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Background: Patients suffering from exercise-induced laryngeal obstruction (EILO) are subjected to several exhausting tests. We aimed to assess the feasibility of using a single test to obtain diagnostic measurements for maximum oxygen uptake (VO2max) and exercise-induced laryngeal obstruction (EILO).Methods: Patients referred to the outpatient respiratory clinic at the University Hospital of Bispebjerg, Copenhagen with exercise-induced dyspnoea were evaluated for inclusion over 13 months. Eligible patients were aged 18–43 years, had a known EILO diagnosis (moderate or severe) and were inactive (self-reported activity) with less than 3 hours activity per week. In randomised order, all participants (n = 11) underwent three tests: a VO2max test with and without concurrent laryngoscopy. VO2max and EILO values from the two testing methods were compared.Findings: There was no difference in VO2max measured by ergospirometry with and without simultaneous continuous laryngoscopy during exercise (CLE) testing (mean difference −22 ml O2･min−1; 95% CI −125 to 81 ml O2･min−1; P = 0.647). EILO scores obtained during the CLE testing on the treadmill versus CLE testing on the ergometer bike revealed identical supraglottic scores in nine of the 11 participants (82%) with substantial agreement between the two types of test (x = 0.71). Glottic scores were identical in six of the 11 (55%), showing moderate agreement between test types (x = 0.38).Conclusions: Based on our findings in inactive individuals, ergospirometry with laryngoscopy is feasible and well tolerated, yielding measurements for maximal oxygen uptake comparable to those of standard bike ergospirometry. Likewise, measurements of supraglottic EILO are comparable to those of the standard treadmill CLE test.

Exercise‐induced respiratory symptoms limit physical activity and sport performance in adolescents. Etiologies include exercise‐induced bronchoconstriction, laryngeal obstruction, dysfunctional breathing, and in rarer cases, large airway obstruction and cardiac pathologies. Accurate diagnosis requires assessment during exercise that elicits the symptoms patients experience in the field. This is particularly important considering that misdiagnosis with asthma is common among those with laryngeal obstruction and leads to ineffective treatment and increased financial burden for patients and families. Continuous laryngoscopy is the gold standard for the evaluation of intermittent upper airway obstruction during exercise. Researchers recently established the feasibility of continuous bronchoscopy during exercise to assess the large airway in adults. We present the case of a 13‐year‐old female patient reporting dyspnea, chest tightness, and wheezing during exercise. A double aortic arch causing mild fixed tracheal compression did not appear to explain her symptoms. Vascular rings can cause tracheomalacia, another possible source of intermittent obstruction during exercise. We performed continuous bronchoscopy during exercise following continuous laryngoscopy during a cardiopulmonary exercise test. We found exercise‐induced laryngeal obstruction and ruled out tracheomalacia and other potential causes. To our knowledge, this was the first continuous bronchoscopy during exercise performed in a pediatric patient worldwide.

Manual diagnostic methods for assessing exercise-induced laryngeal obstruction (EILO) contain human bias and can lead to subjective decisions. Several studies have proposed machine learning methods for segmenting laryngeal structures to automate and make diagnostic outcomes more objective. Four state-of-the-art models for laryngeal image segmentation are implemented, trained, and compared using our pre-processed dataset containing laryngeal images derived from continuous laryngoscopy exercise-test (CLE-test) data. These models include both convolutional-based and transformer-based methods. We propose a new framework called LarynxFormer, consisting of a pre-processing pipeline, transformer-based segmentation, and post-processing of laryngeal images. This study contributes to the investigation of using machine learning as a diagnostic tool for EILO. Furthermore, we show that a transformer-based approach for larynx segmentation outperforms conventional state-of-the-art image segmentation methods in terms of performance metrics and computational speed, demonstrating up to 2x faster inference time compared to the other methods.

BackgroundExercise-induced laryngeal obstruction (EILO) is common in athletes and presents with dyspnoea, chest tightness, inspiratory stridor and sometimes panic reactions. The evidence for conservative treatment is weak, but case reports suggest effects from inspiratory muscle training (IMT). We aimed to explore effects from IMT used in athletes with EILO.MethodTwenty-eight athletes, mean age 16.4 years, diagnosed with EILO at our clinic, participated in a 6-week treatment programme, using a resistive flow-dependent IMT device (Respifit S). Four athletes competed at international level, 13 at national and 11 at regional levels. Video-recorded continuous transnasal flexible laryngoscopy was performed from rest to peak exercise (continuous laryngoscopy exercise (CLE) test) and scored before and 2–4 weeks after the training period. Ergospirometric variables were obtained from this CLE set-up. Lung function was measured according to guidelines. Symptom scores and demographic variables were obtained from a questionnaire.ResultsAfter the treatment period, symptoms had decreased in 22/28 (79%) participants. Mean overall CLE score had improved after treatment (p<0.001), with the scores becoming normal in five athletes but worse in two. Most of the improvement was explained by changes at the glottic laryngeal level (p=0.009). Ergospirometric variables revealed significantly higher peak minute ventilation explained by higher tidal volumes and were otherwise unchanged.ConclusionThis explorative study underlines the heterogeneous treatment response of EILO and suggests that IMT may become an efficient conservative treatment tool in subgroups, possibly contributing to better control of the vocal folds. The signals from this study should be tested in future controlled interventional studies.

Vocal cord dysfunction (VCD)-associated symptoms are not rare in pediatric patients. Dyspnea, wheezing, stridor, chest pain or tightness and throat discomfort are the most commonly encountered symptoms. They may occur either at rest or more commonly during exercise in patients with VCD, as well as in asthmatic subjects. The phase of respiration (inspiration rather than expiration), the location of the wheezing origin, the rapid resolution of symptoms, and the timing occurring in relation to exercise, when VCD is exercise induced, raise the suspicion of VCD in patients who may have been characterized as merely asthmatics and, most importantly, had not responded to the appropriate treatment. The gold standard method for the diagnosis of VCD is fiberoptic laryngoscopy, which may also identify concomitant laryngeal abnormalities other than VCD. However, as VCD is an intermittent phenomenon, the procedure should be performed while the patient is symptomatic. For this reason, challenges that induce VCD symptoms should be performed, such as exercise tests. Recently, for the evaluation of patients with exercise-induced VCD, continuous laryngoscopy during exercise (such as treadmill, bicycle ergometer, swimming) was used. A definite diagnosis of VCD is of importance, especially for those patients who have been erroneously characterized as asthmatics, without adequate response to treatment. In these cases, another therapeutic approach is necessary, which will depend on whether they suffer solely from VCD or from both conditions.