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• W4386885358 abstract "To the Editor: We thank Dr Weinberger for his letter and for participation in the recent Delphi consensus survey.1Weinberger M. VCD and ILO are not synonymous.J Allergy Clin Immunol. 2023; 152 (xxx-xxx)Google Scholar His letter raises points on terminology, differential diagnosis, and the attribution of exercise-induced symptoms in pediatric populations. On terminology, Dr Weinberger highlights the fact that the terms vocal cord dysfunction (VCD) and inducible laryngeal dysfunction (ILO) are not synonymous, which is technically correct, and where needed, the terms are disambiguated within the Delphi consensus survey. We have adopted a pragmatic approach to the complex, long-standing nomenclature issue. ILO is indeed an umbrella term encompassing all forms of inappropriate laryngeal narrowing during breathing, including obstruction restricted solely to the vocal folds (ie, glottic ILO). However, in the Delphi consensus survey, experts agreed that in some individuals no inducer or trigger can be found. Importantly, the broader clinical community generally recognizes VCD as a syndrome rather than a specific anatomic diagnosis (although by wording, one would assume the label to include only vocal fold abnormalities). ILO is less well recognized as a label. For example, as of August 2023, the National Library of Medicine Medical Subject Headings (MeSH) recognized only VCD and not ILO. Further, the recently published revised Brighton Collaboration anaphylaxis case definition uses VCD as the primary term.2Leong P. Vertigan A.E. Hew M. Baxter M. Phyland D. Hull J.H. et al.Diagnosis of vocal cord dysfunction/inducible laryngeal obstruction: an International Delphi Consensus Study.J Allergy Clin Immunol [E-pub ahead of print]. June 20, 2023; https://doi.org/10.1016/j.jaci.2023.06.007Google Scholar When the Delphi consensus survey’s publication and dissemination were considered, it was important to emphasize this work’s continuity with prior literature and enhance findability; thus, the term VCD/ILO was used. Notably, the 2023 Global Initiative for Asthma Main Report3Gold M.S. Amarasinghe A. Greenhawt M. Kelso J.M. Kochhar S. Yu-Hor Thong B. et al.Anaphylaxis: revision of the Brighton collaboration case definition.Vaccine. 2023; 41: 2605-2614Google Scholar takes an approach similar to that in the Delphi survey, referring to the condition as “inducible laryngeal obstruction (also known as VCD).” Continued debate on language has a real opportunity cost, as has been the experience with many heterogenous disorders, because it can detract from progressing knowledge and outcomes. The priority should be on advancing understanding of this multifaceted condition. Inappropriate laryngeal narrowing in association with dyspnea occurs in myriad clinical situations. It is likely that causal pathways vary, and as such, treatments are also likely to vary. On differential diagnosis, the Delphi consensus survey is limited to situations in which dyspnea can be reasonably attributed to inappropriate laryngeal narrowing within a structurally and neurologically normal larynx. This is a matter for clinical judgment. We lack readily available measurements of respiratory laryngeal function; however, recent research on translaryngeal resistance may move this forward.42023 GINA main report. Global Initiative for Asthma. 2023https://ginasthma.org/2023-gina-main-report/Date accessed: August 4, 2023Google Scholar The experts clearly agreed that other diagnoses should be thoroughly evaluated and that multidisciplinary team input should be considered. It is fundamental in medicine that the diagnosis and differentials undergo continuous iteration, and we counsel against premature diagnostic foreclosure. Finally, Dr Weinberger1Weinberger M. VCD and ILO are not synonymous.J Allergy Clin Immunol. 2023; 152 (xxx-xxx)Google Scholar suggests that “prompt” laryngoscopy following exercise may be useful when stridor is present. This may be valuable, although there is a risk of missing laryngeal obstruction, as it has been shown to dissipate rapidly after maximal workload is achieved (within a few breaths). Further, accumulation of laryngeal narrowing during the exercise session will be missed, perhaps appearing as a solely glottic phenomenon. As such, experts in the Delphi consensus survey regarded continuous laryngoscopy with exercise as the criterion standard for exercise-induced laryngeal obstruction, congruent with International Olympic Committee recommendations.5Fretheim-Kelly Z. Engan M. Clemm H. Andersen T. Heimdal J.H. Strand E. et al.Reliability of translaryngeal airway resistance measurements during maximal exercise.ERJ Open Res. 2022; 8: 00581-2021Google Scholar The members of the VCD/ILO Delphi Steering Committee are as follows: Anne E. Vertigan, PhD (the John Hunter Hospital, Newcastle, Australia, and the Centre of Excellence in Treatable Traits, University of Newcastle, Newcastle, Australia); Vanessa M. McDonald, PhD (the John Hunter Hospital, Newcastle, Australia, and the Centre of Excellence in Treatable Traits, University of Newcastle, Newcastle, Australia); Mark Hew, PhD (2Monash University, Melbourne, Victoria, Australia, and the Alfred Hospital, Melbourne, Victoria, Australia), Malcolm Baxter, FRACS (Monash Health, Melbourne, Victoria, Australia, and Monash University, Melbourne, Victoria, Australia), Debra Phyland, PhD (Monash Health, Melbourne, Victoria, Australia, and Monash University, Melbourne, Victoria, Australia), Thomas L. Carroll, MD (the Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Division of Otolaryngology-Head and Neck Surgery, Brigham and Women’s Hospital, Boston, Mass), Hege Havstad Clemm, PhD (the Department of Paediatric and Adolescent Medicine, Haukeland University Hospital, Bergen, Norway, and the Faculty of Medicine, Department of Clinical Science, University of Bergen, Bergen, Norway), Maria Vollsæter, PhD (the Department of Paediatric and Adolescent Medicine, Haukeland University Hospital, Bergen, Norway, and the Faculty of Medicine, Department of Clinical Science, University of Bergen, Bergen, Norway), and Ola Drange Røksund, PhD (the Department of Paediatric and Adolescent Medicine, Haukeland University Hospital, Bergen, Norway, and the Faculty of Health and Social Sciences, Western Norway University of Applied Sciences, Bergen, Norway). All of the Steering Committee members participated in this Reply; however, journal policy limited byline authorship to 6 members. VCD and ILO are not synonymousJournal of Allergy and Clinical ImmunologyPreviewThe publication by Leong et al1 synonymizes vocal cord dysfunction (VCD) and a neologism, inducible laryngeal obstruction (ILO). The function of the vocal cords during normal respiration is to abduct during inspiration to maximize air intake. One form of VCD involves paradoxical adduction during inspiration, resulting in obstruction to inspiratory airflow (Fig 1, A). Another type of VCD involves adduction during both inspiration and expiration, resulting in obstruction to airflow throughout the respiratory cycle (Fig 1, B). Full-Text PDF" @default.
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