Triggers of Breathlessness in Inducible Laryngeal Obstruction and Asthma

BackgroundInducible laryngeal obstruction (ILO) is often misdiagnosed as, or may coexist with, asthma. Identifying differences in triggering factors may assist clinicians to differentiate between the two conditions, and could give mechanistic insights.ObjectiveTo identify and compare patient‐reported triggers in ILO and asthma.MethodsThis was a two‐part study. Initially we conducted a retrospective case note review of the triggers of ILO from endoscopically‐confirmed ILO patients to generate a Breathlessness Triggers Survey (BrTS). Triggers were categorised as: scents, environmental factors, temperature, emotions, mechanical factors and daily activities. Secondly, ILO and/or asthma patients completed the BrTS prospectively, rating the likelihood of each item triggering their symptoms using a five‐point Likert scale (strongly disagree to strongly agree). Chi‐square testing was performed to compare responses by cohort.ResultsData from 202 patients with ILO [73% female, mean (SD) age 53(16) years] were included in the case note review. For the prospective study, 38 patients with ILO‐only [63% females, age 57(16) years], 39 patients with asthma‐only [(56% female, age 53(13) years] and 12 patients with both ILO and asthma [83% female, mean age, 57 (14) years)] completed the BrTS. The triggers identified in the case note review were confirmed in the independent sample of patients with ILO and/or asthma and identified several difference in prevalence of the triggers between disease types. Mechanical factors [talking (

Utility of ultrasound in the assessment of swallowing and laryngeal function: A rapid review and critical appraisal of the literature

BACKGROUND: Ultrasound (US) is not widely used as part of the speech and language therapy (SLT) clinical toolkit. The COVID-19 pandemic has intensified interest in US as an alternative to SLT instrumental tools such as the videofluoroscopic swallowing study (VFSS), fibreoptic endoscopic evaluation of swallowing (FEES) and endoscopic evaluation of the larynx (EEL) as a non-invasive, non-aerosol-generating procedure that can be delivered at the bedside to assess swallowing and/or laryngeal function. To establish the appropriacy of routine US use, and in response to a national professional body request for a position statement, a group of expert SLTs conducted a rapid review of the literature. AIM: To explore critically the clinical utility of US as an assessment tool for swallowing and laryngeal function in adults. METHODS & PROCEDURES: A rapid review of four databases was completed to identify articles using US to assess swallowing and/or laryngeal function in adults compared with reference tests (VFSS/FEES/EEL/validated outcome measure). Screening was completed according to predefined inclusion/exclusion criteria and 10% of abstracts were rescreened to assess reliability. Data were extracted from full texts using a predeveloped form. The QUADAS-2 tool was used for quality ratings. Information from included studies was summarized using narrative synthesis and visual illustration. OUTCOMES & RESULTS: Ten papers used US to assess swallowing, and 13 to assess laryngeal function. All were peer-reviewed primary studies across a range of clinical populations and with a wide geographical spread. Four papers had an overall low risk of bias, but the remaining 19 had at least one domain where risk of bias was judged as high or unclear. Applicability concerns were identified in all papers. The papers that used US to assess swallowing varied widely in terms of the anatomical structures assessed and methodology employed. The papers assessing laryngeal function were more homogenous in their methodology. Sensitivity and specificity data were provided for 12 of the laryngeal function papers with ranges of 64.3–100% and 48.5–100%, respectively. CONCLUSIONS & IMPLICATIONS: There is burgeoning evidence to support the use of US as an adjunct to SLT clinical assessment of swallowing and laryngeal function. However, the current literature does not support its use as a tool in isolation. Further research is required to establish reliability in US assessment as well as clear SLT-driven protocols and training

Speech and language therapy for management of chronic cough

Background Cough both protects and clears the airway. Cough has three phases: breathing in (inspiration), closure of the glottis, and a forced expiratory effort. Chronic cough has a negative, far‐reaching impact on quality of life. Few effective medical treatments for individuals with unexplained (idiopathic/refractory) chronic cough (UCC) are known. For this group, current guidelines advocate the use of gabapentin. Speech and language therapy (SLT) has been considered as a non‐pharmacological option for managing UCC without the risks and side effects associated with pharmacological agents, and this review considers the evidence from randomised controlled trials (RCTs) evaluating the effectiveness of SLT in this context. Objectives To evaluate the effectiveness of speech and language therapy for treatment of people with unexplained (idiopathic/refractory) chronic cough. Search methods We searched the Cochrane Airways Trials Register, CENTRAL, MEDLINE, Embase, CINAHL, trials registries, and reference lists of included studies. Our most recent search was 8 February 2019. Selection criteria We included RCTs in which participants had a diagnosis of UCC having undergone a full diagnostic workup to exclude an underlying cause, as per published guidelines or local protocols, and where the intervention included speech and language therapy techniques for UCC. Data collection and analysis Two review authors independently screened the titles and abstracts of 94 records. Two clinical trials, represented in 10 study reports, met our predefined inclusion criteria. Two review authors independently assessed risk of bias for each study and extracted outcome data. We analysed dichotomous data as odds ratios (ORs), and continuous data as mean differences (MDs) or geometric mean differences. We used standard methods recommended by Cochrane. Our primary outcomes were health‐related quality of life (HRQoL) and serious adverse events (SAEs). Main results We found two studies involving 162 adults that met our inclusion criteria. Neither of the two studies included children. The duration of treatment and length of sessions varied between studies from four sessions delivered weekly, to four sessions over two months. Similarly, length of sessions varied slightly from one 60‐minute session and three 45‐minute sessions to four 30‐minute sessions. The control interventions were healthy lifestyle advice in both studies. One study contributed HRQoL data, using the Leicester Cough Questionnaire (LCQ), and we judged the quality of the evidence to be low using the GRADE approach. Data were reported as between‐group difference from baseline to four weeks (MD 1.53, 95% confidence interval (CI) 0.21 to 2.85; participants = 71), revealing a statistically significant benefit for people receiving a physiotherapy and speech and language therapy intervention (PSALTI) versus control. However, the difference between PSALTI and control was not observed between week four and three months. The same study provided information on SAEs, and there were no SAEs in either the PSALTI or control arms. Using the GRADE approach we judged the quality of evidence for this outcome to be low. Data were also available for our prespecified secondary outcomes. In each case data were provided by only one study, therefore there were no opportunities for aggregation; we judged the quality of this evidence to be low for each outcome. A significant difference favouring therapy was demonstrated for: objective cough counts (ratio for mean coughs per hour on treatment was 59% (95% CI 37% to 95%) relative to control; participants = 71); symptom score (MD 9.80, 95% CI 4.50 to 15.10; participants = 87); and clinical improvement as defined by trialists (OR 48.13, 95% CI 13.53 to 171.25; participants = 87). There was no significant difference between therapy and control regarding subjective measures of cough (MD on visual analogue scale of cough severity: −9.72, 95% CI −20.80 to 1.36; participants = 71) and cough reflex sensitivity (capsaicin concentration to induce five coughs: 1.11 (95% CI 0.80 to 1.54; participants = 49) times higher on treatment than on control). One study reported data on adverse events, and there were no adverse events reported in either the therapy or control arms of the study. Authors' conclusions The paucity of data in this review highlights the need for more controlled trial data examining the efficacy of SLT interventions in the management of UCC. Although a large number of studies were found in the initial search as per protocol, we could include only two studies in the review. In addition, this review highlights that endpoints vary between published studies. The improvements in HRQoL (LCQ) and reduction in 24‐hour cough frequency seen with the PSALTI intervention were statistically significant but short‐lived, with the between‐group difference lasting up to four weeks only. Further studies are required to replicate these findings and to investigate the effects of SLT interventions over time. It is clear that SLT interventions vary between studies. Further research is needed to understand which aspects of SLT interventions are most effective in reducing cough (both objective cough frequency and subjective measures of cough) and improving HRQoL. We consider these endpoints to be clinically important. It is also important for future studies to report information on adverse events. Because of the paucity of data, we can draw no robust conclusions regarding the efficacy of SLT interventions for improving outcomes in unexplained chronic cough. Our review identifies the need for further high‐quality research, with comparable endpoints to inform robust conclusions

Investigation of co-morbid factors in patients with vocal cord dysfunction (VCD)

Background: Differential diagnosis of asthma and VCD can be challenging. Previous research (e.g. Newman, Mason & Schmaling, 1995) has suggested a number of risk factors for VCD. Aims and Objectives: To compare co-morbidity characteristics of patients with complex breathlessness referred to a tertiary Airways service. To analyse whether specific factors are associated with an increased likelihood of confirming a diagnosis of VCD. Methods: Descriptive and correlational statistics were used to analyse patient characteristics and co-morbid factors in a sample of 155 patients, of whom 83 had confirmed VCD. A logistic regression analysis was used to identify significant predictor variables for VCD. Results: The majority of patients diagnosed with VCD were female (72%). A high proportion of these patients had reflux (49%), rhinitis (41%) and/or co-morbid asthma (33%). Partial correlations showed that Forced Vital Capacity percent (FVC%) within lung function tests was significantly correlated with a diagnosis of VCD (rs= 0.329, n=73, p=0.005). Age, gender, reflux, rhinitis and Forced Expiratory Volume 1 percent were not significantly correlated with VCD diagnosis. A logistic regression was performed to assess the impact of FVC% on diagnosis of VCD. The model was significant: χ 2 (1, N=73) =10.38, p=0.001. The model explained between 13.3% and 21.8% of the variance in VCD diagnosis, and correctly classified 83.6% of cases. Conclusions: A number of possible co-morbid factors were identified. Lung function, as described by FVC%, was found to be a significant predictor for VCD diagnosis in a sample of patients with complex breathlessness. This measure may be useful in the differential diagnosis of asthma and VCD

Can patient factors predict response to speech and language therapy for inducible laryngeal obstruction?

Introduction Inducible laryngeal obstruction (Ilo) is defined as an inappropriate adduction of the larynx on inspiration. Speech and language therapy (SLT) is viewed as the cornerstone of treatment of Ilo. Clinical consensus indicates that the optimal number of SLT sessions is between four and six. Our previous research has shown that% Forced Vital Capacity (% FVC) is a reliable predictor of Ilo in patients with breathlessness referred to our tertiary airways service (ERS Congress, 2017). In our current research, we aimed to investigate whether% FVC and other patient factors can predict improvement in Ilo symptoms following SLT intervention. Methods Data were analysed from 59 patients presenting to our service with symptoms of breathlessness. All had a diagnosis of Ilo via videolaryngoscopy and received SLT treatment. Analyses investigated relationships between improvement on Ilo symptoms and% FVC as well as other patient details. The VCDQ, a validated questionnaire measuring Ilo symptoms and response to SLT, was used pre- and post-therapy to assess improvement. Results VCDQ scores decreased following SLT for forty (68%) patients, demonstrating improvement. Of patients who improved, the mean number of SLT sessions was four, with the majority (60%) attending three to five sessions. No relationships were found between post-SLT improvement on the VCDQ and patient factors including age, gender, and potential co-morbidities such as asthma, GORD and rhinitis. There was a significant relationship between% FVC and VCDQ improvement (r=0.346, n=51, p=0.01). A binary logistic regression assessed the impact of% FVC on VCDQ improvement. The model was significant (χ 2=6.337 (1, n=59) p=0.012), and explained between 12% and 16% of the variance in improvement, correctly classifying 69% of cases. Patients with higher% FVC were five times more likely to show improvement on the VCDQ following SLT. Conclusions In line with clinical consensus, 3 to 5 sessions of SLT were sufficient to lead to improvements on VCDQ scores for the majority of patients. Patient demographic data did not predict improvements in Ilo following SLT, however% FVC may be a predictor of good treatment response to SLT for Ilo

Relationships between onset factors for inducible laryngeal obstruction and laryngeal obstruction initiation timing

Introduction Inducible laryngeal obstruction (Ilo) is defined as inappropriate adduction of the vocal cords on inspiration. Currently, there is no agreed aetiology for Ilo described in literature. Exploration of relationships between patient-reported onset factors and Ilo classification on video laryngoscopy may further understanding of the nature and causes of Ilo. Previous research by our Tertiary Airways service described patient-reported Ilo onset factors in a five category taxonomy: Respiratory, Medical, Psychological, Irritant and Exercise (BTS Winter Meeting, 2017), and classified laryngeal presentation of Ilo on videolaryngoscopy according to the ERS/ACCP (2014) International Consensus nomenclature (BTS Winter Meeting, 2017), including speed of initiation of Ilo symptoms (i.e. fast or slow). Aims and objectives To explore possible relationships between Ilo onset factors and observed speed of Ilo initiation as seen on laryngoscopy. Methods Self-reported Ilo onset factors for 102 patients were compared with videolaryngoscopy classification of initiation timing of Ilo. Results There were significant relationships between Ilo initiation speed and certain onset factors. ‘Slow’ initiation was associated with Medical (e.g. surgery, medication) onset factors (χ 2=4.627, df=1, p=0.031). ‘Fast’ initiation was associated with Respiratory (e.g. Asthma, chest infection) onset factors (χ 2=7.976; df=1; p=0.005). A binary logistic regression assessed the impact of these onset factors on initiation speed. The model was significant (χ2=12 (2, n=102) p=0.002), and explained between 11% and 16% of the variance in onset timing, correctly classifying 74% of cases. Patients with Medical onset factors were five times more likely to have fast Ilo initiation, whilst patients with Respiratory onset factors were two and a half time as likely to have slow Ilo initiation. Conclusions Comparing Ilo onset factors with initiation speed highlighted associations which may help to elucidate relationships between onset factors and subsequent Ilo presentation. The ‘slow’ pattern associated with Medical onset factors may suggest a steady-state physiological or neuropathic aetiology, whereas the ‘fast’ pattern, associated with Respiratory onset factors may indicate mechanisms related to airway hyper-responsiveness