Ipratropium Bromide (Atrovent®) Used to Treat Exercise Induced Laryngeal Obstruction (EILO). An Open Label Pilot Study

Exercise induced inspiratory symptoms (EIIS) is increasingly recognized as an important differential diagnosis to exercise induced asthma (EIA) in otherwise healthy adolescents. EIIS is most often linked to laryngeal abnormalities and if so, often labelled exercise induced laryngeal obstruction (E-ILO). In unselected populations, E-ILO has been found in 7.5% and 5.7% of adolescents. Causal mechanisms remain unclear, and a variety of structural and/or functional pathways have been proposed, such as abnormalities related to the epiglottis, the laryngeal cartilage-skeleton or its support, mucosal structures as well as the laryngeal muscular system or its nerve supply. All these abnormalities might conceivably disturb the airflow on its way through the laryngeal inlet, increase the turbulence and the airflow resistance, and thereby set up a sense of dyspnea and trigger the symptoms that are characteristic of EIIS. Additionally, various psychological characteristics have been proposed to be implicated in this causal cascade.

As the causal mechanisms of E-ILO have not been clarified, all attempts on treatment of this condition have been empirical and there is currently no properly evidence-based treatment available. Speech therapy, often in combination with some kind of psychotherapy, have been viewed as mainstay therapy by most authors, whereas other psychological measures such as relaxation therapy, hypnosis and biofeedback have been advocated by others. Anticholinergic aerosols applied before exercise has been suggested and there are reports of successful surgical treatment using laser supraglottoplasty. The common goal of these treatment initiatives has been to increase the size of the laryngeal inlet during the increasing airflow velocity that is induced by increasing exercise intensity.

Inducible laryngeal obstructions were previously often labeled vocal cord dysfunction (VCD), and Ayres et al. proposed in 2002 in an article in Thorax that VCD could be a function of an altered autonomic balance. This view opened for a theoretical framework for treatment of VCD using inhaled anticholinergic agents such as Ipratropium bromide (Atrovent®).

To our knowledge, positive effects from inhaled anticholinergic agents in VCD have so far only been published as case reports, and systematic studies have not been performed.

This study aims to address potential effects from Atrovent in patients with E-ILO verified during a continuous laryngoscopy exercise (CLE) test. The study will primarily include 20 patients consecutively referred to our clinic for EIIS and diagnosed with E-ILO during a routine CLE test. Requirement for inclusion will be a CLE score ≥ 3. The primary endpoint will be the laryngeal response to maximal exercise, described quantitatively by a blinded observer using the CLE score system. Two CLE tests will be performed in each subject, one with - and one without - prior treatment with Atrovent. The patient will thus serve as her/his own control. Half the patients will receive Atrovent before the first study test (at T1), the other half before the second (at T2).