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Aim: To compare overall, fine, and gross motor abilities in adults born preterm with very low birthweight (VLBW) and a control group of term‐born individuals. Method: In a joint assessment of the Helsinki Study of Very Low Birth Weight Adults and NTNU Low Birth Weight in a Lifetime Perspective study, data were collected with harmonized methods for 118 adults born preterm (gestational age < 37 weeks) with VLBW (≤1500 g) and 147 control individuals. The primary outcome was overall motor abilities; secondary outcomes were fine and gross motor abilities. Results: The Bruininks Motor Ability Test Short Form total score was 4.1 (95% confidence interval 2.7–6.0) points lower in adults born with VLBW than in the control group, adjusted for cohort, age, and sex. This was partly mediated by their shorter height. They also had lower scores for other fine and gross motor tests. Results were similar when participants with neurosensory impairment were excluded, and when we adjusted for additional covariates. Interpretation: Adults born preterm with VLBW had poorer overall, fine, and gross motor abilities than adults born at term. This indicates that substantial difficulties in motor function among individuals born preterm with VLBW persist into mid‐adulthood. [ABSTRACT FROM AUTHOR]

Aim: Investigate potential long- term cohort influences on health-related quality of life (HRQoL) in adults born extremely preterm (EP) during the 1980-90s, in view of advancements in neonatal care within that timeframe. Methods: Two cohorts of EP-born adults (82-85 cohort and 91-92 cohort) enrolling matched term controls, were compared. Participants were assessed at 18 years and again in their mid-twenties using the Child Health Questionnaire Children Form- 87 (CHQ-CF87) and the Short Form Health Survey (SF-36). Results: At 18 years, 77 (90%) EP- born and 75 (93%) term controls had data, followed by 67 (78%) EP-born and 66 (82%) term controls in their mid-twenties. At 18 years, there were no differences across the birth decades, and EP-born and term-born reported relatively similar HRQoL scores. In the mid- twenties, birth decade did also not significantly impact HRQoL scores, although the EP--born 82-85 cohort scored numerically poorer than the 91-92 cohort in three domains. Term controls scored similarly across birth decade in all domains. Regarding influence from neonatal factors, postnatal corticosteroids had a negative impact in some domains. Conclusion: No significant differences in HRQoL were observed between EP-born adults from the 82-85 cohort versus the 91-92 cohort, although the EP- born 82-85 cohort tended to score poorer in their mid-twenties. [ABSTRACT FROM AUTHOR]

Aim: To (1) compare the perceived benefit of long‐term mechanical insufflation‐exsufflation (MI‐E) of children with neuromuscular disorders (NMDs) and central nervous system (CNS) disorders, including health care needs and treatment routines and (2) describe the children's health‐related quality of life (HRQoL). Method: This cross‐sectional study used a questionnaire and memory card data to assess the perceived benefit of MI‐E via the Visual Analogue Scale (VAS; 10 maximum), willingness to pause treatment, level of health care needs before and after MI‐E initiation, and the children's treatment routines. A DISABKIDS questionnaire assessed HRQoL (100 maximum). Results: Seventy‐three children using MI‐E participated (42 males, median [interquartile range {IQR}] age 10 years 2 months [6 years 3 months–14 years 1 month]), 47 with NMDs (such as spinal muscular atrophy and Duchenne muscular dystrophy) and 26 with CNS disorders (such as cerebral palsy, encephalitis, neurometabolic and other diseases). The median (IQR) VAS score for the perceived benefit of MI‐E therapy at stable state and respiratory tract infection were 9 (6–10) and 10 (8.5–10) respectively. Sixty‐two per cent were reluctant or unwilling to pause MI‐E therapy, with no NMD versus CNS disorder group difference. After MI‐E initiation, fewer physician consultations and hospitalizations were reported by the group with NMDs. The MI‐E routine was similar in both groups. The mean (SD) HRQoL score for 26 of 51 eligible children was 71 (16.7). Interpretation: MI‐E treatment was generally perceived as beneficial and performed equally in both diagnostic groups. HRQoL was in line with children with a moderate‐to‐severe chronic condition. What this paper adds: Mechanical insufflation‐exsufflation (MI‐E) was generally perceived as beneficial by the children and parents.The reported benefit of MI‐E was higher among daily than sporadic MI‐E users.The MI‐E treatment routine did not differ between diagnostic groups.The health‐related quality of life in this neuropaediatric population was in line with that of children with other moderate‐to‐severe chronic conditions. [ABSTRACT FROM AUTHOR]

The article focuses on the measurement of translaryngeal resistance as a parameter to assist decision-making in upper airway pathology, particularly exercise-induced laryngeal obstruction (EILO). It discusses the feasibility of measuring translaryngeal resistance and its potential use in guiding clinical decisions for patients with EILO or other laryngeal disorders, highlighting the importance of establishing normative data for this parameter.

The article focuses on evaluating lung function in extremely preterm-born adults in their fourth decade of life, revealing widespread lung function impairments including airway obstruction and reduced gas diffusion capacity, which may indicate the presence of a unique lung phenotype related to early preterm birth.

Background: Lifelong pulmonary consequences of being born extremely preterm or with extremely low birth weight remain unknown. We aimed to describe lung function trajectories from 10 to 35 years of age for individuals born extremely preterm, and address potential cohort effects over a period that encompassed major changes in perinatal care.Methods: We performed repeated spirometry in three population-based cohorts born at gestational age ≤28 weeks or with birth weight ≤1000 g during 1982-85, 1991-92 and 1999-2000, referred to as extremely preterm-born, and in term-born controls matched for age and gender. Examinations were performed at 10, 18, 25 and 35 years. Longitudinal data were analysed using mixed models regression, with the extremely preterm-born stratified by bronchopulmonary dysplasia (BPD).Results: We recruited 148/174 (85%) eligible extremely preterm-born and 138 term-born. Compared with term-born, the extremely preterm-born had lower z-scores for forced expiratory volume in 1 s (FEV1) at most assessments, the main exceptions were in the groups without BPD in the two youngest cohorts. FEV1 trajectories were largely parallel for the extremely preterm- and term-born, also during the period 25-35 years that includes the onset of the age-related decline in lung function. Extremely preterm-born had lower peak lung function than term-born, but z-FEV1 values improved for each consecutive decade of birth (p=0.009). More extremely preterm-than term-born fulfilled the spirometry criteria for chronic obstructive pulmonary disease, 44/148 (30%) vs 7/138 (5%), p<0.001.Conclusions: Lung function after extremely preterm birth tracked in parallel, but significantly below the trajectories of term-born from 10 to 35 years, including the incipient age-related decline from 25 to 35 years. The deficits versus term-born decreased with each decade of birth from 1980 to 2000. [ABSTRACT FROM AUTHOR]

Purpose: Exercise‐induced bronchoconstriction (EIB) and exercise‐induced laryngeal obstruction (EILO) are the two disorders commonly considered when athletes complain of exertional dyspnea. They are highly different but often confused. We aimed to address this diagnostic challenge and its consequences in elite athletes. Methods: We included all athletes competing at national or international level, referred to our institution for workup for EILO during 2013–2016. We diagnosed EILO from video‐recorded laryngoscopy performed during maximal cardiopulmonary treadmill exercise (CLE test). Symptoms and previous diagnostic evaluations were obtained from referral letters and chart reviews. Results: Exercise‐induced laryngeal obstruction was diagnosed in 73/101 referred athletes, of whom 70/73 had moderate/severe supraglottic obstruction and 3/73 had primarily glottic obstruction with only minor supraglottic involvement. Of the 73 athletes with EILO, we were able to identify objective tests for asthma in 55 participants, of whom 22 had findings supporting asthma. However, 58/73 had used asthma therapy at some time previously, with current use in 28. Only three reported that asthma medication had improved their exercise‐related breathing problems, two of whom with tests confirming asthma. Treatment for EILO improved breathing problems in all but four. Conclusions: Objective testing verified EILO in most of the referred athletes. EILO coexisting with asthma was common, and large proportions had used asthma medication; however, few reported effect on exercise‐related breathing problems. Unexplained persistent exertional dyspnea must not lead to indiscriminate escalation of asthma treatment, but instead incite investigation for EILO, either as a co‐morbidity or as a differential diagnosis. [ABSTRACT FROM AUTHOR]

Objectives/hypothesis: To determine if simultaneous tracheal and supraglottic pressure measurement performed during a continuous laryngoscopy exercise (CLE) test is possible, tolerable, and feasible, and if so, whether measurements can be used to determined airflow resistance over the larynx, thus providing an objective outcome measure for the CLE test, the gold standard for diagnosing exercise-induced laryngeal obstruction.Study Design: Explorative descriptive clinical study.Methods: A CLE test was performed with the addition of two pressure sensors (Mikro-Cath 825-0101; Millar, Houston, TX) placed at the epiglottic tip and at the fifth tracheal ring. To place sensors, laryngeal anesthesia and a channel scope were required. Tolerability and feasibility was determined by a Likert score and subjective indication from subjects and operators. Adjustments to the technique were made to increase tolerability. The pressure data were continuously collected and analyzed for artifacts, drifts, frequency response, and used with flow data to calculate translaryngeal resistance.Results: All subjects (n = 7) completed all procedures. Two main areas of concern were identified regarding tolerability: application of topical anesthesia to the larynx and nasal discomfort due to the added diameter of the laryngoscope. Protocol adjustments improved both. Pressure data were obtained from all procedures in all subjects, were consistent, and followed physiological trends.Conclusions: Continuous measurement of the translaryngeal pressure gradient during a CLE test is possible, feasible, and tolerable. A CLE test with direct measurement of the translaryngeal pressure gradient might become a valuable tool in the objective assessment of respiratory function, and normal values should be established in health and disease.Level Of Evidence: NA Laryngoscope, 129:2748-2753, 2019. [ABSTRACT FROM AUTHOR]

The authors comment on a study published within the issue which analyzed flow and pressure graphs generated by mechanical insufflation-exsufflation (MI-E) treatment to detect unwanted upper-airway responses and how this could aid in choosing the right treatment parameters for amyotrophic lateral sclerosis (ALS). Topics covered include the strengths and limitations of the study, and the important contribution of the study to the field of laryngeal involvement in respiratory care.

Exercise‐induced laryngeal obstruction (EILO) is common, but we lack readily available diagnostic tools. The larynx represents an important point of resistance in the airways, and we therefore hypothesized that EILO is associated with characteristic breathing patterns possible to record from a standard incremental ergospirometry test. We studied 24 individuals with moderate/severe EILO and 20 individuals with no‐EILO, mean (SD) age 17 (6.1) and 24 (6.4) years, respectively. EILO versus no‐EILO was verified from maximal continuous laryngoscopy treadmill exercise (CLE) tests, which also included ergospirometry. We described the relationships between minute ventilation (V˙E) versus tidal volume (VT) and V˙E versus carbon dioxide output (V˙CO2), using respectively quadratic and linear equations, and applied adjusted regression models to compare ergospirometry data and curve parameters. Compared to the no‐EILO group, the group with EILO had prolonged inspiratory time (Tin), lower breathing frequency (Bf), lower V˙E, and lower inspiratory flow rate (V˙in) at peak exercise. Mathematical modeling of the breathing pattern relationships was feasible in both groups, with similar coefficients of variation. For V˙E versus VT, the mathematical curve parameters were similar. For V˙E versus V˙CO2, the slope was similar but the intercept was lower in the EILO group. EILO was associated with prolonged Tin, lower Bf, V˙E, and V˙E. The relationship between V˙E versus VT was similar, whereas for V˙E versus V˙CO2, the slope was almost parallel but shifted downward for the EILO group. Most ergospirometry data overlapped, except V˙in which discriminated between EILO and no‐EILO in a promising way. [ABSTRACT FROM AUTHOR]

When the ability to cough is impaired, secretion clearance may be assisted and augmented with mechanical insufflation-exsufflation (MI-E). In some individuals, the efficacy of MI-E may be hampered by counterproductive upper airway reactions, where the airways close in response to positive pressures. To fully utilize the therapeutic potential inherent in the MI-E technology, we need a better understanding of the pathophysiology behind these untoward reactions. There is increasing interest in monitoring and measuring upper airway responses to MI-E and how such information can be used to optimize MI-E settings. The purpose of this narrative review is to increase the theoretical understanding of the larynx as a respiratory organ, summarize the current literature in the area, and provide insight into how this knowledge can affect current clinical practice [ABSTRACT FROM AUTHOR]

Aim: To determine the prevalence of long‐term mechanical insufflation‐exsufflation (MI‐E) and concomitant mechanical ventilation in children with neurological conditions, with reported reasons behind the initiation of treatment. Method: This was a population‐based, cross‐sectional study using Norwegian national registries and a questionnaire. Results: In total, 114 of 19 264 children with a neurological condition had an MI‐E device. Seventy‐three of 103 eligible children (31 females, 42 males), median (min–max) age of 10 years 1 month (1y 5mo–17y 10mo), reported their MI‐E treatment initiation. Overall, 76% reported airway clearance as the main reason to start long‐term MI‐E. A prophylactic use was mainly reported by children with neuromuscular disorders (NMDs). Prevalence and age at initiation differed by diagnosis. In spinal muscular atrophy and muscular dystrophies, MI‐E use was reported in 34% and 7% of children, of whom 83% and 57% respectively received ventilator support. One‐third of the MI‐E users were children with central nervous system (CNS) conditions, such as cerebral palsy and degenerative disorders, and ventilator support was provided in 31%. The overall use of concomitant ventilatory support among the long‐term MI‐E users was 56%. Interpretation: The prevalence of MI‐E in a neuropaediatric population was 6 per 1000, with two‐thirds having NMDs and one‐third having conditions of the CNS. The decision to initiate MI‐E in children with neurological conditions relies on clinical judgment. What this paper adds: The prevalence and age at initiation of mechanical insufflation/exsufflation (MI‐E) differed between diagnoses.MI‐E was most commonly used in spinal muscular atrophy, where it generally coincided with ventilatory support.One‐third of MI‐E devices were given to children with central nervous system conditions, and one‐third also received ventilatory support. What this paper adds: The prevalence and age at initiation of mechanical insufflation/exsufflation (MI‐E) differed between diagnoses.MI‐E was most commonly used in spinal muscular atrophy, where it generally coincided with ventilatory support.One‐third of MI‐E devices were given to children with central nervous system conditions, and one‐third also received ventilatory support. This article is commented on by Langdon and Cooper on pages 494–495 of this issue. [ABSTRACT FROM AUTHOR]

Dynamic laryngoscopy during noninvasive (NIV) respiratory therapy is feasible and may facilitate optimal and individualized treatment in patients with chronic respiratory failure, also in children. [ABSTRACT FROM AUTHOR]

Dynamic obstructions of the larynx are a set of disorders that occur during exercise in equines and humans. There are a number of similarities in presentation, diagnosis, pathophysiology and treatment. Both equines and humans present with exercise intolerance secondary to dyspnea. During laryngoscopy at rest, the larynx appears to function normally. Abnormalities are only revealed during laryngoscopy at exercise, seemingly triggered by increased ventilatory demands, and quickly resolve after cessation of exercise. Lower airway disease (asthma being the most prevalent condition), cardiac disease and lack of fitness are the major differentials in both species. Laryngoscopic examination during exercise should be performed from rest to peak exertion to allow for a comprehensive diagnosis, including where the airway collapse begins, and thereafter how it progresses. Dynamic disorders with most visual similarity between humans and equines are: aryepiglottic fold collapse (both species); equine dynamic laryngeal collapse (DLC) relative to some forms of human combined supraglottic/glottic collapse; and epiglottic retroversion (both species). Quantitative grading techniques, such as airway pressure measurement, that have proven effective in veterinary research are currently being piloted in human studies. Conditions that appear visually similar are treated in comparable ways. The similarities of anatomy and certain types of dynamic collapse would suggest that the equine larynx provides a good model for human upper respiratory tract obstruction during exercise. Thus, close collaboration between veterinarians and medical personal may lead to further advancements in understanding pathophysiologic processes, and enhance the development of improved diagnostic tests and treatments that will benefit both species. [ABSTRACT FROM AUTHOR]

The article discusses a study that formed an in vitro model to explore the role played by the upper airways while using the mechanical insufflation-exsufflation cough-enhancement technique. Highlights include the role of the larynx in controlling air-flow resistance during exercise, the use of several resistance-compliance models to imitate conditions in the respiratory system, and a new geometry generated by the structural changes caused by the air-flow.

Background: Preterm birth and low birth weight are associated with reduced nephron numbers and increased risk of hypertension and kidney disease in later life. Aims: We tested the hypothesis that extremely preterm birth and intrauterine growth restriction is associated with decreased renal function in mid childhood. Methods: At 11 years of age the following measures were obtained in a regional cohort of children born extremely premature (EP, i.e. < 28 weeks gestational age—GA) or with extremely low birth weight (ELBW, i.e. BW < 1000 grams) and in matched controls born at term with appropriate BW (AGA): Height, weight, abdominal circumference, triceps and subscapular skin fold thicknesses, blood pressure, plasma levels of creatinine, cystatin C and symmetric dimethyl arginine (SDMA). Small for gestational age (SGA) was defined as a BW < 10th percentile for GA. Glomerular filtration rate (GFR) was estimated according to the equations by Schwartz, Zappitelli and Gao. Results: Fifty-seven of 61 eligible EP/ELBW children, 20 (35%) born SGA, and 54 controls, were assessed. Estimated GFR decreased while plasma SDMA increased from the children born AGA at term through those born preterm AGA to preterm SGA. Systolic BP was correlated to fat mass indices (p<0.03), but not to renal function (p>0.2) and did not differ between the groups. Conclusions: Children born EP/ELBW, particularly those born SGA, had impaired renal function at age 11 years as judged from estimated GFRs and plasma levels of SDMA. Since reduced renal function is associated with an increased risk of later disease, these children should be followed in order to minimize additional risk factors. [ABSTRACT FROM AUTHOR]

BACKGROUND: Respiratory complications represent the major cause of death in amyotrophic lateral sclerosis (ALS). Noninvasive respiratory support is the mainstay therapy, but treatment becomes challenging as the disease progresses, possibly due to a malfunctioning larynx, which is the entrance to the airways. We studied laryngeal response patterns to mechanically assisted cough (mechanical insufflation-exsufflation) as ALS progresses. METHODS: This prospective longitudinal study of 13 consecutively included subjects with ALS were followed up during 2011-2016 with repeated tests of lung function, neurological status, and laryngeal responses to mechanical insufflation-exsufflation using video-recorded flexible transnasal fiberoptic laryngoscopy. RESULTS: Follow-up time was median 17 (range 6-59) months. In total, 751 laryngoscopy recordings from 67 individual examinations (median 4 per subject, range 2-11 per subject) were analyzed. Adverse laryngeal events that developed with disease progression during insufflation included adduction of true vocal folds in 8 of 9 spinal-onset subjects and adduction of aryepiglottic folds in all subjects, initially at the highest positive pressure and prior to onset of other bulbar symptoms in spinal-onset subjects. As cough became less expulsive with disease progression, laryngeal adduction occurred at lower insufflation pressures. Retroflex movement of the epiglottis was observed in 7 of 13 subjects regardless of insufflation pressures and independent of bulbar involvements. Backward movement of the tongue base occurred regardless of insufflation pressures in all but 1 subject. During exsufflation, constriction of the hypopharynx was observed in all subjects regardless of the presence of bulbar symptoms, after the adverse events that occurred during insufflation. CONCLUSIONS: Applying high insufflation pressures during mechanically assisted cough in ALS can become counterproductive as the disease progresses as well as prior to the onset of bulbar symptoms. The application of positive inspiratory pressures should be tailored to the individual patient, and laryngoscopy during ongoing treatment appears to be a feasible tool. [ABSTRACT FROM AUTHOR]

Objective: Compare respiratory health in children born extremely preterm (EP) or with extremely low birthweight (ELBW) nearly one decade apart, hypothesizing that better perinatal management has led to better outcome. Design: Fifty-seven (93%) of 61 eligible 11-year old children born in Western Norway in 1999–2000 with gestational age (GA) <28 weeks or birthweight <1000 gram (EP1999–2000) and matched term-controls were assessed with comprehensive lung function tests and standardized questionnaires. Outcome was compared with data obtained at 10 years of age from all (n = 35) subjects born at GA <29 weeks or birthweight <1001 gram within a part of the same region in 1991–92 (EP1991–1992) and their matched term-controls. Results: EP1999–2000 had significantly reduced forced expiratory flow in 1 second (FEV1), FEV1 to forced vital capacity (FEV1/FVC) and forced expiratory flow between 25–75% of FVC (FEF25–75), with z-scores respectively -0.34, -0.50 and -0.61 below those of the term-control group, and more bronchial hyperresponsiveness to methacholine (dose-response-slope 13.2 vs. 3.5; p<0.001), whereas other outcomes did not differ. Low birthweight z-scores, but not neonatal bronchopulmonary dysplasia (BPD) or low GA, predicted poor outcome. For children with neonatal BPD, important lung-function variables were better in EP1999–2000 compared to EP1991–1992. In regression models, improvements were related to more use of antenatal corticosteroids and surfactant treatment in the EP1999–2000. Conclusions: Small airway obstruction and bronchial hyperresponsiveness were still present in children born preterm in 1999–2000, but outcome was better than for children born similarly preterm in 1991–92, particularly after neonatal BPD. The findings suggest that better neonatal management not only improves survival, but also long-term pulmonary outcome. [ABSTRACT FROM AUTHOR]

The article examines exercise-related breathing problems. Topics discussed include functions of the larynx including prevention of aspiration, vocalization and maintenance of maximal opening during exercise, consequence of misdiagnosis of exercise-induced laryngeal obstruction (EILO) which is often confused with asthma, and background of the case of a 14-year-old girl who had atopic asthma reversible to albuterol and hyperresponsive to methacholine.