Gas exchange |
||||||
|
Figure 1. Assessing breathlessness using the Treatable Traits
Framework.
|
||||||
|
dry air, pollen and common allergens
. Even exercise-induced laryngeal obstruction( EILO) presents differently
|
Box 1. Concerning features warranting specialist review based on
27, 28 current guidelines
|
pathology interventions. A recent systematic review reports significant benefits in using speech pathology |
not always easy to distinguish from asthma or other causes of dyspnoea. It is therefore critical to main- |
|||
|
from exercise-induced asthma. Sprinting and high intensity cardio training are much more triggering to the larynx than slower paced, longer workouts. EILO, like ILO, presents with sudden-onset breathlessness at peak exercise and is often accompanied by a high-pitched inspiratory stridor, and is unresponsive to bronchodilators either used pre-emptively or as a reliever.
Further investigation
Objective testing plays an important
role in confirming the diagnosis, gauging severity, identifying the
|
• Ever intubated for asthma.
• ED attendance more than once, or once despite standard inhaled LABA plus inhaled corticosteroid therapy being prescribed.
• More than two short courses of oral corticosteroids for their asthma in any 12-month period.
• Use of more reliever inhalers in a year than preventer inhalers.
• Persisting symptoms that are poorly responsive to LABA plus inhaled corticosteroid therapy within 2-3 months.
• Atypical symptoms for asthma alone, such as a productive cough or very rapid onset of symptoms.
• Work-related symptoms.
• Suboptimal symptom control in pregnancy.
• Unable to tolerate common preventer medicines.
|
interventions as first-line therapy, including: a reduction in healthcare utilisation of nearly 60 % following therapy, reduced symptom burden and reduced frequency of ILO attacks. 25
Box 1 outlines concerning features that should prompt a referral to a specialist centre for assessment.
How to refer
ILO services are multidisciplinary
in nature. Most are born from asthma or respiratory services, given the higher prevalence
|
tain a high index of suspicion, as objective testing can confirm the diagnosis and guide appropriate management.
Given that ILO is a treatable condition, delays in recognition and treatment can result in avoidable harm— ranging from inappropriate use of oral steroids to the increased burden on both the individual and the healthcare system through unplanned healthcare utilisation.
References on request from kate. kelso @ adg. com. au
|
|||
level of obstruction, and supporting treatment planning for ILO and EILO. In ILO, flexible nasoendos- |
from misattributing breathlessness as asthma and avoiding ineffective, |
well in excess of the recommended dose, resulting in side effects from |
in asthma patients. The level of speech pathology and respiratory expertise, bespoke equipment and |
Online resources |
|||||||
copy with provocation is considered the gold standard. It allows direct inspection of the larynx both at rest and during exposure to a trigger. For EILO, cardiopulmonary exercise testing with continuous laryngoscopy provides similar direct observation during exercise. This test not only enables grading of laryngeal narrowing at different workloads but also helps exclude other common causes |
unnecessary and harmful salbutamol overuse or oral corticosteroid use.
Speech pathology intervention is considered the first-line treatment in the management of ILO and EILO. 25 The level of obstruction, severity scoring, and response to speech pathology intervention are all important factors to consider first. In some cases, surgical procedures such as intralaryngeal botulinum toxin or supraglottoplasty
|
the beta agonists and perpetuating laryngeal symptoms, as large doses of inhaled particles deposit there.
More concerning are patients who have been prescribed a short course of oral corticosteroids for presumed asthma exacerbations and are frequently supplied with a bottle of 30 tablets with repeats. These patients often go on to self-administer prednisolone without medical supervi-
|
advanced testing required to diagnose and treat people with ILO often means these services are only feasible in a tertiary or quaternary level public hospital setting.
Referring to a specialist asthma or airways clinic in a tertiary public hospital is generally the preferred route of referral. To determine your most appropriate referral pathway, contact your local specialist asthma service.
|
• Asthma Australia
— asthma. org. au / blog / inducible-laryngealobstruction
— asthma. org. au / smarter-oral-steroids
• Inducible laryngeal obstruction and available treatments
ilovcdtoolkit. org
|
|||||||
|
of exertional breathlessness, such as exercise-induced bronchospasm or cardiac limitation.
Testing also has immediate therapeutic benefits. During an observed attack, the patient is taught manoeuvres to release their constriction and, once resolved, they are shown the recordings of their larynx and biofeedback is provided. This process also helps patients untangle
|
may be considered. |
The role of primary care
Awareness of ILO as a differential
for asthma is important to prevent harm. Often patients fall into a rabbit hole of repetitive unsuccessful trials of treatments and feel frustrated that there is no change to their symptoms. Patients can spend large amounts of money on over-the-
|
sion, developing cumulative effects of oral corticosteroid toxicity and adrenal insufficiency in some cases. Both salbutamol overuse and prednisolone prescribing are common scenarios which illustrate the importance of quality use of medicines.
As GPs, it is important to know that ILO does not respond to inhaled asthma therapies or oral corticosteroids but rather to therapies directed
|
Conclusions
Undiagnosed breathlessness remains highly prevalent in Australia, with poorly controlled asthma being common. ILO is an important contributor to both problems.
ILO typically presents with rapid-onset breathlessness triggered by laryngeal irritation, often accompanied by noisy or difficult inspira-
|
This article has been allocated 0.5 EA by the RACGP and ACRRM for the 2026- 2028 triennium. Self-report this CPD / PDP activity by logging it online with the RACGP and ACRRM. Scan the QR code for RACGP Quick Log or go to your ACRRM page. |
||||||
their symptoms, preventing them |
counter salbutamol and often use |
at the larynx, primarily speech |
tion. However, these features are |