Research Article|Articles in Press

Identification of Breathing Pattern Disorder in Athletes With Exercise-Induced Laryngeal Obstruction: A Novel Assessment Tool

Published:January 27, 2023DOI:



      To report the diagnostic utility of the novel, high-ventilatory task assessment tool called the Milstein Breathing Pattern Assessment Index (M-BPAI) for evaluation of Breathing Pattern Disorder (BPD) in athletes with and without breathing difficulty, and to evaluate the prevalence of BPD in athletes referred for Exercise Induced Laryngeal Obstruction (EILO). BPD is an abnormal respiratory biomechanical pattern caused from functional or structural factors. The presence of BPD in athletes with EILO is unknown. The current clinical evaluations of dysfunctional breathing patterns are limiting for evaluation of BPD in patients with EILO, as these only evaluate the patients in low ventilatory output tasks of rest breathing.

      Study Design and Methods

      In this prospective study, a total of 77 athletes referred to the clinic for suspected EILO and 58 athletes without any respiratory difficulty underwent M-BPAI assessment. Data collection from the experimental group also included the Dyspnea Index, and laryngeal video endoscopic provocation test.


      The M-BPAI score was significantly larger in the patient group compared to the control group. An overall M-BPAI score of ≥8 corresponds to the AUC of 0.87 (95% CI: 0.81-0.93) with a sensitivity of 0.862 and specificity of 0.792. A total of 60 (78%) patients had an overall M-BPAI score of ≥8.


      The M-BPAI has the potential to be a valuable clinical diagnostic marker for identifying BPD in patients with suspected EILO with further research and validation.

      Key Words

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        • Patel RR
        • Venediktov R
        • Schooling T
        • et al.
        Evidence-based systematic review: effects of speech-language pathology treatment for individuals with paradoxical vocal fold motion.
        Am J Speech Lang Pathol. 2015; 24: 566-584
        • Shay EO
        • Sayad E
        • Milstein CF.
        Exercise-induced laryngeal obstruction (EILO) in children and young adults: from referral to diagnosis.
        Laryngoscope. 2020; 130: E400-E4E6
        • Christensen PM
        • Thomsen SF
        • Rasmussen N
        • et al.
        Exercise-induced laryngeal obstructions: prevalence and symptoms in the general public.
        Eur Arch Otorhinolaryngol. 2011; 268: 1313-1319
        • Christopher KL
        • Wood 2nd, RP
        • Eckert RC
        • et al.
        Vocal-cord dysfunction presenting as asthma.
        N Engl J Med. 1983; 308: 1566-1570
        • Smith B
        • Milstein C
        • Rolfes B
        • et al.
        Paradoxical vocal fold motion (PVFM) in pediatric otolaryngology.
        Am J Otolaryngol. 2017; 38: 230-232
        • Rogers JH
        • Stell PM
        Paradoxical movement of the vocal cords as a cause of stridor.
        J Laryngol Otol. 1978; 92: 157-158
        • Barker N
        • Thevasagayam R
        • Ugonna K
        • et al.
        Pediatric dysfunctional breathing: proposed components, mechanisms, diagnosis, and management.
        Front Pediatr. 2020; 8: 379
        • Hagman C
        • Janson C
        • Emtner M
        A comparison between patients with dysfunctional breathing and patients with asthma.
        Clin Respir J. 2008; 2: 86-91
        • Chapman EB
        • Hansen-Honeycutt J
        • Nasypany A
        • et al.
        A clinical guide to the assessment and treatment of breathing pattern disorders in the physically active: part 1.
        Int J Sports Phys Ther. 2016; 11: 803-809
        • Ionescu MF
        • Mani-Babu S
        • Degani-Costa LH
        • et al.
        Cardiopulmonary exercise testing in the assessment of dysfunctional breathing.
        Front Physiol. 2020; 11620955
        • Boulding R
        • Stacey R
        • Niven R
        • et al.
        Dysfunctional breathing: a review of the literature and proposal for classification.
        Eur Respir Rev. 2016; 25: 287-294
        • Thomas M
        • McKinley RK
        • Freeman E
        • et al.
        Breathing retraining for dysfunctional breathing in asthma: a randomised controlled trial.
        Thorax. 2003; 58: 110-115
        • Todd S
        • Walsted ES
        • Grillo L
        • et al.
        Novel assessment tool to detect breathing pattern disorder in patients with refractory asthma.
        Respirology. 2018; 23: 284-290
        • Courtney R
        • van Dixhoorn J
        • Cohen M.
        Evaluation of breathing pattern: comparison of a Manual Assessment of Respiratory Motion (MARM) and respiratory induction plethysmography.
        Appl Psychophysiol Biofeedback. 2008; 33: 91-100
        • Hagman C
        • Janson C
        • Emtner M.
        Breathing retraining - a five-year follow-up of patients with dysfunctional breathing.
        Respir Med. 2011; 105: 1153-1159
        • Lauhkonen E
        • Cooper BG
        • Iles R.
        Mini review shows that structured light plethysmography provides a non-contact method for evaluating breathing patterns in children.
        Acta Paediatr. 2019; 108: 1398-1405
        • Gartner-Schmidt JL
        • Shembel AC
        • Zullo TG
        • et al.
        Development and validation of the Dyspnea Index (DI): a severity index for upper airway-related dyspnea.
        J Voice. 2014; 28: 775-782
        • Youden WJ.
        Index for rating diagnostic tests.
        Cancer. 1950; 3: 32-35
        • Yi JS
        • Davis AC
        • Pietsch K
        • et al.
        Demographic differences in clinical presentation of pediatric paradoxical vocal fold motion (PVFM).
        J Voice. 2021; (Online ahead of print)
        • Hylton H
        • Long A
        • Francis C
        • et al.
        Real-world use of the breathing pattern assessment tool in assessment of breathlessness post-COVID-19.
        Clin Med. 2022;
        • Harbour E
        • Stoggl T
        • Schwameder H
        • et al.
        Breath tools: a synthesis of evidence-based breathing strategies to enhance human running.
        Front Physiol. 2022; 13813243
        • Christensen PM
        • Heimdal JH
        • Christopher KL
        • et al.
        ERS/ELS/ACCP 2013 international consensus conference nomenclature on inducible laryngeal obstructions.
        Eur Respir Rev. 2015; 24: 445-450
        • Olin JT
        • Clary MS
        • Fan EM
        • et al.
        Continuous laryngoscopy quantitates laryngeal behaviour in exercise and recovery.
        Eur Respir J. 2016; 48: 1192-1200
        • Heimdal JH
        • Roksund OD
        • Halvorsen T
        • et al.
        Continuous laryngoscopy exercise test: a method for visualizing laryngeal dysfunction during exercise.
        Laryngoscope. 2006; 116: 52-57