Exercise-induced laryngeal obstruction: From clinical examination to continuous laryngoscopy during exercise

The diagnosis of exercise-induced laryngeal obstruction (EILO) should be suspected when exercise triggers inspiratory stridor. EILO is common in adolescent populations and has a significant impact on sports. Identification of laryngeal obstruction during continuous laryngoscopy during exercise (CLE) is the gold standard diagnostic tool for this disorder, which is not widely known in France. The challenge faced by otolaryngologists is to identify, among patients referred by pulmonologists or sports physicians, those with exercise-induced inspiratory symptoms or poorly controlled exercise-induced asthma, in whom a diagnosis of EILO is strongly suspected. Laryngoscopy at rest may reveal a laryngeal, glottic or supraglottic abnormality predictive of obstruction at increased inspiratory airflow. When pulmonary function tests are normal or in the case of failure of treatment of exercise-induced asthma, the otolaryngologist must complete the examination by a CLE test to confirm the diagnosis of EILO and identify the site of obstruction. This examination is well tolerated, minimally invasive and allows identification of the site of airflow obstruction, allowing specific conservative or surgical treatment. This technical note describes in detail clinical examination and CLE testing in patients with suspected EILO.     

Pediatric problematic severe asthma: Recent advances in management

Problematic severe asthma remains a significant challenge to manage, accounting for the majority of healthcare utilization among children with asthma. The heterogeneity is recognized and the clinical phenotypes of “difficult-to-treat” asthma (DA) and “severe therapy-resistant asthma” (STRA) help to guide management. Recent evidence supports molecular distinctions between these phenotypes and shows poor correlations between peripheral and airway markers of inflammation, especially in STRA. Airway neutrophils in the context of childhood severe asthma have been explored, but their role in disease causation, protection, or as bystanders remain unknown, and thus, treatment implications are unclear. Several novel management strategies, including once-daily maintenance therapy, single-device maintenance and reliever therapy, and novel biological treatments are being increasingly used for DA and STRA. However, pediatric data for efficacy of novel treatments is scarce, and when available, is restricted to adolescents. The aim of this review is to highlight recent advances in objective biomarkers that aid stratification and management of childhood severe asthma and to highlight gaps in pediatric evidence. Specifically, the urgent need for efficacy studies to improve the management of problematic severe asthma in children younger than 12 years.     

Switching between biologics in severe asthma patients. When the first choice is not proven to be the best

During the last decades, new treatments targeting disease mechanisms referred as biologics have been introduced in the therapy of asthma and currently, five monoclonal antibodies have been approved. Although these therapeutic agents have been formulated to target specific asthma endotypes, it is often difficult for the treating physician to identify which patient is the best candidate for each one of these specific treatments especially in the clinical scenario of a patient in whom clinical characteristics overlap between different endotypes, allowing the selection of more than one biologic agent. As no head-to-head comparisons between these biologics have been attempted, there is no evidence on the superiority of one biologic agent over the other. Furthermore, a physician's first therapeutic decision, no matter how carefully has been made, may often result in suboptimal clinical response and drug discontinuation, indicating the need for switching to a different biologic. In this short review, we discuss the available evidence regarding the switching between biologics in patients with severe asthma and we propose a simple algorithm on switching possibilities in case that the physicians’ initial choice is proven not to be the best.     

Pannexin 1 channels facilitate communication between T cells to restrict the severity of airway inflammation

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