Right when you hit the peak of your workout or race, when heart rate is high and you are breathing hard, it happens: it feels like the air has suddenly become as thick as your post workout protein smoothie. You gasp, straining for the next breath. But Darth Vader has a Force-like grip on your throat. You wheeze. You cough. You panic. You reach for your puffer, and it helps...sort of. Your doctor has said it is exercise induced asthma, yet it seems to be getting worse. And now you’re starting to avoid those high intensity workouts for fear that you’ll stop breathing completely!
Exercise Induced Laryngeal Dysfunction
Often confused with exercise induced asthma, you may be experiencing exercise induced laryngeal dysfunction (EILO) During a normal breathing cycle, the vocal cords/upper airway widen with inhalation, narrow slightly with exhalation, and close completely during coughing and swallowing. Talking produces variable movement of the vocal cords. In EILO however, the normal reflexive action of the vocal cords are disrupted and the cords, or other structures of the upper airway, come together during inhalation, restricting airflow.
As EILO is often misdiagnosed, true representation of its prevalence and incidence is difficult to determine. Retrospective studies have reported that its prevalence is anywhere between 2.5 -22%, with higher incidences occurring within the asthma population. Several studies have highlighted that athletes with exercise induced VD seem to have common characteristics of being high achievers, having real or perceived external pressures (from coaches, parents or peers) and are intolerant to personal failure.
Symptoms
EILO is often misdiagnosed for asthma, mainly because the symptoms are strikingly similar; however, careful review of what the athlete is reporting should give clues that further diagnostic review is required.
It should be noted that EILO often co-exists with asthma or exercise induced asthma. In addition, issues such as gastroesophageal reflux disorder (acid reflux) and post nasal drip may also be present, causing increased sensitivity within the larynx, thereby increasing the likelihood of EILO.
Diagnosis
EILO is often diagnosed by exclusion, mainly due to a lack of familiarity of the condition and its mistaken identity with exercise induced asthma. Testing, including spirometry (lung function) and laryngoscopy (camera view of the larynx and vocal cords), may help to confirm the diagnosis.
Treatment
Influence of co-existing disorders, psychological effects and breathing patterns in EILO require an integrated approach to its treatment. This may mean pharmacological intervention for issues of reflux or sinus involvement. Daily sinus rinses may help with post-nasal drip to reduce irritation of the larynx. Education and patient counseling reduce anxiety; letting the athlete know they are not just imaging these symptoms plays a key role in alleviating fears over the condition. Relaxation training using self-awareness and biofeedback assist in decreasing both muscle tension and anxiety. Using imagery coupled with breathing techniques can often be helpful during acute episodes.
Breathing retraining is required to reduce the frequency and severity of acute events.
Studies have demonstrated that activation of the diaphragm may facilitate contraction of muscles that help to open the vocal cords. Alternatively, shallow upper chest breathing may increase tension of the muscles in the front of the neck and throat. This tension then contributes to laryngeal tightness and spasm. Manual therapy techniques, including soft tissue massage and mobilization of the larynx may help to decrease muscle tension, but learning new breathing strategies is key to maintaining an open airway.
With practice, the athlete can learn to engage in diaphragmatic (belly) breathing at rest and with activity, and limit accessory (neck and chest) muscle use. Inspiratory muscle training, which is breathing in against a resistance, may also be helpful to reduce acute events of vocal cord dysfunction.
Athletes experiencing difficulty breathing during high intensity exercise, yet fail to respond well to traditional asthma management plans should be reevaluated for EILO. An integrated approach that includes both behavioural changes and breathing retraining appears to be the most successful in symptom management.
CONTRIBUTED BY: Jessica DeMars, Respiratory Physiotherapist BSc.P.T, MSc