularly as a limitation of physical activity in an effort to minimize the occurrence and severity of inspiratory symptoms. Objective visualization of the laryngeal obstruction and determining the level of obstruction within the larynx (supraglottic and/or glottic) during ongoing exercise is considered gold-standard for diagnosing EILO and seems of importance for subsequent treatment planning. Treatment options are based on weak evidence, with evaluation of different modalities mainly based on subjective outcomes. Information about the diagnosis and breathing advice (IBA) seems to be fundamental elements. Small studies and case reports suggests effect from speech therapy, biofeedback, inspiratory muscle training (IMT) and surgical supraglottoplasty. Robust treatment algorithms and follow-up streams are yet to be established. Aims: The overall aim of the thesis was to explore improvement of symptoms and laryngeal obstruction in EILO patients treated with IMT and supraglottoplasty in short- and long term. Study #I: To investigate laryngeal response pattern(s) during inspiratory muscle training (IMT) in healthy subjects using laryngoscopic evaluation and imaging. Study #II: To expand our knowledge and to explore possible effects from inspiratory muscle training in patients diagnosed with EILO. Study #III: To investigate the efficacy and safety of laser supraglottoplasty for patients with supraglottic EILO, using continuous laryngoscopy exercise (CLE) tests before and after surgery. Study #IV: To assess changes of self-reported symptoms and laryngeal outcomes shortly after IMT, and to compare self-reported symptoms with a control group 4-6 years later. Methods: Study design: An explorative approach with combined descriptive and quasi-experimental observational design. Study #I: cross-sectional study, Study #II: prospective pre-post study Study #III: retrospective pre-post study. Study #IV: follow-up study. Subjects and study procedures: Study #I: Twenty healthy volunteers examined with laryngoscopy during inspiratory muscle training (IMT). The laryngeal movements were retrospectively assessed from video files. Study# II and #III: EILO patients examined with continuous laryngoscopy exercise (CLE)-test before and after a treatment; six-week training program with IMT or supraglottoplasty. Outcome data were self-reported symptom scores and laryngeal obstruction (by CLE-scores from video recordings). Study #IV: Two groups were retrospectively identified from the EILO-register; one group receiving IBA only at diagnosis, and the other additionally receiving six weeks of IMT (IBA+IMT). Laryngeal outcome was assessed shortly after IMT, and the two groups’ self-reported symptoms were compared with a new questionnaire 4-6 years later. Results: Study #I: IMT facilitated laryngeal abduction in the investigated healthy subjects and application of medium intensity resistance seemed superior to higher resistance in opening of the laryngeal aperture. Study #II: IMT was safe and the perceived symptoms and laryngeal obstruction improved in subgroups of EILO after IMT, with improvement mainly observed at the glottic level. Study #III: Supraglottoplasty improved symptoms and reduced laryngeal obstruction in the investigated patients with predominantly supraglottic EILO and appeared safe in highly selected severe cases. Notably, supraglottoplasty might improve also glottic obstruction in patients with combined supraglottic and glottic obstruction. Study #IV: The response rate after 4-6 years was 40 % in the IBA-group and 55% in IBA+IMT-group. After 2-4 weeks, 23/32 in the IBA+IMT-group reported symptom improvements, associated mainly with glottic changes, contrasting unchanged laryngeal scores in 9/32 without symptom improvements. After 4-6 years, self-reported exercise-related symptoms and activity had decreased to similar levels in both groups. Full symptom resolution was reported by 8/55. Conclusion: Self-reported symptoms and laryngeal obstruction as observed and rated in CLE-tests can improve in EILO patients treated with IBA, IMT or supraglottoplasty. Heterogeneous responses to treatment were observed and substantiates that EILO is a heterogeneous condition, thus it is unlikely that one mode of treatment will work in all. Individual treatment and follow-up based on laryngeal findings seems essential. Future controlled studies with longer follow-up time are needed to establish effects from the treatment modalities applied in EILO patients. This work provides hypotheses that may serve as a basis in doing so

Fellesskap og menighetsutvikling i storbyen : en casestudie av Trefoldighet menighet i Oslo

Utgangspunktet for denne avhandlingen var mitt møte med Trefoldighet menighet gjennom noen av deres Storbymesser i 2008. Jeg ble nysgjerrig på denne menigheten som la stor vekt på diakonalt arbeid, en gjennomarbeidet liturgi og livsnær forkynnelse. Denne nysgjerrigheten falt sammen med min økende interesse for kirkelig fellesskap generelt. En masteroppgave i diakoni ble muligheten til å undersøke dette i sammenheng. Det var altså ikke slik at jeg bestemte tema først, for så å sette opp utvalgskriterier jeg deretter valgte casemenighet ut i fra. Utgangspunktet var interessen for et spesifikt, lokalt miljø som hadde gjennomgått et konkret utviklingsforløp, noe religionssosiologen Repstad beskriver som et vanlig startsted for kvalitative studier. Jeg ville undersøke en menighet som ingen andre hadde gjort en casestudie av før, og som skilte seg såpass ut i flokken av statskirkemenigheter ved sin spesielle soknesituasjon (svært lite arbeid med kasualia), og ved det faktum at den trakk mellom 300-500 besøkende på noen av sine månedlige gudstjenester. Retningen for avhandlingen, problemstilling og teoretiske fortolkningsrammer valgte jeg i etterkant av denne første interessen for å skrive om Trefoldighet. Jeg visste ikke på forhånd hva som ville komme ut av en slik undersøkelse, og stilte meg åpen for det jeg måtte finne. Samtidig regnet jeg med å få innsikt i både positive og negative erfaringer, slik det ofte er med utviklingsprosesser i organisasjoner

Exercise related respiratory problems in the young—Is it exercise-induced bronchoconstriction or laryngeal obstruction?

Complaints of breathlessness during heavy exercise is common in children and adolescents, and represent expressions of a subjective feeling that may be difficult to verify and to link with specific diagnoses through objective tests. Exercise-induced asthma and exercise-induced laryngeal obstruction are two common medical causes of breathing difficulities in children and adolescents that can be challenging to distinguish between, based only on the complaints presented by patients. However, by applying a systematic clinical approach that includes rational use of tests, both conditions can usually be diagnosed reliably. In this invited mini-review, we suggest an approach we find feasible in our everyday clinical work