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Wednesday, November 7, 2012

Rebecca thought she had asthma. So why didn't inhalers help?


'I felt as if a weight had been lifted off my shoulders,' said Rebecca
'I felt as if a weight had been lifted off my shoulders,' said Rebecca

Rebecca Eno was used to feeling a bit puffed after exercise. She regularly pushed her body to the limit and was a competitive rower for her school team. However, after one training session in 2010, when Rebecca was just 17, not only did her breathing not return to normal — it got worse. ‘People talk about fighting for breath and that’s what I felt — I just could not grab in enough air to breathe properly,’ says Rebecca, 20, a biology and chemistry student at Durham University. ‘It felt as if someone was trying to strangle me.’ She was in such distress an ambulance was called. Paramedics gave her oxygen and she also used her inhaler as she is mildly asthmatic, but her wheezing did not improve. After half an hour, just as she was starting to panic, her breathing returned to normal of its own accord.



Ambulance staff told her it was an attack of exercise-induced asthma.  It sounded a reasonable diagnosis.  Exercise, though beneficial, can bring on an attack for many of Britain’s 5.4million asthmatics. An Asthma UK survey found 76per cent of people with asthma say exercise is a trigger for their symptoms. Quite why it does this is not fully understood, but it’s thought that breathing in more air as you exercise dries the airways. This triggers the release of chemicals that make the airways contract, leading to breathlessness. And this becomes worse if you exercise outside in the cold as this dries the airways further still.

However, normally this should be controllable with an inhaler. The strange thing about Rebecca’s case was that her inhaler was not doing anything.  Nor did it when the next attacks occurred. Between February and July that year she had six more, each during her training sessions. ‘The last attack I had it took 1½ hours for me to recover,’ says Rebecca. ‘I had to be taken out of the rowing boat, put into a speedboat and taken to an ambulance on the shore, where I was given oxygen and a nebuliser.’ For a year, specialists at St Mary’s Hospital in Paddington tried her on a variety of asthma medications. Yet none worked. The issue was that while Rebecca has asthma, it wasn’t this that was causing the breathlessness when she exercised.  The problem was coming from her voice box — and if it wasn’t for a new test there is every chance her breathlessness would still be mistaken for asthma. What she has is called exercise-induced laryngeal obstruction (EILO).

It’s essentially a spasm of the voice box and the vocal cords (the thin membranes that sit over the voice box at the top of the windpipe). The symptoms — wheezing and breathlessness — are almost identical to asthma, and until now there has been no easy way to tell the difference. The problem is that the treatment for each condition is entirely different. EILO will not respond to inhalers because while asthma is caused by overly sensitive airways in the lungs that inflame through exposure to allergens or, indeed, exercise, EILO is caused by the vocal cords closing over the windpipe during exercise.

A study is under way to see if having asthma makes you more prone to EILO, and if any age groups are especially at risk. EILO is helped by physiotherapy and learning to breathe through the nose (this warms the air before it goes into the lungs; cool air is likely to trigger EILO). It’s estimated that thousands of people, if not more, may be taking asthma medication needlessly. There are no accurate figures yet, but one study published in the medical journal Chest in 2003 found that at least 5per cent of all athletes suffer from it. 
 Exercise, though beneficial, can bring on an attack for many of Britain's 5.4 million asthmatics

Exercise, though beneficial, can bring on an attack for many of Britain's 5.4 million asthmatics

A paper in the European Respiratory Society’s journal last year said that while the frequency of EILO among the general population remains unknown, it ‘could also have a major influence’ on the diagnosis of those with asthma-like symptoms. ‘Normally, the vocal cords should stay completely out of the way during exercise, but what we see with EILO is the cords almost completely closing, which generates a lot of discomfort, wheezing and breathing difficulty,’ says Dr Andrew Menzies-Gow, a consultant respiratory physician at the Royal Brompton Hospital. ‘This can be a problem for anyone exercising, and for an elite athlete it can be critical. ‘Why the vocal cords close in this way in some people we don’t know. 'Normally, they move to make speech and move over the windpipe when we swallow to stop food going into the lungs. ‘It may be that when you breathe deeply during exercise, the turbulence of the breath being forced past makes them shut in some people.’

The only slight difference between the symptoms of EILO and asthma is that the wheeze is more pronounced when you breathe in with EILO —  and when you breathe out  with asthma. ‘However, if you are struggling to breathe properly then you won’t notice at what point exactly you wheeze more — and if you tell your GP you are wheezing and breathless after exercise, they will most probably initially diagnose asthma,’ says Dr Menzies-Gow. Some may solely have the vocal cord problem, while others might have asthma as well. ‘About 5per cent of people with asthma have severe asthma and do not respond well to medication and may need admission to hospital for help with their breathing. ‘It may be that some of these people also have EILO and that by using physiotherapy to help this the symptoms of their asthma will improve, too,’ says Dr Menzies-Gow.

Until now there has been no easy way to diagnose EILO, but now there is a new test that can diagnose it on the spot. It involves inserting a tiny camera — about half as thick as a pencil — up the nose to look at the back of the throat. The patient is then asked to pedal on an exercise bike or use a treadmill to replicate symptoms. This test was imported from Denmark and is being used at the Royal Brompton Hospital in South-West London. It should soon be available more widely. The camera allows the team to watch any movement of the vocal cords and the results are recorded on to a computer.

Over the past six months the team at the Royal Brompton have done ten tests in young adults and 25 others in severe asthmatics in a study funded by Asthma UK — a large number has been found to have the vocal cord problem as well as asthma. For Rebecca it’s been life-transforming. Her local hospital had said there was no more they could do to help with her ‘asthma’ and she faced having to give up the sport she loved. Luckily, a consultant had heard about the new test and thought Rebecca would be a good candidate to try it. ‘When they told me that my results showed I had EILO, I felt as if a weight had been lifted off my shoulders. 'Half an hour later I was on my way to see the physiotherapist to learn how to manage my condition.’ Since then she has been doing her exercises almost daily. ‘It takes a long time to build up — at first, I would do the techniques for 30 seconds. 'I have to get up to 25 minutes before I can start proper training, but I hope to get there in eight weeks,’ she says. ‘If I hadn’t had the test, things could have turned out very differently for me.’

 Source: Daily Mail UK 

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