Hospitals With Continuous Laryngoscopy During Exercise

Editor's Note: This article is published to report the experience of a patient undergoing assessment and treatment of a rare disease from the perspective of the patient and her father. This is not a scientific assessment of treatment efficacy. Readers are advised to consult the peer-reviewed medical literature for evidence-based information on the benefits and risks of various proposed treatments for the condition described in this narrative.

M. Blake Hargrove

Section:

I am an Associate Professor of Management in the John L. Grove College of Business at Shippensburg University in Pennsylvania. I am a behavioral scientist who conducts research on occupational stress.

My 15-year-old daughter, Alice, is a high school student and an avid field hockey player (Figure 1 ). My wife and I have watched our daughter suffer from respiratory disorders since she was a toddler. We have subjected Alice to hundreds of appointments, seen dozens of doctors, and tried every drug therapy recommended by her physicians. Despite our efforts to get her the best care, Alice continued to suffer with breathlessness. We have always encouraged Alice not to be defined by her illness. She is a terrific, resilient young woman who powers through her problems and pursues sports with a passion.

Alice E. Hargrove

Section:

I cannot remember a time when I did not have breathing problems. Basically, my breathing problems are part of who I am and affect me every day. In 2013, we traveled to a regional medical research center where I received a comprehensive multidisciplinary diagnostic workup over a 4-day period. These doctors told me some things I already knew: I had asthma and eczema. While I was there, one doctor mentioned that I might also have a condition called vocal cord dysfunction that was making my breathing problems worse.

Blake

Section:

Alice's mother and I were very interested in this new potential diagnosis. I have always taken an active stance with regard to Alice's care. Despite more than a decade of trying to learn about Alice's respiratory problems and diligently reviewing the literature, I had never even heard of vocal cord dysfunction. As usual, I scoured the Internet for information on vocal cord dysfunction. In 2013, we obtained a referral to a pulmonologist, and Alice had a resting laryngoscopy. The pulmonologist explained that, unless Alice has an episode during the procedure, he would be unable to make a diagnosis; the procedure produced no evidence of vocal cord dysfunction. Despite this finding, the pulmonologist said there were a few specialized speech therapists who might be able to help, so we found her a speech therapist (1 h from our house) who said she could help.

Alice

Section:

At the first speech therapist visit, I learned about vocal cord dysfunction. She showed me a section model of my head and tried to describe the problem. She taught me to purse my lips and to hold my stomach so that I could concentrate on breathing using my diaphragm. At several visits to her office, she put me on a treadmill to induce an episode. Each time I had an attack in her office, she was not able to help me bring my breathing back in to control. I left her office each time feeling worse than when I came in.

I was disappointed and was still unconvinced about vocal cord dysfunction, but my parents still wanted to give it a try. They found a new therapist for me to work with. This second therapist was super supportive. She also put me on a treadmill and listened to me breathe during several sessions. She was pretty sure these were vocal cord dysfunction episodes. During the next months, she even met with me four times outside, while I played field hockey with a friend, to show me how to breathe while I was playing. However, her methods (pursed lips and holding my stomach) just didn't work well. Neither technique was at all practical when I was playing hockey. After a few months of therapy, I still wasn't sure vocal cord dysfunction was a real thing.

Blake

Section:

Alice's issues took a turn for the worse. During late 2014, Alice had a severe asthma exacerbation, which resulted in two visits to an emergency department, an emergent transfer to a regional research hospital, and 6 days of in-patient treatment. Alice was breathing supplemental oxygen, inhaled hundreds of milligrams of an inhaled corticosteroid, and received daily intravenous corticosteroid injections. When discharged, she was still using her rescue inhaler hourly.

She began omalizumab injections beginning in 2014. Although this produced some marginal improvement, Alice continued to have serious breathing problems and regular exacerbations requiring oral prednisone. During 2015, her physicians were never satisfied with her condition and had her on oral prednisone continuously. They strongly advised us to seek help from an international research hospital that specialized in treating pediatric respiratory illness.

J. Tod Olin

Section:

I am a pediatric pulmonologist at National Jewish Health in Denver, Colorado. I have a clinical and research interest in exercise-induced laryngeal obstruction, a condition formerly known as vocal cord dysfunction. This condition, first described in the 1980s, is characterized by partial laryngeal obstruction that occurs during high-intensity exercise, and may occur in as many as 5% of adolescent patients (1–3).

I direct a clinical program called the Pediatric Exercise Tolerance Center, which caters to local and out-of-state adolescent and young adult patients with exertional dyspnea. This program interfaces with a separate departmental program (in which Alice was admitted) that provides evaluation of out-of-state patients with refractory respiratory, allergic, and immunologic disease. Historically, our institution has developed broad expertise in the respiratory manifestations of upper airway dysfunction (4, 5). For this reason, the Pediatric Exercise Tolerance Center is unique in that it annually serves hundreds of patients with exercise-induced laryngeal obstruction. Patients from over 30 states have been evaluated and treated.

Our unique patient population has provided us with the insight that not all patients with exercise-induced laryngeal obstruction respond to conventional respiratory retraining and voice therapy, which echoed in Alice's prior experience. Our patients have also enabled us to improve on the diagnostic and therapeutic strategies for this condition.

More specifically, we have developed and recently described a procedure called therapeutic laryngoscopy during exercise (6). This is a procedure in which real-time laryngoscopy video footage is used as biofeedback to treat refractory cases of exercise-induced laryngeal obstruction (Video 2). During this procedure, the patient performs as many as 10 interval sprints while learning respiratory retraining techniques that can be used during high-intensity exercise and simple tools to decrease the psychological stress of exercise.

At the time of presentation, Alice was a 15-year-old female with uncontrolled respiratory symptoms attributable to a combination of known severe-persistent asthma and suspected exercise-induced laryngeal obstruction, despite intensive medical and behavioral treatment. Both diagnoses were confirmed at the time of her diagnostic exercise challenge with continuous laryngoscopy during exercise, as spirometry dropped over 40% several minutes after exercise and moderate inspiratory glottic and supraglottic obstruction were noted during exercise (Video 1).

https://thoracic-prod-streaming.literatumonline.com/journals/content/annalsats/2017/annalsats.2017.14.issue-3/annalsats.201612-948or/20170227/media/annalsats.201612-948or_vid1.,1500,964,750,300,180,.mp4.m3u8?b92b4ad1b4f274c70877528310abb28bace78d0a07e4112cd1274061185e9c1798b36ede31f69860c9d88cbf33f704a4241888f197dd69c39c729644ccc8094b2ca6019f37e118ba181bfad5e2998c3fb11a1070ad0c48bf28c7fdec3655d6c30f472b59769d9ff74103d25e4597fd2454f5579b3e9b560f1fe23d682b75bbc3e82d997d9ed1c8a2e2176171c2436a03918d013a0dc44329ccca99acce070ad882b0ae1afec74c033f50dd11c410f06cac92ce769eede6d4ecc92eb216576031c2b62e974a416fe907804cdd

Video 1.

Findings from continuous laryngoscopy during exercise. Note the moderate glottic and supraglottic obstruction during inspiration at peak exercise.

Alice

Section:

The diagnostic continuous laryngoscopy during exercise was a little scary (Video 2). I was hooked up to a bunch of equipment and Dr. Olin pushed me to work really hard on the bike (the seat was really hard on my butt). However, Dr. Olin's description of vocal cord dysfunction made a lot more sense to me, because I could see what was actually happening to my vocal folds during an episode.

https://thoracic-prod-streaming.literatumonline.com/journals/content/annalsats/2017/annalsats.2017.14.issue-3/annalsats.201612-948or/20170227/media/annalsats.201612-948or_vid2.,1500,964,750,300,180,.mp4.m3u8?b92b4ad1b4f274c70877528310abb28bace78d0a07e4112cd1274061185e9c1798b36ede31f69860c9d88cbf33f704a4241888f197dd69c39c729644ccc8094b2ca6019f37e118ba181bfad5e2998c3fb11a1070ad0c48bf28c7fdec3655d6c30f472b59769d9ff74103d25e4597fd2454f5579b3e9b560f1fe23d682b75bbc3e82d997d9ed1c8a2e2176171c2436a03918d013a0dc44029fc98452c182a1752550b1734522b6880afc5855fa9e48d29a083044c46ad54210837446a035deda444ae1a4fcab80356f7e22078

Video 2.

The author is performing therapeutic laryngoscopy during exercise.

The day after my diagnostic session, I went to a speech therapist who taught me a different breathing technique on a treadmill. She made me practice until I could reliably perform the technique. I was a little less scared about the first therapeutic laryngoscopy during the exercise session than I had been about the diagnostic session. I knew what to expect. The main difference between the sessions was that I could watch the video during the procedure and see how my breathing techniques could change my vocal folds in real time. During this session, the doctor focused on helping me to be aware of my distress, being aware of my breathing technique, and working on the timing of my breathing technique.

Blake

Section:

It had been hard to watch Alice during the diagnostic session, but my wife and I knew what to expect during the therapeutic session, and were confident that our daughter would be okay. We watched as the doctor pushed her to exercise hard. We watched her ability to perform on the bike challenges increase. We could see the results of her breathing and the corresponding improvement to her vocal folds.

Alice

Section:

For the second therapeutic session, I was barely worried about the scope procedure. My main concern was how sore my legs would be after the exercise on the stationary bike. During this session, the doctor again showed me my vocal folds on video. He worked to fine tune my breathing. I had to work hard to practice the timing and force for my breathing. By the end of the session, I feel I had a basic handle on the technique and the effect of the technique on my vocal folds.

Blake

Section:

As an occupational stress researcher, I could not help but to view this demanding procedure through my academic lens. My view of stress, like that of most in the behavioral field, is that stress is a physio-psycho-affective response to stimuli that is adaptive and beneficial to humans and other organisms. As a parent and behavioral scientist, I believe that Alice experienced both negative stress (such as anxiety and fear) and eustress, defined as "the healthy, positive outcome of stressful events and the stress response" in her therapeutic laryngoscopy during exercise sessions (7).

One of the ways that demands are viewed is the Challenge Hindrance Framework (8–10), which describes particular types of stressors that are likely to produce a positive stress response—challenge stressors. Watching my daughter work hard during the therapy, I believe Alice experienced positive stress related to the challenges of the therapy itself. Alice really wanted to get better, and directly related the therapy to her own personal goal of improving her health. The therapy challenged Alice physically, cognitively, and emotionally. Physically, Alice was pushed by the exercise challenges. She remained intellectually aroused by watching her breathing on the monitor and listening to Dr. Olin's instructions. Emotionally, Alice's trepidation and anxiety moderated to anticipation and nervousness. Overall, it seemed to me that Alice may have been experiencing physio-affective flow (11).

To be challenging rather than hindering, individuals must be able to cognitively appraise demands as manageable. To prepare her for the therapeutic laryngoscopy sessions, she received instruction from both the speech therapist and the physician regarding the new breathing technique that she was expected to perform during the therapy; she was given additional coping resources to deal with the stress. As an athlete, she was confident of dealing with the challenge of strenuous exercise. Crucially, she was given the opportunity to see the motion of her vocal folds and was motivated to manipulate their shape by breathing. Because Alice believed that the variety of tasks set before her during the therapy were manageable, she "stepped up" to the physical and cognitive challenge. I believe she was excited to see her physical performance improve over the course of the therapeutic laryngoscopies.

Alice

Section:

I did not enjoy therapeutic laryngoscopy during the exercise sessions. I did not like being hooked up to machines, and the scope in my nose felt weird. Though the exercise was tough, I knew I was capable of doing the cardiovascular portion of the procedure. As a field hockey player, I knew that the muscle soreness from the exercise would be gone in a day or so. The scope itself did not hurt.

I felt that the procedure was helping me reach my goal of getting better. After being taught the breathing technique, I could both see and feel the improvement in my breathing. I could watch myself change the shape of my vocal folds by using the new breathing technique. I felt that the discomfort and distress of the procedure was a step toward breathing better.

Blake

Section:

It was stressful to watch Alice receive this therapy. All the sensors and therapy apparatus attached to Alice were intimidating despite the fact that we are relatively medically sophisticated. Because the therapeutic laryngoscopy took place after a diagnostic session, and because the two therapeutic sessions challenged Alice in an incremental fashion, we were able to effectively manage the stress of seeing our daughter in discomfort. I believe we managed the stress effectively because the importance of the procedure and the benefits of the therapy were clearly explained to us by a caring healthcare professional. I believe it is essential that this therapy be performed in a supportive environment with compassionate therapists and physicians.

Dr. Olin

Section:

As a proceduralist, I am the first to admit that this is an exceedingly difficult procedure to perform. The logistic challenges of providing patients with consistently excellent laryngoscopy footage suitable for learning are significant. In addition, it is challenging to guide the translation of my verbal instruction to achievement of an open larynx during intense exercise. Patients like Alice have highlighted the fact that I, in addition to managing specific muscular movements, need to provide insight regarding a variety of cognitive-behavioral factors within the patient and observers during the procedure to achieve immediate and lasting success.

Alice

Section:

After receiving the therapeutic laryngoscopies during exercise, I now believe in vocal cord dysfunction and am confident that I can do something to improve part of my breathing problem. The therapy really helped me to visualize some of my breathing problems and provided me with a tool to better manage my exercise-induced breathing problems.

Since I left the hospital 11 months ago, I have completed three indoor field hockey seasons and just finished my fall season. In all of that time, I have only had to stop exercising three times because of vocal cord dysfunction. In each case, I was able to use the breathing technique I learned to recover. All in all, I am glad I had the therapy and feel better empowered to manage my breathing disease. In summary, therapeutic laryngoscopy during exercise is not fun, but it is worth it.

References

Section:

1 .	Lakin RC , Metzger WJ , Haughey BH . Upper airway obstruction presenting as exercise-induced asthma. Chest 1984;86:499–501. Crossref, Medline, Google Scholar
2 .	McFadden ER Jr, Zawadski DK . Vocal cord dysfunction masquerading as exercise-induced asthma: a physiologic cause for "choking" during athletic activities. Am J Respir Crit Care Med 1996;153:942–947. Abstract, Medline, Google Scholar
3 .	Johansson H , Norlander K , Berglund L , Janson C , Malinovschi A , Nordvall L , Nordang L , Emtner M . Prevalence of exercise-induced bronchoconstriction and exercise-induced laryngeal obstruction in a general adolescent population. Thorax 2015;70:57–63. Crossref, Medline, Google Scholar
4 .	Christopher KL , Wood RP II, Eckert RC , Blager FB , Raney RA , Souhrada JF . Vocal-cord dysfunction presenting as asthma. N Engl J Med 1983;308:1566–1570. Crossref, Medline, Google Scholar
5 .	Olin JT , Clary MS , Fan EM , Johnston KL , State CM , Strand M , Christopher KL . Continuous laryngoscopy quantitates laryngeal behaviour in exercise and recovery. Eur Respir J 2016;48:1192–1200. Crossref, Medline, Google Scholar
6 .	Olin JT , Deardorff EH , Fan EM , Johnston KL , Keever VL , Moore CM , Bender BG . Therapeutic laryngoscopy during exercise: a novel non-surgical therapy for refractory EILO. Pediatr Pulmonol [online ahead of print] 31 Oct 2016; DOI: 10.1002/ppul.23634. Google Scholar
7 .	Quick JC , Wright TA , Adkins JA , Nelson DL , Quick JD . Preventive stress management in organizations. Washington, DC: American Psychological Association; 2013. Crossref, Google Scholar
8 .	Boswell WR , Olson-Buchanan JB , LePine MA . Relations between stress and work outcomes: The role of felt challenge, job control, and psychological strain. J Vocat Behav 2004;64:165–181. Crossref, Google Scholar
9 .	Cavanaugh MA , Boswell WR , Roehling MV , Boudreau JW . An empirical examination of self-reported work stress among U.S. managers. J Appl Psychol 2000;85:65–74. Crossref, Medline, Google Scholar
10 .	LePine JA , Podsakoff NP , LePine MA . A meta-analytic test of the challenge stressor–hindrance stressor framework. Acad Manage J 2005;48:764–775. Crossref, Google Scholar
11 .	Nelson DL , Simmons BL . Handbook of occupational health psychology: savoring eustress while coping with distress: the holistic model of stress. Washington, DC: American Psychological Association; 2011. Google Scholar

arnoldthroing.blogspot.com

Source: https://www.atsjournals.org/doi/10.1513/AnnalsATS.201612-948OR

Share this post