Page 15 - Škrgat, Sabina, ed. 2023. Severe Asthma Forum - Monitoring and Treatable Traits in Severe Asthma. Koper: University of Primorska Press. Severe Asthma Forum, 2
P. 15
nts and other airborne triggers, chlorine in ryngeal irritation associated with GORD 15
swimmers and others9. may also contribute to bronchial constriction.
It is a vagally mediated reflex18. dysfunctional breathing – view of otorhinolaryngologist
The role of psychogenic factors
– triggers Exercise as a trigger
Initial reports of VCD emphasized the dom-
inant underlying psychological disorders. EILO – exercise-induced laryngeal obstruc-
It is still thought that psychological stimu- tion is caused by maximal exercise or ath-
li can trigger VCD, including anxiety disor- letic competitions, it can be also seen during
der, stress, somatoform disorders, depression, routine exercise, but is related to exercise in-
psychiatric illness, social stress in competitive tensity. EILO symptoms resolve quickly on
sports, prior history of sexual abuse, conver- exercise cessation16. Most patients are high-
sional profile, and others. Psychological stim- ly competitive, elite athletes and military per-
uli can trigger VCD and are considered major sonnel, who are required to exercise regularly.
precipitating factors for VCD18. Not all pa- EILO is common, affecting 5-7% of adoles-
tients have an underlying psychiatric illness. cents and up to a quarter of athletes present-
And anxiety can be also the result of chronic ing with “exertional asthma-type”. EILO has
respiratory illness, not the cause9,17,22. a female preponderance and a peak age of on-
set in the teenage years. It has been speculat-
Irritant triggers ed that the laryngeal growth difference be-
Irritant triggers can be extrinsic including tween genders seen in the peri-pubertal age
chemical, olfactory, and even visual. Irritants group might explain this observation38. Pa-
are environmental and occupational irritant tients develop wheezing during exercise. The
exposure to smoke, gasses, vapors, dust, air- differential diagnosis is asthma, but metha-
borne pollutants, and odors. Triggers can be choline challenge testing is negative, as is the
intrinsic such as gastroesophageal reflux, si- bronchoprovocation testing9. Some patients
nusitis, postnasal drip, pharyngitis, and lar- can have both asthma and VCD. 35 – 56%
yngitis. They lead to chronic inflammation of patients with VCD have coexistent asth-
and hyper-responsiveness. Reflex adduction ma. EILO represents a maladaptive response
of vocal cords might be protective and is re- to exercise. Increased work breathing might
sponsible for the development of VCD1,9,18. contribute to exercise limitation. Endurance
training induces large and significant adap-
The role of gastroesophageal reflux tations within the cardiovascular, musculo-
disease – GORD skeletal, and hematological systems. But the
There is much speculation in different studies. structural and functional properties of lungs
In some, there is a high proportion of GORD and airways do not change in response to re-
in patients with VCD (95%), and in others petitive physical activity. In elite athletes, the
low proportion of patients with GORD. In a pulmonary system may become a limiting
group of elite athletes with exercise-induced factor to exercise. As a consequence, of this re-
laryngeal obstruction (EILO), only 2.3% had spiratory paradox, the highly trained athlete
GORD38. VCD is triggered by acid reflux in may develop intrathoracic and extrathoracic
some patients. Laryngospasm is induced by obstruction, expiratory flow limitation, respi-
hydrochloric acid in the esophagus by sensi- ratory muscle fatigue, and exercise-induced
tization of subglottic chemoreceptors through hypoxemia. All of these maladaptations may
a vagally mediated mechanism. Reflux events influence performance29. Increased and ab-
cause vocal cord adduction and apneas. La- normal ventilation through the narrowest part
of the airway causes the collapse of laryngeal
swimmers and others9. may also contribute to bronchial constriction.
It is a vagally mediated reflex18. dysfunctional breathing – view of otorhinolaryngologist
The role of psychogenic factors
– triggers Exercise as a trigger
Initial reports of VCD emphasized the dom-
inant underlying psychological disorders. EILO – exercise-induced laryngeal obstruc-
It is still thought that psychological stimu- tion is caused by maximal exercise or ath-
li can trigger VCD, including anxiety disor- letic competitions, it can be also seen during
der, stress, somatoform disorders, depression, routine exercise, but is related to exercise in-
psychiatric illness, social stress in competitive tensity. EILO symptoms resolve quickly on
sports, prior history of sexual abuse, conver- exercise cessation16. Most patients are high-
sional profile, and others. Psychological stim- ly competitive, elite athletes and military per-
uli can trigger VCD and are considered major sonnel, who are required to exercise regularly.
precipitating factors for VCD18. Not all pa- EILO is common, affecting 5-7% of adoles-
tients have an underlying psychiatric illness. cents and up to a quarter of athletes present-
And anxiety can be also the result of chronic ing with “exertional asthma-type”. EILO has
respiratory illness, not the cause9,17,22. a female preponderance and a peak age of on-
set in the teenage years. It has been speculat-
Irritant triggers ed that the laryngeal growth difference be-
Irritant triggers can be extrinsic including tween genders seen in the peri-pubertal age
chemical, olfactory, and even visual. Irritants group might explain this observation38. Pa-
are environmental and occupational irritant tients develop wheezing during exercise. The
exposure to smoke, gasses, vapors, dust, air- differential diagnosis is asthma, but metha-
borne pollutants, and odors. Triggers can be choline challenge testing is negative, as is the
intrinsic such as gastroesophageal reflux, si- bronchoprovocation testing9. Some patients
nusitis, postnasal drip, pharyngitis, and lar- can have both asthma and VCD. 35 – 56%
yngitis. They lead to chronic inflammation of patients with VCD have coexistent asth-
and hyper-responsiveness. Reflex adduction ma. EILO represents a maladaptive response
of vocal cords might be protective and is re- to exercise. Increased work breathing might
sponsible for the development of VCD1,9,18. contribute to exercise limitation. Endurance
training induces large and significant adap-
The role of gastroesophageal reflux tations within the cardiovascular, musculo-
disease – GORD skeletal, and hematological systems. But the
There is much speculation in different studies. structural and functional properties of lungs
In some, there is a high proportion of GORD and airways do not change in response to re-
in patients with VCD (95%), and in others petitive physical activity. In elite athletes, the
low proportion of patients with GORD. In a pulmonary system may become a limiting
group of elite athletes with exercise-induced factor to exercise. As a consequence, of this re-
laryngeal obstruction (EILO), only 2.3% had spiratory paradox, the highly trained athlete
GORD38. VCD is triggered by acid reflux in may develop intrathoracic and extrathoracic
some patients. Laryngospasm is induced by obstruction, expiratory flow limitation, respi-
hydrochloric acid in the esophagus by sensi- ratory muscle fatigue, and exercise-induced
tization of subglottic chemoreceptors through hypoxemia. All of these maladaptations may
a vagally mediated mechanism. Reflux events influence performance29. Increased and ab-
cause vocal cord adduction and apneas. La- normal ventilation through the narrowest part
of the airway causes the collapse of laryngeal
