Novel pulmonary rehabilitation approach in a 46-year-old female with significant decline in lung and functional status following H1N1.

INTRODUCTION: Pulmonary rehabilitation (PR) is an established therapeutic intervention for improving limb muscle dysfunction, reducing morbidity and mortality in a variety of chronic lung conditions. Providers are instrumental in improving success by optimizing disease management, minimizing barriers and tailoring a program to meet the patient's goals and functional needs. CASE REPORT: We present a case of a young woman with mild asthma who developed severe chronic obstructive pulmonary disease following H1N1. She remained limited in instrumental activities of daily living following traditional PR but participated in therapeutic horseback riding with notable improvement in functional capacity and emotional well-being. CONCLUSIONS: There is a growing body of knowledge on the benefits of PR but little is known about the physiologic and psychological benefits of other forms of exercise such as horseback riding. This case highlights the importance of individualizing care and identifies a novel area of research to be explored.

Bronchial thermoplasty.

Bronchial thermoplasty is a relatively new therapy for the management of severe asthma. It involves the direct bronchoscopic application of thermal energy to airways by a catheter-directed expandable basket. The airways of the lower and upper lobes are treated in 3 separate sessions spaced 3 weeks apart. The therapy targets airway smooth muscle, with studies showing a decrease in airway smooth muscle after bronchial thermoplasty therapy. After therapy, an improvement in quality of life and decrease in asthma exacerbations can be expected. Adverse events can occur with bronchial thermoplasty and careful patient selection is critical to ensure benefits outweigh the potential risks.

Sex differences in asthma symptom profiles and control in the American Lung Association Asthma Clinical Research Centers.

OBJECTIVE: Important differences between men and women with asthma have been demonstrated, with women describing more symptoms and worse asthma-related quality of life (QOL) despite having similar or better pulmonary function. While current guidelines focus heavily on assessing asthma control, they lack information about whether sex-specific approaches to asthma assessment should be considered. We sought to determine if sex differences in asthma control or symptom profiles exist in the well-characterized population of participants in the American Lung Association Asthma Clinical Research Centers (ALA-ACRC) trials. METHODS: We reviewed baseline data from four trials published by the ALA-ACRC to evaluate individual item responses to three standardized asthma questionnaires: the Juniper Asthma Control Questionnaire (ACQ), the multi-attribute Asthma Symptom Utility Index (ASUI), and Juniper Mini Asthma Quality of Life Questionnaire (mini-AQLQ). RESULTS: In the poorly-controlled population, women reported similar overall asthma control (mean ACQ 1.9 vs. 1.8; p = 0.54), but were more likely to report specific symptoms such as nocturnal awakenings, activity limitations, and shortness of breath on individual item responses. Women reported worse asthma-related QOL on the mini-AQLQ (mean 4.5 vs. 4.9; p < 0.001) and more asthma-related symptoms with a lower mean score on the ASUI (0.73 vs. 0.77; p ≤ 0.0001) and were more likely to report feeling bothered by particular symptoms such as coughing, or environmental triggers. CONCLUSIONS: In participants with poorly-controlled asthma, women had outwardly similar asthma control, but had unique symptom profiles on detailed item analyses which were evident on evaluation of three standardized asthma questionnaires.

Etiology of dyspnea in elite and recreational athletes.

BACKGROUND: Breathing complaints are common in athletes. Studies have suggested that the prevalence of asthma and exercise-induced bronchoconstriction (EIB) is higher in elite athletes than the general population. Vocal cord dysfunction (VCD) may mimic asthma and EIB as a cause of dyspnea in athletes. However, the majority of studies to date have primarily relied on symptoms to diagnose VCD, and there are limited data on coexistence of asthma, EIB, and/or VCD. It is well established that symptoms alone are inadequate to accurately diagnose EIB and VCD. Our goal was to define via objective testing the prevalence of asthma, EIB, VCD alone, or in combination in a cohort of athletes with respiratory complaints. METHODS: A retrospective chart review was done of 148 consecutive athletes (collegiate, middle school, high school, and recreational) referred to a tertiary care center's asthma center for evaluation of respiratory complaints with exercise. An evaluation including medical history, physical examination, and objective testing including pulmonary function testing (PFT), eucapnic voluntary hyperventilation, and video laryngostroboscopy, were performed. RESULTS: The most common symptom was dyspnea on exertion (96%), with < 1% complaining of either hoarseness or stridor. The most common diagnosis prior to referral was asthma (40%). Only 16% had PFTs prior to referral. Following evaluation by a pulmonologist, 52% were diagnosed with EIB, 17% with asthma, and 70% with VCD. Of those diagnosed with asthma before our evaluation, the diagnosis of asthma was confirmed, with PFTs in only 19 of 59 (32%) athletes based on our testing. Vocal cord dysfunction was more common in females and in adolescent athletes. Coexistence of multiple disorders was common, such as EIB and asthma (8%), EIB and VCD (31%), and VCD and asthma (6%). CONCLUSIONS: Asthma and EIB are common etiologies of dyspnea in athletes, both competitive and recreational. However, VCD is also common and can coexist with either asthma or EIB. Vocal cord dysfunction may contribute to exercise-related respiratory symptoms more frequently in middle school- and high school-aged athletes than in college athletes. Effective treatment of dyspnea requires appropriate identification and treatment of all disorders. Classic symptoms of stridor and/or hoarseness are often not present in athletes with VCD. Accurate diagnosis of asthma, EIB, and VCD requires objective testing and can prevent exposure of patients to medications that are ineffective and have potential adverse side effects. Furthermore, there is need for increased awareness of VCD as a common cause of respiratory complaints in athletes, either as a single diagnosis or in combination with EIB, especially in females, as well as middle school and high school athletes.

Pregnancy related treatment disparities of acute asthma exacerbations in the emergency department.

OBJECTIVE: Asthma is one of the most common medical conditions complicating pregnancy. Despite the presence of published guidelines outlining the care of the pregnant patient with asthma, disparities in the treatment of acute asthma exacerbations in the emergency department related to pregnancy status are known to exist. We sought to determine if pregnancy status affected the treatment of women presenting to a tertiary emergency department for care of acute asthma exacerbations. METHODS: We retrospectively compared the emergency department treatment of acute asthma exacerbations in 123 pregnant women to 123 non-pregnant controls. Asthma exacerbations were classified by severity according to pre-determined criteria. RESULTS: In the emergency department (ED), pregnant women were significantly less likely to be treated with systemic corticosteroids than non-pregnant controls (50.8% versus 72.4%, p = 0.001). Similarly, 41% of pregnant women received prescriptions for prednisone at the time of discharge from the ED compared to 69.2% of non-pregnant women (p < 0.001). CONCLUSIONS: In this population of asthmatics presenting to a tertiary emergency department with acute asthma exacerbations, pregnant women were less likely to receive appropriate therapy with systemic corticosteroids.

Vocal cord dysfunction and asthma.

PURPOSE OF REVIEW: Vocal cord dysfunction can occur independently or can co-exist with asthma. It often mimics asthma in presentation and can be challenging to diagnose, particularly in those with known asthma. Vocal cord dysfunction remains under-recognized, which may result in unnecessary adjustments to asthma medicines and increased patient morbidity. There is a need to review current literature to explore current theories regarding disease presentation, diagnosis, and treatment. RECENT FINDINGS: The underlying cause of vocal cord dysfunction is likely multifactorial but there has been increased interest in hyper-responsiveness of the larynx. Many intrinsic and extrinsic triggers have been identified which in part may explain asthma-like symptomatology. A variety of techniques have been reported to provoke vocal cord dysfunction during testing which may improve diagnosis. There is a significant gap in the literature regarding specific laryngeal control techniques, duration of therapy, and the effectiveness of laryngeal control as a treatment modality. SUMMARY: Those with vocal cord dysfunction and asthma report more symptoms on standardized asthma control questionnaires, which can result in increasing amounts of medication if vocal cord dysfunction is not identified and managed appropriately. Clinicians need to maintain a high index of suspicion to identify these patients. Videolaryngostroboscopy remains the diagnostic method of choice. Evidence-based guidelines are needed for the most effective diagnostic techniques. Laryngeal control taught by speech pathologists is the most common treatment. Effectiveness is supported in case reports and clinical experience, but not in larger randomized trials which are needed.

Vocal cord dysfunction: beyond severe asthma.

BACKGROUND: Vocal cord dysfunction (VCD) is the abnormal adduction of the vocal cords during inspiration causing extrathoracic airway obstruction. VCD has been described as a confounder of severe asthma. The influence of VCD among less severe asthmatics has not been previously defined. METHODS: We retrospectively reviewed the medical records of 59 patients with pulmonologist-diagnosed asthma who were referred for videolaryngostroboscopy (VLS) testing from 2006 to 2007. RESULTS: A total of 44 patients had both asthma and VCD. 15 patients had asthma without concomitant VCD. Females were predominant in both groups. Overall, the majority of patients referred for VLS testing had mild-to-moderate asthma (78%) and 72% of these patients had VCD. Few patients from either group had "classic" VCD symptoms of stridor or hoarseness. Gastroesophageal reflux disease (GERD) and rhinitis were common in both groups. CONCLUSIONS: Vocal cord dysfunction occurs across the spectrum of asthma severity. There was a lack of previously described "classic" VCD symptoms among asthmatics. Symptoms were diverse and not easily distinguished from common symptoms of asthma, highlighting the need for a high index of suspicion for VCD in patients with asthma. Failure to consider and diagnose VCD may result in misleading assumptions about asthma control, and result in unnecessary adjustments of asthma medications. The high prevalence of GERD raises the question of the role of acid reflux in the pathogenesis of VCD in asthmatics.