Exercise-induced laryngeal obstruction is a cause of exercise-induced dyspnea. Although clinicians are increasingly familiar with exercise-induced laryngeal obstruction as a diagnosis, information regarding effective interventions for exercise-induced laryngeal obstruction is not well published. Respiratory retraining is a cornerstone of interventions for exercise-induced laryngeal obstruction and these techniques have evolved over time. However, complete symptom resolution also requires recognition and management of coexisting medical conditions. We present the case of an intercollegiate athlete with long-standing symptoms who responded to a multifaceted approach using a multidisciplinary health care team.
A 21-year-old female intercollegiate basketball player volunteered for a study of exercise-induced respiratory symptoms. She reported a history of exercise-induced bronchoconstriction, but did not undergo pulmonary function testing at the time of diagnosis. Her 5-year history of exercise-induced dyspnea was not controlled with inhaled corticosteroids prescribed for exercise-induced bronchoconstriction. Her medical history was otherwise unremarkable. Familial history included first-degree relatives with cardiovascular disease; a prior complete cardiovascular examination revealed no cardiac abnormalities for this patient.
Pulmonary function testing associated with the research study did not support the previous diagnosis of exercise-induced bronchoconstriction; the patient had a negative response to mannitol and demonstrated no decrease in forced expiratory volume after an intense exercise challenge. Spirometry at rest and after an intense exercise challenge demonstrated a flattened inspiratory flow loop suggesting laryngeal obstruction (Figure 1A). The relationship of expiratory and inspiratory flow at 50% of vital capacity is useful in assessment of airway obstruction. The MEF50/MIF50 ratio in this case was 1.85; a ratio exceeding 1.5 is indicative of extrathoracic airway obstruction.1 A subsequent laryngoscope evaluation provided direct visualization of vocal cord dysfunction.
(A) Pre-intervention spirometry flow volume loop with truncated inspiration and MEF50/MIF50 ratio of 1.85. (B) Post-intervention flow volume loop with normalized inspiration and MEF50/MIF50 ratio of 1.10.
The patient had a single session of instruction from a speech-language pathologist on resistive breathing exercises with emphasis on a “relaxed throat” (Table 1) and was encouraged to perform these two to four times daily.2 (“Relaxed-throat” breathing supplants “diaphragmatic breathing,” yet shares the goal of using primary inspiratory muscles while reducing laryngeal tension.) The patient was also treated for seasonal allergies (cetirizine) at this time, and inhaled corticosteroids were discontinued. The athletic trainer working with the team was advised of the breathing exercises to encourage adherence.
Resisted Inhalation Exercises
The patient reported improvement in respiratory symptoms 6 weeks after receiving initial instruction on resistive breathing, but occasional episodes of dyspnea during basketball practice and conditioning sessions continued. At this time she was treated for moderate gastroesophageal reflux (famotidine); non-drowsy antihistamines, effective in controlling her allergy symptoms, were continued. Resisted inspiration exercises were reviewed with attention to early recognition of laryngeal tension and the patient was reminded to continue to practice these daily and to use these techniques to abort exercise-induced laryngeal obstruction. The patient was further instructed to contact the medical team if exercise-induced laryngeal obstruction persisted; no additional therapy sessions were requested. A follow-up query at 4 months indicated exercise-induced dyspnea was well controlled during the second half of the basketball season and was no longer considered a problem for this patient. A follow-up spirometry evaluation at that time demonstrated normalization of the flow volume loop (Figure 1B). The MEF50/MIF50 ratio at follow-up was 1.10.
The patient in this report was misdiagnosed for several years. Perhaps this was a result of a low index of suspicion, but the lack of objective testing for exercise-induced bronchoconstriction cannot be overlooked. Health care providers should advocate for objective testing, including bronchoprovocation, spirometry, and/or impulse oscillometry to identify exercise-induced laryngeal obstruction. Laryngoscopy remains the gold standard for laryngeal obstruction,1 although non-invasive techniques such as spirometry and, increasingly, oscillometry may be suitable alternatives.2,3 The patient's obstruction was first identified through spirometry during a research study and the diagnosis was confirmed through laryngoscopy.
Overall, exercise-induced laryngeal obstruction is increasingly recognized in the athletic population, particularly in those presenting with exercise-induced dyspnea1,4 (Table 2). Although athletic health care providers have become more adept at recognizing exercise-induced laryngeal obstruction, therapeutic interventions are not well described in the literature and symptom control remains somewhat elusive.5 Patients with exercise-induced laryngeal obstruction must overcome two problems. One is inappropriate glottic closure and the other is breathing pattern dysfunction resulting from chronic exercise-induced dyspnea.
Differentiating Causes of Exercise-Induced Dyspnea
In this case, the patient received some relief from pharmacological management of seasonal allergies and resistive breathing exercises emphasizing “relaxed-throat” or “diaphragmatic” breathing. However, substantive resolution of troublesome exercise-induced dyspnea was not achieved without additional pharmacologic treatment for reflux. Controlling seasonal allergies and reflux were important in reducing the sensitivity and hyperresponsiveness of the larynx.6 Breathing pattern dysfunction was addressed through resisted inspiration, which promotes deeper inhalation with a reduction of accessory respiratory muscle activation,7 and pursed lip breathing (exhaling through pursed lips), which reduces respiratory rate and improves the inspiratory to expiratory ratio, gas exchange, and breathing efficiency at rest and during exercise.8
Resisted inspiration has been suggested as a means of correcting muscle recruitment patterns associated with breathing pattern dysfunction.8 Submaximal resisted inhalation has been shown to increase laryngeal abduction, and thus appears to be well suited for interventions for exercise-induced laryngeal obstruction.5 Case reports indicated 5 to 11 weeks of inspiratory muscle training with adjustable resistance trainers allowed athletes with exercise-induced laryngeal obstruction to return to competitions without recurrence of exercise-induced dyspnea.9–11 Our efforts at intervention did not use mechanical resistance trainers, but instead focused on inhalation and expiration through pursed lips while maintaining diaphragmatic rather than clavicular breathing patterns. Our patient was able to use this technique for acute episodes of dyspnea and as a retraining exercise, without withdrawing from activity at any time.
Finally, although there are reports of symptom resolution of exercise-induced laryngeal obstruction in adolescents following a single breathing and behavior modification education session,12 or with use of anticholergenic inhalers prior to exercise,13 findings in those studies were based on telephone conversations with former patients with no objective evidence to confirm reversal of inappropriate glottic closure.
Implications for Clinical Practice
Athletic patients present an interesting paradox for the clinician. Breathing is typically a mindless activity and the athlete with exercise-induced laryngeal obstruction is asked to focus on a task he or she normally does without much attention. The clinician must approach breathing instruction, or retraining, knowing that the athletic patient is used to mastering physical tasks without much difficulty. There is potential for frustration as one attends to an automatic task such as breathing. However, the clinician can reinforce appropriate recruitment patterns for “relaxed-throat” breathing by having the patient consciously alternate appropriate lower ribcage expansion with inappropriate clavicular breathing (where the shoulder girdle rises and falls with respiration). The patient's attention should be drawn to the airway resistance associated with inappropriate clavicular breathing. Traditional breathing exercises (Table 3) may be helpful as introductory exercises for some individuals, although these were not used in the current case.
Traditional Breathing Exercises Using Voluntary Control
Dysfunctional breathing patterns may be addressed through efforts that change the breathing pattern. Pursed lip breathing slows respiration overall (12 to 16 breaths per minute). These efforts to slow the respiratory rate and prolong exhalation may initially make the athlete uncomfortable as the body adjusts to a lower level of carbon dioxide.14 The athlete will not be able to perform long sessions of pursed lip breathing because the lower carbon dioxide levels are not well tolerated and the urge to inhale is overwhelming.15 Pursed lip breathing should therefore be employed in short sessions that alternate with normal breathing with a target of up to 10 minutes of pursed lip breathing per retraining session.
When resisted inspiration is introduced, the clinician must continue to reinforce diaphragmatic, rather than clavicular, breathing. This may be helped by pursing the lips prior to, not simultaneously with, inhalation. In addition, one must also reinforce the tenets of motor learning in that these skills are taught and practiced with increasing levels of distraction or stress. Once the athlete has become accustomed to lower levels of carbon dioxide, the new breathing patterns become normal and continued training is not needed.14
Exercise-induced dyspnea is relatively common among competitive athletes. Successful management requires an accurate diagnosis. Successful management of exercise-induced laryngeal obstruction requires medical management of coexisting conditions and breathing retraining that promotes diaphragmatic breathing, appropriate recruitment of accessory respiratory muscles, and relaxation of the larynx.
- Mathers-Schmidt BA. Paradoxical vocal fold motion: a tutorial on a complex disorder and the speech language pathologist's role. Am J Speech-Language Pathol. 2001;10:111–125. doi:10.1044/1058-0360(2001/012) [CrossRef]
- Eisenbeis JF, Fuller DP. Voice disorders: abuse, misuse and functional problems. Missouri Med. 2008;105:240–243.
- Komarow HD, Young M, Nelson C, Metcalfe DD. Vocal cord dysfunction as demonstrated by impulse oscillometry. J Allergy Clin Immunol Practice. 2013;1:387–393. doi:10.1016/j.jaip.2013.05.005 [CrossRef]
- Nielsen EW, Hull JH, Backer V. High prevalence of exercise-induced laryngeal obstruction in athletes. Med Sci Sports Exerc. 2013;45:2030–2035. doi:10.1249/MSS.0b013e318298b19a [CrossRef]
- Sandnes A, Anderson T, Hilland M, et al. Laryngeal movements during inspiratory muscle training in healthy subjects. J Voice. 2013;27:448–453. doi:10.1016/j.jvoice.2013.02.010 [CrossRef]
- Kenn K, Balkissoon R. Vocal cord dysfunction: what do we know?Eur Respir J. 2011;37:194–200. doi:10.1183/09031936.00192809 [CrossRef]
- Jones AYM, Dean E, Chow CCS. Comparison of the oxygen cost of breathing exercises and spontaneous breathing in patients with stable chronic obstructive pulmonary disease. Phys Ther. 2003;83:424–431.
- Fregonezi GA, Resqueti VR, Güell Rous R. Pursed lips breathing [article in Spanish]. Arch Bronconeumol. 2004;40:279–282. doi:10.1016/S1579-2129(06)70099-4 [CrossRef]
- Mathers-Schmidt BA, Brilla LR. Inspiratory muscle training in exercise-induced paradoxical vocal fold motion. J Voice. 2005;19:635–644. doi:10.1016/j.jvoice.2005.03.005 [CrossRef]
- Ruddy BH, Davenport P, Baylor J, Lehman J, Baker S, Sapienza C. Inspriatory muscle strength training with behavioral therapy in a case of a rower with presumed exercise-induced paradoxical vocal-fold dysfunction. Int J Ped Otorhinolaryngol. 2004;68:1327–1332. doi:10.1016/j.ijporl.2004.04.002 [CrossRef]
- Dickinson J, Whyte G, McConnell A. Inspiratory muscle training: a simple cost-effective treatment for inspiratory stridor. Br J Sports Med. 2007;41:694–695. doi:10.1136/bjsm.2006.033654 [CrossRef]
- Rameau A, Foltz RS, Wagner K, Zur KB. Multidisciplinary approach to vocal cord dysfunction diagnosis and treatment in one session: a single institutional outcome study. Int J Ped Otorhinolaryngol. 2013;76:31–35. doi:10.1016/j.ijporl.2011.09.017 [CrossRef]
- Doshi DR, Weinberger MM. Long-term outcome of vocal cord dysfunction. Ann Allergy Asthma Immunol. 2006;96:794–799. doi:10.1016/S1081-1206(10)61341-5 [CrossRef]
- Innocenti DM. Hyperventilation. Edinburgh: Churchill Living-stone; 1998.
- Grossman P, DeSwart JCG, Defares PB. A controlled study of a breathing therapy for treatment of hyperventilation syndrome. J Psychosomatic Res. 1985;29:49–58. doi:10.1016/0022-3999(85)90008-X [CrossRef]
Resisted Inhalation Exercises
|Pursed lip inhalation of 6 to 8 seconds followed by pursed lip exhalation of the same length|
|Perform two restrictive breathing cycles and reassess.|
|Use as needed in acute onset; practice technique with relaxed upper accessory musculature (sternocleidomastoid, scalenes, upper trapezius) 2 to 4 times daily in nonstressful environment|
Differentiating Causes of Exercise-Induced Dyspnea
|EXERCISE-INDUCED BRONCHOSPASM||EXERCISE-INDUCED LARYNGEAL OBSTRUCTION|
|Onset 5 to 10 minutes into exercise||Sudden onset anytime during exercise|
|Spontaneous resolution within 20 to 30 minutes after stopping exercise or with a bronchodilator||Spontaneous resolution within minutes of stopping exercise|
|Chest tightness||Throat tightness|
|Difficulty during expiration||Visible tension in sternocleidomastoid and/or scalenes|
|Wheeze, cough||Difficulty usually during inspiration|
|Refractory period||Stridor, cough, hoarseness|
|Responds to inhaled drug therapy||Recurrent, intermittent|
|Does not respond to inhaled drug therapy|
|Fall in forced expiratory volume with bronchoprovocation and/or exercise challenge||Laryngoscope direct visualization|
|Response to beta-agonists||Oscillometry—increase in impedance, variability|
|Spirometry—flow-volume loop (MEF50/MIF50)|
Traditional Breathing Exercises Using Voluntary Control
|Supine (knees bent)|
| Place hands on abdomen for kinesthetic feedback|
| Inhale through nose as abdomen rises; keep neck and shoulders relaxed|
| Exhale slowly, making a “f” or “sh” sound;|
| Inhale to exhale ratio may start at 1:1 and progress toward 1:2|
| Inhale by sniffing quickly – maintain diaphragmatic breathing – exhale slowly|
| Revert to clavicular breathing pattern for 2 to 3 breaths|
| Return to diaphragmatic breathing – note ease of breathing|
| Alternate to realize control of respiratory muscle recruitment|
| Perform same exercises in a standing position, use a mirror for additional feedback|