Evaluation of Exercise- Induced Dyspnea in the Pediatric ...€¦ · Boys with exercise-induced...
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Evaluation of Exercise-Induced Dyspnea in the
Pediatric PatientHoward B. Panitch, M.D.
Division of Pulmonary MedicineThe Children’s Hospital of Philadelphia
Case History• 16 year old girl• Mild, intermittent asthma X 2 years• Track, tennis• Penn Relays• New exercise-related dyspnea• Rapid onset, clears within few minutes of stopping exercise• Hyperventilation in office: Stridor
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Differential Diagnosis of Exercise-Related Dyspnea•EIB•Exercise-induced laryngeal obstruction
• Vocal Cord Dysfunction• Exercise-induced laryngomalacia
•Exercise-induced hyperventilation•Exercise-induced anaphylaxis•GERD•Exercise-induced cardiac disease•Pulmonary hypertension•Poor conditioning
Exercise-Induced Bronchospasm
• Common in athletes at all levels• Symptoms variable and nonspecific
• Chest tightness• Cough• Wheeze• Dyspnea
• Poor predictive value for objectively confirmed EIB
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Exercise-Induced Bronchospasm• With or without asthma• Depends on both intensity and duration of exercise• Defined as >10% drop in FEV1 from baseline after exercise• In asthmatics, related to sputum eosinophilia
• allergen exposure increases response
Randolph C. Clinic Rev Allerg Immunol 34:205; 2008
Exercise-Induced Bronchospasm
• Cooling of airways• Reflex parasympathetic stimulation
• Reflex bronchoconstriction and mucosal edema
• Water loss• Release of newly formed and preformed mediators
• Environmental exposures• Swimming, hockey, pollution
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Prevalence of EIB
• Depends on population studied and methods to detect it• >90% in patients with persistent asthma• 30 – 70% in elite athletes• 5 – 20% of the general population
EIB in Trained Athletes
• Increased neutrophil counts in induced sputum fromswimmers and winter athletes
• Correlation with number of hours of training• Increased eosinophil counts in swimmers• 2 wks of rest resulted in reduced BHR
Carlsen KH. Eur Respir J 38:713; 2011
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0
5
10
15
20
25
Total population Girls Boys
EIB EILO
EIBEILOEIB & EILONegative EIB & EILO
Estimated Prevalence of EIB or EILO Among Swedish Adolescents
n=9(26.5%)
n=22(64.7%)
n=3(8.8%)
n=24(48.9%)
n=19(38.8%)
n=2(4.1%)
n=4(8.2%)
Boys with exercise-induced dyspnea N=34
Girls with exercise-induced dyspnea N=49
19.67
5.68 5.68 5.68
18.5919.15
Prev
alen
ce, %
Johansson H et al. Thorax 70:57; 2015
The Importance of Testing
• Retrospective review• n = 148 athletes• 12 – 57 yo
• 61% college• 22% high school• 2% middle school• 15% adult recreational
• 26% running• 18% swimming
0%
5%
10%
15%
20%
EIB testing PFT VLS
Testing Prior to Referral
0%
20%
40%
60%
80%
EIB Asthma VCD
Dx priorto referralDx afterevaluation
5%
16%
0%
70%
0%
17%
40%52%
24%
Testing Pre- and Post-Referral
Hanks CD et al. Phys Sportsmed 40:28; 2012
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Exercise-Induced Bronchospasm
•Ideal protocol• Rapid increase in exercise intensity over 2-4 min• Dry air (<10 mg H2O/L)• Nose clips• Exercise at load to raise HR to 80-90% max• Continue at that level for 4-6 min• Measure FEV-1 baseline, 5,10,15,and 30 min
Parsons JP et al. Am J Respir Crit Care Med 187:1016; 2013
The Exercise Challenge
• Response expressed as %fall in FEV-1 from baseline• ≥ 10% fall = positive response
• Severity• ≥ 10% to < 25% Mild• ≥ 25% to <50%Moderate• ≥ 50% Severe
Parsons JP et al. Am J Respir Crit Care Med 187:1016; 2013
0 5 10 15 2520 30
-20
-10
0
10
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-40
Time (min)
Fall
of F
EV1
(%)
Exercise
Baseline
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Recommended Therapies
• SABA 15 min before exercise• Add controller if SABA used ≥ daily• Daily leukotriene receptor antagonist• Mast cell stabilizing agent before exercise• Inhaled anticholinergic agent before exercise• Interval or combination warm-up exercises• Avoid
• LABA• ICS alone
Parsons JP et al. Am J Respir Crit Care Med 187:1016; 2013
Parsons JP et al. Am J Respir Crit Care Med 187:1016; 2013
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Forced Flow-Volume Loop
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Case History
• 17 year old high school junior• Competitive swimmer (scholarship)• With activity, “high-pitched inspiratory wheeze”• Unable to swim, even during practice• No problems with other sports• Unresponsive to inhaled steroids and bronchodilators
Olfactory Stimulation
Baseline After Chlorine
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VCD: DefinitionEpisodic adduction of the vocal folds during inspiration and / or expiration,
resulting in partial obstruction of the extrathoracic airway and
symptoms of dyspnea, neck or throat tightness, and stridor
Pediatric VCD
• Early information from case reports• Stressed association with psychiatric and emotional
problems• Noted excessive treatment for chronic asthma• No gender predilection in early reports
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Retrospective Review of VCD
• n = 37, 4 - 19 years old (x = 13 years)• 68% female, 81% Caucasian• 84% Academic achievers• 61% Athletes• 33% previous psychiatric illness• 70% individual or family dysfunction• 11% with identified sexual abuse, suspected in
another 16%
Brugman SM et al. Am Rev Respir Dis 149:A353; 1994
_
Exercise-Induced Paradoxical Arytenoid Motion
Tilles SA. Ann Allergy Asthma Immunol 104:361; 2010
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“Susceptible Larynx” Syndrome
Tilles SA et al. Ann Allergy Asthma Immunol 111:342; 2013
Flow-Volume Loop Shapes
Pandit CA et al J Paed Child Health 50:829; 2011
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Continuous Exercise Laryngoscopy
Maat RC et al. Eur Arch Otorhinolaryngol 264:401; 2007
Continuous Exercise Laryngoscopy
From: Roksund OD et al. Respira Med 103:1911; 2009
Glottic
Supraglottic
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(Exercise) Inducible Laryngeal Obstruction
• Supraglottic• Arytenoids, epiglottis, vestibular folds
• Glottic• Vocal folds
• Both supraglottic and glottic
• Phase• Inspiratory, expiratory, biphasic
Olin JT et al. Phys Sportsmed 43:13; 2015
VCD: Anxious Over-Achievers?
Age and Gender
PsychiatricDiagnosis
AcademicAchievement
16 F A12 F Anxiety Disorder A14 F Depressive Disorder
12 FAnxiety Disorder,Depressive Disorder A
15 M A16 F Depressive Disorder A18 F
Landwehr, LP. Pediatrics 98:971; 1996
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Psychological Issues•Immature personality / family conflict•Anxiety disorder / Depressive disorder•Competitive personality•Little tolerance for failure•Recent advance to higher level ofcompetition
•High academic and performance standards•Parental pressure to succeed
Mathers-Schmidt BA. Am J Speech-Lang Pathol 10:111; 2001
VCD vs EIBVCD EIB
Symptoms Situation dependentAbrupt onset and endDistraction
ReproduciblePeak in 5 – 10 minResolve within 30 –60 minCold or dry airPersistent cough
Sensation of tightness
Throat Chest
Stridor or Wheeze Audible inspiratory stridor
Expiratory wheeze
Treatment Breathing exercise Beta agonist
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Pulmonary Function TestsVCD EIB
Inspiratory loop
Truncated or flattened
Normal
FVC N or UsuallyFEV1 N or > 20%FEF25-75% NFEV1 / FVC No change FEV1 > FVCFEF50 / FIF50 Ratio > 1 Ratio < 1
Adapted from Koester MC and Amundson CL. J Athletic Train 37:320; 2002
E-ILO Therapies
• Breathing exercises• Psychological counseling• GERD therapy• Treatment of postnasal drip• Ipratropium• Surgery
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Breathing Exercises for Dysfunctional Breathing• Cochrane review• Breathing techniques in children <18• NO Studies identified that fulfilled criteria• Some studies in adults point to utility of various breathing
exercises
Barker NJ et al. Cochrane Database of Systematic Reviews. 12; 2013
Long Term Outcomes of VCD
•13 year retrospective review•N = 49
• Laryngoscopy (n = 24)• Spirometry (n = 8)• History (n = 17)
•2 patterns described• Exercise-induced VCD (EIVCD) (n = 29)• Sudden onset VCD (SVCD) (n = 20)• Both (n = 4)
Doshi DR and Weinberger MM. Ann Allergy Asthma Immunol 96:794; 2006
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Follow Up Structured Interviews• N = 28, 0.5 – 12 (median 3) years• Eventual resolution in 26
• 11 (8 F) SVCD• 10 (91%) without symptoms
• 17 (10 F) EIVCD• 16 (94%) without symptoms
• 8 followed with Speech therapy• 6 prescribed Ipratropium
Doshi DR and Weinberger MM. Ann Allergy Asthma Immunol 96:794; 2006
Surgery for Supraglottic EILO
Maat RC et al. Eur Arch Otorhinolaryngol 264:401; 2007
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Exercise-Induced Symptoms and Cardiac Disease
• Hypertrophic Cardiomyopathy• Dysrhythmias
• Prolonged QT syndrome• Supraventricular tachycardia• Congenital malformations
• Valvular disease• Anomalous coronary artery anatomy
• Pulmonary hypertension
Clues to A Cardiac Etiology
• Symptoms• Syncope• Palpitations• Irregular heart beat
• Other findings• Hypertension• Pathologic murmur
• Family History
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Evaluation: History•Site of obstruction•Dysphonia, dysphagia•Onset and cessation•? Triggers
• Exercise, exertion, hyperventilation• Stress• Dust, smoke, fumes, odors, chemicals
•Timing• ? During sleep?
•Response to anti-asthma therapies
Evaluation• Physical examination
• Overall• Bright• Anxious• Body habitus
• Auscultation• Normal• Stridor with panting or hyperventilation
• Non-pulmonary findings
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Evaluation• Exercise challenge• Laryngoscopy
• Hypnosis1
• Olfactory Challenge2,3
• Hyperventilation• *Exercise
• Flow-volume curve
1Anbar RD and Hehir DA. Pediatrics 106:E81; 20002Tomares SM et al. Pediatr Pulmonol 16:259; 19933Bhargava S et al. Chest 118:295S; 2000
Summary
• Exercise-related dyspnea is common• Testing required for accurate diagnosis• Exercise challenge good first step
• Formal• Field• Video
• High degree of successful treatment