High prevalence of exercise-induced stridor during Parkrun: a cross-sectional field-based evaluation.

BACKGROUND AND OBJECTIVE: The differential diagnosis for exercise-associated breathlessness is broad, however, when a young athletic individual presents with respiratory symptoms, they are most often prescribed inhaler therapy for presumed exercise-induced asthma (EIA). The purpose of this study was therefore to use a novel sound-based approach to assessment to evaluate the prevalence of exertional respiratory symptoms and characterise abnormal breathing sounds in a large cohort of recreationally active individuals. METHODS: Cross-sectional field-based evaluation of individuals completing Parkrun. PHASE 1: Prerace, clinical assessment and baseline spirometry were conducted. At peak exercise and immediately postrace, breathing was monitored continuously using a smartphone. Recordings were analysed retrospectively and coded for signs of the predominant respiratory noise. PHASE 2: A subpopulation that reported symptoms with at least one audible sign of respiratory dysfunction was randomly selected and invited to attend the laboratory on a separate occasion to undergo objective clinical workup to confirm or refute EIA. RESULTS: Forty-eight participants (22.6%) had at least one audible sign of respiratory dysfunction; inspiratory stridor (9.9%), expiratory wheeze (3.3%), combined stridor+wheeze (3.3%), cough (6.1%). Over one-third of the cohort (38.2%) were classified as symptomatic. Ten individuals attended a follow-up appointment, however, only one had objective evidence of EIA. CONCLUSIONS: The most common audible sign, detected in approximately 1 in 10 individuals, was inspiratory stridor, a characteristic feature of upper airway closure occurring during exercise. Further work is now required to further validate the precision and feasibility of this diagnostic approach in cohorts reporting exertional breathing difficulty

Physical in-activity: lacking inspiration to exercise?

Case report A 44-year-old female (BMI: 33.6 kg/m2) presented to the unexplained exertional breathlessness clinic complaining of respiratory symptoms ‘like breathing through a straw’ during moderate-high-intensity exercise. Patient recall confirmed signs and symptoms since childhood, and until recently, considered her breathing as a ‘normal’ response to vigorous physical exertion. She described gradual weight gain and a deterioration in physical fitness with increasing age. Eighteen months prior to consultation she appointed a personal trainer to ‘get back in shape’; however, despite a significant reduction in body weight (approximately 16-kilograms), she continues to report severe exertional breathlessness, limiting her physical activity engagement. Prior to referral she had undergone a comprehensive work-up including chest radiograph, spirometry, bronchial provocation testing with methacholine and mannitol, fractional exhaled nitric oxide - with no objective evidence of airways disease. An efficacy trial of inhaled terbutaline was in-effective. A continuous laryngoscopy exercise (CLE) test was conducted to evaluate the upper airway response to exercise. In brief, a self-determined incremental exercise test to volitional exhaustion was conducted whilst visualising the larynx using a flexible nasendoscope. At peak exercise a loud inspiratory stridor developed, correlating directly with severe glottic and supraglottic laryngeal obstruction - in keeping with a diagnosis of exercise-induced laryngeal obstruction (EILO) (Figure 1). Breathing control exercises were initiated in continuation of the exercise test and the patient was referred for further non-invasive treatment, including speech and language therapy (SLT) and breathing retraining. Six-months post diagnosis the patient continues to receive SLT however now describes a ‘substantial improvement’ in her exertional respiratory symptoms and overall quality of life. Conclusion Exercise-induced laryngeal obstruction is characterised by temporary closure of the larynx precipitating breathlessness on exertion. Recent research evaluating EILO in adolescents indicates a prevalence between 5-7% and significantly higher (>30%) in selected populations undergoing asthma work-ups in respiratory outpatient settings. A reduction in physical in-activity remains a key global health priority - therefore the importance of securing an early diagnosis and optimising the management of patients reporting exertional breathlessness should not be overlooked

Validity and reliability of grade scoring in the diagnosis of exercise-induced laryngeal obstruction

The current gold-standard method for diagnosing exercise-induced laryngeal obstruction (EILO) is continuous laryngoscopy during exercise (CLE), with severity classified by a visual grade scoring system. We evaluated the precision of this approach, by evaluating test–retest reliability of CLE and both inter- and intra-rater variability. In this prospective case–control study, subjects completed four consecutive treadmill CLE tests under identical conditions. Laryngoscopic video recordings were anonymised and graded by three expert raters. 2 months following initial scoring, videos were re-randomised and rating repeated to assess intra-rater agreement. 20 subjects (16 cases and four controls) completed four CLE tests. The time to exhaustion increased by 30 s (95% CI 0.02–57.8, p<0.05) in the second CLE compared with the first test, but remained identical in the subsequent tests. Only one-third of subjects retained their initial diagnosis in the subsequent three tests. Inter-rater agreement on grade scores (weighted Cohen's ϰ) was 0.16–0.45, while intra-rater agreement ranged from 0.30 to 0.67. The CLE test is key in the diagnostic assessment of patients with EILO. However, the widely adopted visual grade scoring system does not appear to be a robust means for reliably classifying severity of EILO

Temporary bilateral sensorineural hearing loss following cardiopulmonary bypass -A case report-

Sudden sensorineural hearing loss has been reported to occur following anesthesia and various non-otologic surgeries, mostly after procedures involving cardiopulmonary bypass. Unilateral sensorineural hearing loss resulting from microembolism is an infrequent complication of cardiopulmonary bypass surgery that has long been acknowledged. Moreover, there are few reports on the occurrence of bilateral sensorineural hearing loss without other neurologic deficits and its etiology has also not been determined. We describe here a rare case of bilateral hearing loss without other neurologic deficits in an otherwise healthy 27-year-old woman who underwent cardiopulmonary bypass surgery for repair of severe mitral valve stenosis. The patient suffered from profound sensorineural hearing loss in both ears that was recognized immediately upon extubation, and audiometry tests confirmed the diagnosis. Without any treatment, her hearing recovered almost completely by the time of her discharge one week after surgery

Exercise-induced bronchoconstriction in athletes – A qualitative assessment of symptom perception

© 2016Background A poor relationship between perceived respiratory symptoms and objective evidence of exercise-induced bronchoconstriction (EIB) in athletes is often reported; however, the reasons for this disconnect remain unclear. The primary aim of this study was to utilise a qualitative-analytical approach to compare respiratory symptoms in athletes with and without objectively confirmed EIB. Methods Endurance athletes who had previously undergone bronchoprovocation test screening for EIB were divided into sub-groups, based on the presence or absence of EIB ± heightened self-report of dyspnoea: (i) EIB-Dys- (ii) EIB + Dys+ (iii) EIB + Dys- (iv) EIB-Dys+. All athletes underwent a detailed semi-structured interview. Results Twenty athletes completed the study with an equal distribution in each sub-group (n = 5). Thematic analysis of individual narratives resulted in four over-arching themes: 1) Factors aggravating dyspnoea, 2) Exercise limitation, 3) Strategies to control dyspnoea, 4) Diagnostic accuracy. The anatomical location of symptoms varied between EIB + Dys + athletes and EIB-Dys + athletes. All EIB-Dys + reported significantly longer recovery times following high-intensity exercise in comparison to all other sub-groups. Finally, EIB + Dys + reported symptom improvement following beta-2 agonist therapy, whereas EIB-Dys + deemed treatment ineffective. Conclusion A detailed qualitative approach to the assessment of breathlessness reveals few features that distinguish between EIB and non-EIB causes of exertional dyspnoea in athletes. Important differences that may provide value in clinical work-up include (i) location of symptoms, (ii) recovery time following exercise and (iii) response to beta-2 agonist therapy. Overall these findings may inform clinical evaluation and development of future questionnaires to aid clinic-based assessment of athletes with dyspnoea