Background Vocal cord dysfunction (VCD), or inducible laryngeal obstruction (ILO), is an episodic upper airway disorder that can mimic anaphylaxis. Objective To determine the prevalence of VCD/ILO among adults referred to allergy clinic for suspected anaphylaxis and to identify clinical markers that distinguish VCD/ILO from anaphylaxis. Methods We conducted a retrospective study of adults referred for suspected anaphylaxis to a tertiary allergy clinic in Newcastle, Australia, in 2023. Patients were classified as confirmed VCD/ILO (laryngoscopy-proven), suspected VCD/ILO (spirometry findings or high clinical suspicion after exclusion of alternate diagnoses), anaphylaxis, or other. Demographics, triggers, comorbidities, clinical features, investigations, and health care utilization were compared between laryngoscopy-confirmed VCD/ILO and anaphylaxis. Results Among 133 adults, 11 (8.3%) had laryngoscopy-confirmed VCD/ILO. Inclusion of suspected cases (n = 21 [15.8%]) increased prevalence of VCD/ILO to 24.1% (n = 32). Compared with anaphylaxis, VCD/ILO was characterized by predominant upper airway symptoms, including throat tightness (100% vs 53.8%, P = .004), stridor (36.4% vs 1.9%, P = .003), dysphonia (72.7% vs 17.3%, P < .001), and cough (54.5% vs 1.9%, P < .001) with fewer systemic symptoms (urticaria 18.2% vs 84.6%, P < .001; gastrointestinal 9.1% vs 44.2%, P = .04; cardiovascular 0% vs 55.8%, P < .01). Multiple triggers were more common in VCD/ILO (72.7% vs 1.9%, P < .001), particularly aerosolized chemicals (36.4% vs 0%, P < .001). IgE sensitization to the proposed trigger was uncommon (9.1% vs 63.5%, P < .008) in VCD/ILO. Conclusions VCD/ILO is a frequent differential diagnosis in adults referred for anaphylaxis. Recognition of its characteristic clinical features and trigger profiles may prevent misdiagnosis, reduce health care utilization, and improve patient outcomes.

Background:Speech pathology intervention is an effective treatment for refractory and unexplained chronic cough (RUCC); however, data regarding treatment outcomes in real-world settings are limited. Similarly, the influence of cough phenotypes on treatment response variability is unknown. This study aimed to 1) identify trajectories of response to speech pathology intervention and 2) determine predictors of treatment response trajectories. Methods:The medical records of 205 participants referred to speech pathology for assessment and management of RUCC were reviewed. Data included demographics, medical comorbidities, appointment dates, Leicester Cough Questionnaire (LCQ) scores and clinical outcome. Participants with three or more LCQ scores were included in the analysis. A growth mixture model was used to estimate participant treatment response trajectories and logistic regression models identified baseline predictors of trajectory membership. Results:Three treatment response trajectory groups were identified: Severe Cough-Slow Response (21%), Severe Cough-Rapid Response (23%) and Moderate Cough-Slow Response (56%). Asthma diagnosis (p=0.034) and baseline LCQ score (p≤0.001) were predictors of trajectory group. Most patients (76%) achieved improvement exceeding the LCQ minimally clinically important difference. Notably, the Severe Cough-Rapid Response group demonstrated marked improvement in LCQ score with a shorter treatment duration (median 56 days). Conclusions:This novel application of trajectory analysis to investigate treatment response to speech pathology intervention in RUCC supports the heterogeneous nature of RUCC. We identified a group with severe cough who demonstrated a faster and greater treatment response. Our findings demonstrate the effectiveness of speech pathology intervention and support further exploration of cough phenotyping.

RATIONALE: Inducible Laryngeal Obstruction (ILO) significantly impacts the lives of affected patients and is associated with substantial healthcare burden, but to date there are no randomised controlled trials investigating treatment effectiveness for ILO. Speech pathology treatment is considered first-line intervention for ILO, whether neuromodulators are an effective adjunct treatment is unclear. This study aimed to determine if the addition of amitriptyline to speech pathology, further improves symptoms in ILO. METHODS: Participants with newly diagnosed ILO confirmed via laryngoscopy and no contraindications for the use of amitriptyline were recruited. Participants were randomised using block stratification (1:1) to speech pathology and amitriptyline or speech pathology and placebo. Speech Pathology was provided in 6 fortnightly sessions with concurrent amitriptyline – to a maximal dose of 75mg or placebo over a 10-week treatment period. Outcome measures were taken at baseline and after completion of treatment. The primary outcome measure was the difference between the intervention groups in post treatment ILO symptom severity and frequency scores, assessed using the Vocal Cord Dysfunction Questionnaire (VCDQ) and the Dyspnoea Index (DI). Secondary outcome measures included differences between intervention groups in post treatment laryngeal hypersensitivity, the psychosocial impact of a voice disorder and anxiety or depressive symptoms as measured by the Laryngeal Hypersensitivity Questionnaire (LHQ), the Voice Handicap Index (VHI) and the Hospital Anxiety and Depression Scales (HADS). In addition, baseline to post treatment VCDQ, DI, LHQ, VHI and HADS scores were compared within the two groups. RESULTS: 41 participants aged between 18-67 years were recruited. There was no significant difference in post treatment adjusted VCDQ or DI mean between the treatment groups; VCDQ post treatment mean 37.35 (speech pathology and amitriptyline) and 38.12 (speech pathology and placebo) p=.820 or DI post treatment mean 15.96 (speech pathology and amitriptyline) and 16.52 (speech pathology and placebo) p=.833. There was a significant improvement in post treatment means compared to baseline in all outcome measures within treatment groups. The minimal clinically important difference on ILO symptom questionnaires (VCDQ and/or DI) was achieved in 73.7% of participants. CONCLUSION: In this double-blind randomised controlled trial, speech pathology effectively reduced ILO symptoms, laryngeal hypersensitivity, the impact of voice problems on patients’ quality of life and anxiety and depression scores, with no additional benefit from concurrent amitriptyline.

IntroductionAsthma and mental health problems co-occur at high rates. In context of a holistic approach to health, considering the extent to which social determinants relate to mental health in people with asthma helps identify health inequity and inform population-level preventative strategies. The aim of the current exploratory study was to examine how social determinants are associated with depression, anxiety and resilience in people with mild-moderate and severe asthma.MethodsA cross-sectional study of 144 adults (aged ≥18 years) with a diagnosis of asthma was conducted. Participants were classified as having mild-moderate asthma or severe asthma based on international guidelines. As part of a multidimensional assessment, participants self-reported age, sex, ethnicity, country of birth, living arrangements, employment, and postcode. They also completed validated self-report questionnaires for depression and anxiety [Hospital Anxiety and Depression Scale (HADS)], and resilience [Resilience Scale (RS-25)]. Bayesian regression analyses were conducted to examine the extent to which social determinants were associated with depression, anxiety and resilience.Results74 participants had mild-moderate asthma and 70 participants had severe asthma. Participants were on average 60 years old (SD = 14), 72% were female, 94% were Caucasian, 94% were Australian-born, 26% lived alone, 42% were working full- or part-time, and 83% lived in a major city of Australia. Anxiety and depression were relatively common (35% anxiety; 16% depression using HADS threshold of scores ≥8). Few social determinants were associated with depression, anxiety and/or resilience. Older age was associated with greater resilience. Females had higher levels of anxiety compared to males. Compared to participants currently working full- or part-time, those who were not working or studying due to their health had worse depressive symptoms and those who were not working for other reasons such as retirement had greater resilience.DiscussionAs in the general population, age, sex and employment/student status were associated with components of mental health in people with asthma. Although limited by the small sample size and sociodemographic homogeneity, the findings of this exploratory study contribute to the large body of work fostering a holistic approach to health and striving for health equity in people with asthma, particularly those who experience mental health problems.

BackgroundChronic refractory cough (CRC) is a challenging condition that responds to speech pathology intervention. Clinical observation suggests abnormal breathing patterns occur in CRC and may be indirectly addressed as part of behavioural treatment, yet breathing pattern changes in CRC are poorly understood. The aims of this study were to 1) describe breathing patterns in patients with CRC, 2) compare breathing pattern features between patients with CRC and inducible laryngeal obstruction (ILO), and 3) estimate the effect of breathing pattern features on clinical measures of laryngeal sensory and motor dysfunction.MethodsThis retrospective cross-sectional observational study included 634 patients with CRC or ILO. A file audit of speech pathology assessment data was undertaken. Analysis of self-reported laryngeal symptoms (viaquestionnaires) and clinical assessment of voice and breathing of those with CRC and ILO was conducted.ResultsMost participants with CRC (73%) demonstrated at least one abnormal breathing pattern feature. The most common feature was thoracic breathing (69%) followed by oral breathing (33%). The type and prevalence of abnormal breathing patterns were similar between CRC and ILO. Abnormal breathing patterns were associated with reduced maximum phonation time (MPT); however, there was no association between these features and Newcastle Laryngeal Hypersensitivity Questionnaire scores.ConclusionsAbnormal breathing features are common in patients with CRC and are not significantly different from those occurring in ILO. There is some association between abnormal breathing features and MPT, suggesting impairment of laryngeal motor function. Conversely, there is no association between abnormal breathing features and laryngeal hypersensitivity.

BACKGROUND:Asthma and vocal cord dysfunction (VCD), also known as inducible laryngeal obstruction (ILO), may coexist, resulting in worse outcomes for patients. The experience of people with VCD/ILO and coexisting asthma is unknown. OBJECTIVE:We sought to determine whether coexistent VCD/ILO and asthma have deleterious impacts on quality of life. METHODS:We undertook a descriptive qualitative study using one-to-one semistructured interviews with 30 purposively recruited adult participants with a prior confirmed doctor asthma diagnosis and laryngoscopy-confirmed VCD/ILO. A thematic and content analysis was conducted to explore the data. RESULTS:Participants were mostly female (63%), mean ± SD age 63 ± 12 years. Four themes were identified: trapped voice, altered life, knowledge about VCD/ILO, and looking for solutions. Participants reported their voice being trapped in their throat or the voice being suddenly cut off when talking or singing. Self-reported VCD/ILO symptoms including throat tightness and breathlessness were highlighted by participants. The second theme described how patients struggle to communicate or tended to shorten conversations. Insufficient knowledge and existing confusion regarding whether asthma was causing the breathlessness was described in the third theme. Looking for solutions depicted participants' diagnostic journey and how they sought an explanation for the symptoms. CONCLUSIONS:People with asthma and coexisting VCD/ILO experience a substantial burden affecting the quality of life. These data describe the impact on patients with coexisting conditions and should be used to increase clinician awareness of the experience of VCD/ILO from patients' perspectives to support a personalized approach to care.

Wildfires, including forest fires, bushfires, and landscape fires, have become increasingly prevalent, fueled by climate change and environmental factors and posing significant challenges to both ecosystems and public health. This review article examines the relationship between wildfires and respiratory diseases in outdoor workers, with a main focus on airway disease. In addition to the expected effects of direct thermal respiratory injuries and possible carbon monoxide poisoning, there are associations between wildfires and upper and lower respiratory effects, including infections as well as exacerbations of asthma and chronic obstructive pulmonary disease. A few studies have also shown an increased risk of new-onset asthma among wildfire firefighters. Outdoor workers are likely to have greater exposure to wildfire smoke with associated increased risks of adverse effects. As wildfires become increasingly prevalent globally, it is crucial to understand the various dimensions of this association. Furthermore, this review addresses preventive measures and potential interventions to alleviate the airway burden on individuals during and after work with wildfires events.

Background: The Newcastle Laryngeal Hypersensitivity Questionnaire (LHQ) was developed to measure abnormal laryngeal sensation and was originally validated in a patient sample from otolaryngologic and respiratory outpatient clinics. Modification is needed for patients who are mechanically ventilated via an endotracheal tube or a tracheostomy tube. Objectives: We sought to adapt and preliminarily validate a modified version of the LHQ appropriate for nurses and other clinicians to administer in acute hospital settings called the LHQ-Acute (LHQ-A). Methods: Internal consistency and construct validity analyses using secondary data from patients at a tertiary teaching hospital who presented with symptoms of laryngeal irritability/hypersensitivity between September 2012 and October 2013 were performed. Results: A total of 131 patients, most complaining of coughing and dysphonia, with a median age of 58 (interquartile range: 48, 66) years and 29 healthy participants with a median age of 62 (interquartile range: 50, 66) years were analysed. The original LHQ was reduced from 14 questions with responses on a 7-point scale to the LHQ-A containing 13 questions with responses on a 4-point scale. Correlations between items of the LHQ and LHQ-A were similar, and internal consistency was excellent and highly comparable, with Cronbach's alpha 1/4 0.906 and 0.902, respectively. Conclusions: The LHQ-A, which has been adapted for nurses and other clinicians to administer to a critically ill patient population, demonstrated comparable reliability and validity to the original LHQ. Validation of the LHQ-A in independent patient populations from acute settings is necessary to better understand norms and changes during recovery from acute illness. (c) 2023 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. All rights reserved.

Although cough is a protective reflex, it can occur in the absence of any physical need to clear the airway. In chronic cough, cough can be triggered by innocuous stimuli and persist despite medical treatment. Nonpharmacological interventions such as cough control therapy, provided by speech pathologists, have gained popularity in recent years. Intervention targets refractory or unexplained chronic cough, and efficacy has been studied in randomized controlled trials. Key elements of cough control therapy include education, anticipation, and control of the urge to cough, reducing laryngeal irritation and psychoeducational counseling. Our understanding of the mechanisms behind the success of nonpharmacological treatment is developing. It is likely the mechanisms of action are multifactorial across peripheral, central, and higher cortical regions. Nonpharmacological cough control therapy interventions are now included in international cough guidelines. However, approach to service delivery is not standardized and varies between regions and countries.

The authors declare no conflict of interest. The data for this study are not publicly available due to privacy and ethical restrictions.

AimSpeech pathology is the first-line treatment for inducible laryngeal obstruction (ILO) and involves behavioral techniques to address symptoms and modify maladaptive laryngeal postures. Benefit from speech pathology is reliant on patients engaging in treatment sessions, regular home practice, and generalizing techniques to everyday activities. There is limited research exploring engagement in speech pathology treatment for ILO, particularly from the patient perspective. This study aimed to explore the experiences of living with ILO and how this experience may impact the way patients engage in speech pathology treatment.Study designQualitative study.MethodsSemistructured interviews were completed with seven participants exploring their experiences living with ILO, their diagnostic process and their experiences with speech pathology treatment. Data were analyzed using reflexive thematic analysis to determine shared meanings across participants and themes were developed.FindingsThree major themes were identified - Life with ILO, Challenges of Speech Pathology Treatment, and What Matters to Me. Patients’ reports of living with ILO and interacting with speech pathology suggested that these experiences impacted their readiness to start treatment and persist through the challenges of the treatment. Engagement appeared to be positively associated with significant ILO symptom burden and life impact, confidence in the diagnostic process, recommendation for speech pathology treatment, a tailored intervention by a patient-perceived expert in the field and working in a partnership with the speech pathologist to develop a sense of agency. Patients indicated their engagement was negatively influenced by competing time demands, social embarrassment when using symptom relief techniques and laryngeal exercises, and a low ILO symptom burden and life impact.ConclusionThe reasons behind engagement in speech pathology treatment for ILO appear to be a complex interaction between previous experiences of living with ILO including the diagnostic process and the experience of speech pathology treatment. A patient-centered approach to therapy may help to maximize engagement by exploring readiness and expectations for treatment. The greater understanding of the patient experience provided through this study may allow speech pathologists to devise meaningful ways to maximize engagement in treatment for people with ILO.

BACKGROUND: Breathlessness is a disabling symptom, with complexity that is often under-recognized and undertreated in asthma. OBJECTIVE: To highlight the burden of breathlessness in people with severe compared with mild-to-moderate asthma and identify psychophysiological correlates of breathlessness. METHODS: This was a cross-sectional study of people with mild-to-severe asthma, who attended 2 in-person visits to complete a multidimensional assessment. The proportion of people with mild-to-moderate versus severe asthma who reported physically limiting breathlessness (modified Medical Research Council [mMRC] dyspnea score >= 2) was compared. Psychophysiological factors associated with breathlessness in people with asthma were identified via a directed acyclic graph and explored with multivariate logistic regression to predict breathlessness. RESULTS: A total of 144 participants were included, of whom, 74 (51%) had mild-to-moderate asthma and 70 (49%) severe asthma. Participants were predominantly female (n[ 103, 72%) with a median (quartile 1, quartile 3) age of 63.4 (50.5, 69.5) years and body mass index (BMI) of 31.3 (26.2, 36.0) kg/m(2). The proportion of people reporting mMRC >= 2 was significantly higher in those with severe- (n = 37, 53%) than those with mild-to-moderate (n = 21, 31%) asthma (P = .013). Dyspnoea-12 Total (8.00 = 4.75, 17.00] vs 5.00 [2.00, 11.00], P = .037) score was also significantly higher in the severe asthma group. Significant predictors of physically limiting breathlessness were BMI, asthma control, exercise capacity, and hyperventilation symptoms. Airflow limitation and type 2 inflammation were poor breathlessness predictors. CONCLUSIONS: Over half of people with severe asthma experience physically limiting breathlessness despite treatment. Targeting psychophysiological factors, or traits, associated with breathlessness may help relieve this distressing symptom, which is of high priority to people with asthma. (C) 2024 The Authors. Published by Elsevier Inc. on behalf of the American Academy of Allergy, Asthma & Immunology. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

Abstract Background The 2019/2020 Australian landscape fires (bushfires) resulted in prolonged extreme air pollution; little is known about the effects on breastfeeding women and their infants. This study aimed to examine the impact of prolonged landscape fires on infant feeding methods and assess the concentration of polycyclic aromatic hydrocarbons (PAHs) and elements in breast milk samples. Methods From May – December 2020, women with asthma, who were feeding their infants during the fires, were recruited from an existing cohort. Data on infant feeding and maternal concern during the fires were retrospectively collected. Breast milk samples were collected from a sample of women during the fire period and compared with samples collected outside of the fire period for levels of 16 PAHs (gas chromatography coupled with mass spectrometry), and 20 elements (inductively coupled plasma-mass spectrometry). Results One-hundred-and-two women who were feeding infants completed the survey, and 77 provided 92 breast milk samples. Two women reported concern about the impact of fire events on their infant feeding method, while four reported the events influenced their decision. PAHs were detected in 34% of samples collected during, versus no samples collected outside, the fire period (cross-sectional analysis); specifically, fluoranthene (median concentration 0.015 mg/kg) and pyrene (median concentration 0.008 mg/kg) were detected. Women whose samples contained fluoranthene and pyrene were exposed to higher levels of fire-related fine particulate matter and more fire days, versus women whose samples had no detectable fluoranthene and pyrene. Calcium, potassium, magnesium, sodium, sulphur, and copper were detected in all samples. No samples contained chromium, lead, nickel, barium, or aluminium. No statistically significant difference was observed in the concentration of elements between samples collected during the fire period versus outside the fire period. Conclusions Few women had concerns about the impact of fire events on infant feeding. Detection of fluoranthene and pyrene in breast milk samples was more likely during the 2019/2020 Australian fire period; however, levels detected were much lower than levels expected to be related to adverse health outcomes.

Objective: To analyze the validity of the Newcastle Laryngeal Hypersensitivity Questionnaire (LHQ-Br) in Brazilian Portuguese.Methods: The present study sample consisted of 89 individuals from the laryngeal hypersensitivity group and 41 individuals from the healthy group. The Newcastle Laryngeal Hypersensitivity Questionnaire's validation process for Brazilian Portuguese was composed of five stages: construct validity, reliability of internal consistency, and reliability regarding reproducibility, convergent validity, and discriminant validity. The software SPSS 25.0 was used. A significance level of 5% was considered statistically significant.Results: In construct validation, it was observed that the instrument was unifactorial; however, it was necessary to exclude two items with a low commonality that did not fit the model. The final instrument consisted of 12 items, and a factor called total, which explained 70.55% of the variance. In the internal consistency analysis, Cronbach's alpha was 0.962. The reproducibility had an intraclass correlation coefficient (ICC) was 0.949. In terms of convergent validity, there was a negative correlation between the total domain of the LHQ-Br and the total Cough Severity Index translated and adapted for the Brazilian Portuguese (P = 0.001) and total Voice Handicap Index - 10 (P < 0.001). Discriminant validity showed that ten items and the total factor differentiated healthy group individuals from those in the laryngeal hypersensitivity group.Conclusion: The 12-item LHQ-Br is valid and reliable for measuring the self-perception of laryngeal sensation associated with Brazilian patients with laryngeal hypersensitivity syndrome.

Chronic cough is a common problem that can be refractory to medical treatment. Nonpharmaceutical management of chronic cough has an important role in well selected patients. This review article outlines the history of chronic cough management, current approaches to speech pathology management of the condition and new modalities of nonpharmaceutical treatment. There is a need for further research into nonpharmaceutical options with well described randomised control trials.

Introduction Currently there is no consistent and widely accepted approach to the diagnosis of vocal cord dysfunction/inducible laryngeal obstruction (VCD/ILO). Harmonised diagnostic methods are vital to enable optimal diagnosis, advance management and enable research. We aim to obtain consensus on how expert clinicians recognise and diagnose VCD/ILO. Methods and analysis Two-round modified Delphi, with workshop validation. Ethics and dissemination Institutional Board Review was obtained from the Monash Health Human Research Ethics Committee. The dissemination plan is for presentation and publication. Registration details Registered at Australia and New Zealand Clinical Trials Registry ACTRN12621001520820p.