Are Athletic Coaches Aware of Exercise‐Induced Laryngeal Obstruction in Children and Adolescents?

Authors: Robert Brinton Fujiki, Kayla Lewis, Susan L. Thibeault

Abstract

Purpose

Onset of pediatric exercise induced laryngeal obstruction (EILO) often occurs in athletic contexts. This study investigated athletic coach awareness of EILO in children and adolescents. Strategies employed by coaches when working with athletes with EILO and exercise induced dyspnea (EID) of unknown etiology were also examined.

Methods

EILO awareness was assessed using an anonymous electronic survey distributed to three types of athletic sport coaches, dance instructors, and physical education teachers. Survey distribution occurred via social media, Reddit, and sport coach/dance instructor association email listservs.

Results

Three‐hundred and two athletic coaches responded to the survey (mean age = 43.4 years). Overall, only 22.5% (N = 68) of survey respondents indicated familiarity with EILO. Twelve percent (N = 38) of coaches reported that they had worked directly with an athlete diagnosed with EILO. Neither sport coached, respondent age, nor years of experience predicted which coaches were familiar with EILO. Fifty‐eight percent (N = 176) of athletic coaches indicated that they worked with athletes with EID of unknown etiology “often.” Coaches were significantly more confident working with athletes with EID as compared to EILO (p = 0.021). Coaches reported that working with athletes with dyspnea was common, however, athletes rarely disclosed breathing symptom etiology.

Conclusion

Less that one fourth of athletic coaches reported any awareness of EILO. Coaches overwhelmingly indicated that better communication with athletes and increased knowledge of EILO would allow them to coach athletes more effectively. Future work should determine whether coordinating EILO and EID treatment with athletic coaches can improve treatment outcomes.

Introduction

Exercised‐induced laryngeal obstruction (EILO) involves vocal fold closure and/or collapse of supraglottic structures upon inhalation that results in dyspnea, or difficulty breathing [1, 2]. EILO is characterized by inhalation or exhalation difficulty induced by physical exertion [3]. Manifestations may include throat and/or chest tightness, stridor, hyperventilation, and lightheadedness [4, 5]. External or internal triggers such as environmental factors, emotional stress, or physical irritants may also contribute to symptom onset [4]. Although the true prevalence of EILO is unknown, athletes are at particular risk for the condition, with as many as 5.7%–8.1% of recreational athletes [6, 7, 8, 9], and 5% of elite athletes reporting symptoms [10]. It is estimated that as many as 30% of EILO cases occur in pediatric patients [5].

For young athletes, EILO can be particularly debilitating [11]. Symptom onset is often frightening, traumatic, and embarrassing [12]. In addition, individuals may experience emotional and social sequelae associated with the condition [12]. Adolescents have reported that delayed diagnosis and inappropriate management of symptoms before diagnosis significantly detract from their quality of life [12, 13]. Additionally, the costs of diagnosing and treating EILO may be significant as patients often experience multiple office visits, procedures, and medications before symptom identification and resolution [14, 15]. Timely referral to the appropriate medical professionals is a crucial first step in the treatment of EILO [16, 17].

One of the challenges associated with identifying and treating EILO in athletes is that symptom onset often occurs at peak work capacity [18, 19]. That is; athletes are likely to experience symptoms during athletic events, games, performances, or practices that are associated with high levels of physical exertion [20]. Athletic coaches (i.e., sport coaches, dance teachers, and/or physical education teachers; henceforth referred to as athletic coaches) may be the first adults to observe EILO symptoms in children and adolescents. To complicate matters, EILO symptoms are often nonspecific [3, 4]—overlapping with other conditions such as exercise‐induced asthma and exercise‐induced bronchoconstriction [21, 22]. Patients and providers may misidentify symptoms and misdiagnose the condition [23, 24, 25]. Since parents may or may not observe initial symptom onset, children and adolescent patients may not seek medical intervention until symptom severity has escalated [12].

Despite the high prevalence of EILO among adolescent athletes [9, 21], it is unknown whether athletic coaches are aware of the condition. Athletic coaches often play an important role in the early identification of exercise‐induced health conditions in athletes [26], and may be influential in an athlete's decision to seek treatment. Athletic coaches often offer recommendations for symptom management and make decisions regarding whether athletes can continue to play or perform with exercise‐induced conditions [24]. It is important to consider how athletic coaches understand and approach EILO, its symptoms, and management. This is particularly important given that continuing athletic participation is often a major goal for athletes with EILO [12, 27].

Many EILO symptoms are not condition‐specific [28], and it is outside the athletic coach's purview to diagnose respiratory conditions or upper airway disorders. The etiology of exercise‐induced dyspnea (EID) is often unclear [29], and coaches may not be aware of specific dyspnea etiologies when working with athletes. Since EILO does not respond well to the inhaled treatments prescribed for other conditions with similar symptoms (e.g., asthma) [27], it is important to examine athletic coaches' understanding of EILO within the broader context of EID in general. Coaches of certain sports/events may encounter EILO more frequently than others, and coaches specializing in differing athletic events may perceive EILO and EID differently. For example, the physical demands of track, soccer, football, swimming, dance, and general physical education courses may all differ [30]. It is possible that athletic coaches view the symptoms of EILO differently across these events.

The current study examined athletic coaches' awareness of, and experience with young athletes experiencing EILO and EID. The strategies coaches employed to help athletes manage EILO and EID were also considered. It was hypothesized that coaches' awareness of EILO might be relatively limited, and that rates of EILO awareness would be highest among coaches of high‐aerobic sports.

Methods

Athletic coach awareness of EILO was assessed through an anonymous electronic survey built in Qualtrics. All study procedures were approved by the University of Wisconsin‐Madison institutional review board (IRB 2022‐1598). Participants received an informed consent page before participation. A waiver of signed consent was obtained due to the anonymous nature of the survey.

Survey Development

Survey questions were developed by the study authors. Questions examined EILO and EID awareness, management strategies, coaching philosophy (as related to coaching athletes with EILO or EID), and coach confidence in athletes with these conditions. Questions were then reviewed for clarity and form by a pool of five licensed speech‐language pathologists (SLP) and five adults unfamiliar with the diagnosis and treatment of EILO. SLPs also advised on content and questions were adjusted based on reviewer feedback. The final survey tool consisted of 27 questions. Survey questions were multiple choice, free response, 5‐point Likert scales, or visual analog scales (VAS) in the case of questions pertaining to athletic coach experience and confidence. Survey questions are presented in Appendix S1. The following data points were collected.

Respondent Demographics

Athletic coaches were asked their age, gender identity, the state in which they primarily coached, the athletic events they coached (multiple sports could be listed), and the age of athlete they primarily coached.

EILO

Athletic coaches were asked if they were familiar with the condition of EILO (yes, no). As EILO nomenclature has changed significantly over the past decade [2, 20], the terms paradoxical vocal fold motion (PVFM), vocal cord dysfunction (VCD), laryngeal dysfunction, and fictitious asthma were presented in addition to EILO. If coaches indicated that they were familiar with the condition, they were asked which of the aforementioned terms they utilized. Additionally, they were asked to briefly describe EILO in a free response question to confirm familiarity with the condition. Coaches were then asked if they had worked with athletes with EILO (yes, no, I don't know). If they responded yes, they were asked how often (never, rarely, sometimes, often, always), what symptoms they observed (multiple choice), and in what setting (games, practice, class, or both). Athletic coaches were then asked what strategies they employed when working with athletes with EILO (multiple choice). Visual analog scales (ranging from 0 to 100) were used to ask coaches how often they felt they needed to remove an athlete from game or performance due to EILO symptoms (never [0] to often [100]), what percent of the time EILO made them less confident in an athlete's abilities (never [0] to always [100]), and how confident they were in their ability to work with an athlete with EILO (not confident at all [0] to very confident [100]).

EID

Athletic coaches were asked how often they worked with athletes with EID of any etiology (known or unknown), how often an athlete made them aware of having a diagnosis which could cause EID, and how often they had to remove an athlete from a game or performance due to EID (never, rarely, sometimes, often, always). They were also asked about the reasons why they might remove an athlete from a game or event and the strategies they employed to help them (multiple choice). Visual analog scales (ranging from 0 to 100) were used to ask coaches how often EID made them less confident in an athlete's abilities (never [0] to often [100]) and how confident they were in their ability to work with an athlete with EID (not confident at all [0] to very confident [100]). They were also asked if they had ever undergone any medical training focused on how to work with athletes with EID (yes, no, I'm not sure). Finally, coaches were presented with a free response question asking for any additional thoughts regarding coaching athletes with breathing difficulties. Conventional content analysis was utilized to inductively identify patterns from open‐ended responses [31]. Line‐by‐line open and axial coding were individually performed by two separate raters. Selective coding was then performed via consensus and overarching themes from responses were identified.

To compare the prevalence of EILO awareness with that of other common respiratory conditions, coaches were also asked if they were familiar with asthma, emphysema, pneumonia, and chronic obstructive pulmonary disease (COPD).

Survey Distribution

The survey was distributed using social media (i.e., Twitter, Facebook), Reddit, and athletic coach association listservs. Subreddit pages for dance instructors, athletic coaches, and physical education teachers were utilized. Survey advertisements invited athletic coaches to complete a survey focused on their experience coaching athletes with difficulty breathing. Responses were collected from November 2022 through February 2023.

Statistical Analysis

Descriptive statistics were used to determine the proportion of respondents who selected various responses. Paired t‐tests were employed to compare VAS scores for questions addressing EILO and EID. Logistic regression was utilized to identify predictors of EILO awareness. Years of experience, age, sex, and sport coached were regressed on coach awareness of EILO. Alpha was set at 0.05 for determining statistical significance. Statistical analyses were performed using SPSS Version 28.

Results

Three‐hundred and two athletic coaches responded to the survey. Survey respondents were 62.3% male (N = 188) and 37.4% (N = 112) female. Mean age of survey respondents was 43.4 years (SD = 10.5; range 18–84). Respondents held coaching positions in 46 states (Figure 1).

Ten percent (N = 32) of coaches worked with elementary school aged athletes, 34.7% (N = 87) worked with middle school aged athletes, and 92.3% (N = 279) worked with high‐school aged athletes. Regarding type of athletic coach, 78% (*N *= 238) were primarily sport coaches, 21% (*N *= 64) were primarily physical education teachers, and 21% (*N *= 62) were dance instructors. The distribution of sports coached by survey respondents is presented in Figure 1. Fifty‐nine percent (N = 179) of coaches worked primarily in an educational setting (i.e., elementary, middle, high‐school sports team), 33.7% (N = 102) worked with a private club team or training facility, and 6.9% (N = 21) worked primarily in an instructional setting without a competition component. The most common sport was track/cross country, which made up 29.1% (N = 88) of survey respondents. Other common sports were basketball, football, swimming, and soccer.

EILO

Overall, 22.5% (N = 68) of survey respondents indicated that they were familiar with EILO. Coaches reported that they were familiar with the following terms for EILO; vocal cord dysfunction (67.6%, N = 46), paradoxical vocal fold motion (35.2%, N = 24), EILO (32.3%, N = 22), fictitious asthma (25%, N = 17), and laryngeal dysfunction (14.7%, N = 10).

Thirty‐eight (12.6%) of coaches reported that they had worked directly with an athlete diagnosed with EILO. Of these 38 coaches, 52.6% (N = 20) indicated that they worked with athletes with EILO “sometimes,” 28.9% (N = 11) indicated rarely, and 13.2% (N = 5) indicated they worked with these athletes “often” (Table 1).

Coaches stated that they observed various symptoms in athletes with EILO. These included inhalation difficulty (89.4%, N = 34), stridor (63.1%, N = 24), throat tightness (50%, N = 19), lightheadedness/dizziness (36.8%, N = 14), exhalation difficulty (23.6% N = 9), coughing (15.7%, N = 6), chest tightness (7.8%, N = 3), and fainting (5.2%, N = 2). Treatment strategies used with athletes with EILO are presented in Figure 2. The most common recommendation was relaxing and breathing deeply (81.5%, N = 31). The majority of coaches indicated that they observed EILO symptoms in both practice and competition (57.8%, N = 22), 21% (N = 8) indicated that symptoms occurred solely during practices, 15.7% (N = 6) indicated that symptoms occurred solely during competition, and 5.2% (N = 2) indicated that symptoms occurred only in physical education courses.

When asked on a continuous VAS ranging from 0 to 100, coaches rated their confidence working with athletes with EILO as 44.43 (on average, SE = 3.35) (Figure 3). When asked on another VAS, coaches indicated that when an athlete presented with EILO symptoms, their confidence in the ability of that athlete decreased 30.3% (SE = 3.9) of the time (Figure 3).

Exercise Induced Dyspnea (EID)

Of 302 coaches, the majority indicated that they worked with athletes with EID “often” (58.3%, N = 176). When asked how often athletes make them aware of a diagnosis that would cause dyspnea, the majority of respondents indicated that this only occurred “sometimes” (51.3%, N = 155). The majority of respondents indicated that they “almost never” had to bench athletes due to dyspnea (74.8%, N = 226). Distribution of responses to this question are presented in Table 1. When asked what would lead them to remove an athlete from a game or performance, the most common reasons were dizziness and fainting (Figure 4).

When asked to rate their confidence working with athletes with EID, on average coaches rated their confidence as 52.3 out of 100 (SE = 3.1; Figure 3). Using another VAS, coaches were asked how frequently their confidence in an athlete's abilities decreased when they presented with EID symptoms. Coaches indicated that on average this occurred 43.8% (SE = 4.7) of the time (Figure 3). Overall, 10.9% (N = 33) of coaches indicated that they had received medical training regarding how to work with athletes with breathing difficulty.

Differences in Response to EILO and EID

Significant differences were observed between EILO and EID for measures of coach confidence. For example, coaches indicated that they were significantly more confident working with athletes with EID as compared with EILO (*p *= 0.021, Figure 3). Additionally, coaches indicated that their estimation of athlete ability decreased significantly more frequently when athletes had EID compared to when athletes presented with EILO (p = 0.003, Figure 3).

Additionally, significant differences were also observed in coach response to EILO versus EID (Figure 2). Coaches were 70% less likely to recommend inhaler use for athletes with EILO than for athletes with EID (OR = 0.30, p < 0.01) and 65% less likely to advise athletes with EILO to “push through” their symptoms (OR = 0.35, p < 0.01). No other significant differences were observed in the strategies employed for EILO versus EID.

Predictors of EILO Knowledge

Linear Regression was performed to identify predictors of coach knowledge of EILO. No significant predictors were identified. Neither coach age (β = −0.004, t = −1.16, p = 0.245), years spent coaching (β = 0.002, t = 0.416, p = 0.677), coach gender (β = −0.069, t = −1.37, p = 0.169), nor type of sport coached (β = −0.014, t = ‐.477, p = 0.634) significantly predicted which coaches were familiar with the condition.

Knowledge of Other Respiratory Conditions and Medical Training

Coach knowledge of other common respiratory conditions was probed to compare rates of EILO knowledge with other conditions. Coach knowledge of other respiratory conditions was as asthma (99.6%, N = 301), emphysema (71.8%, N = 217), COPD (67.5%, N = 204), pneumonia (94%, N = 284), and cystic fibrosis (71.1%, N = 215).

Free Response Question

Four major themes were identified when coaches were asked what researchers should know about coaching athletes with EID. These were as follows; (1) coaches expressed a desire for better training regarding conditions which cause EID, (2) coaches expressed a need for better communication with athletes and their families when athletes are diagnosed with conditions which cause EID, (3) coaches indicated that athletes should not have to discontinue a sport for EID, and (4) coaches expressed their concern about keeping their athletes safe. Sample quotations are included in Table 2.

Discussion

EILO and the resulting dyspnea can be traumatic and debilitating [13]. Multiple studies indicate that EILO not only detracts from health‐related quality of life, it constrains athletic performance, diminishes emotional well‐being, and limits social life [12]. As EILO is induced by physical exertion, athletic coaches may be in a unique position to observe the onset and progression of symptoms [12]. In addition, coaches may play an important role in facilitating the management of EILO symptoms, especially in young athletes. However, the extent to which athletic coaches are familiar with, or even aware of, EILO has been unclear. The current study examined athletic coach awareness and management of EILO. It was hypothesized that coaches would report limited knowledge of—or experience with—EILO among young athletes. This hypothesis was supported as only 22.5% of the surveyed participants indicated familiarity with the condition. It was also hypothesized that rates of EILO awareness would be highest among coaches of high‐aerobic sports. This hypothesis, however, was not supported by the data, as the type of athletic activity coached was not a significant predictor of familiarity with EILO. In addition, neither years of experience, sport coached, coach age, nor coach gender predicted EILO awareness. Although it might be expected that high‐aerobic sports would induce more frequent EILO symptoms, coaches of these sports did not report higher awareness of the condition.

Considering that as many as 8% of recreational athletes and 5% of elite athletes [7, 9, 10] experience EILO, it is concerning that less that one fourth of coaches were familiar with the condition. It is highly likely that over a coaching career, an individual will work with a number of athletes with EILO. A coach may play a pivotal role in a young athlete's life, acting as both a facilitator of performance and a gateway to participation [32]. If coaches are unfamiliar with EILO or its management, their ability to support and assist affected athletes will be limited. Young athletes with the condition may be left on their own to find a way to manage their symptoms while attempting to excel at their sport. Sadly, it has been documented that if EILO symptoms cannot be managed, athletes may reduce their training plans or discontinue their participation in sports altogether [33].

It was noted that coaches were considerably more aware of other respiratory conditions such as asthma, pneumonia, cystic fibrosis, and COPD than they were with EILO. This might be predicted for asthma since this condition is commonly recognized in the general population and also affects many adolescent athletes [24]. It is unlikely, however, that athletic coaches encounter other respiratory conditions (pneumonia, cystic fibrosis, COPD) in young athletes as often as they are likely to encounter EILO [7]. One barrier to EILO awareness may be the frequently changing nomenclature of the condition. EILO is a relatively recent term, and coaches were most likely to use the term, vocal cord dysfunction. This supports recent study suggesting that EILO terminology remains inconsistent even among medical professionals [34]. Additionally, evidence suggests athletic coaches receive limited or no medical training [35, 36]. Past study indicates that although athletic coaches are aware of asthma, they may have limited familiarity with its symptomology and management [37]. Furthermore, unless athletes present with obvious symptoms or take regular medication, athletic coaches are often unaware of asthma diagnoses in athletes [38]. Given that asthma was better known than EILO in the current study, further education regarding EILO needs to be designed and disseminated among athletic coaches.

It was encouraging that when athletic coaches were familiar with EILO, they used different strategies to help athletes than they used with athletes of EID of unknown etiology. This is important as varying etiologies of dyspnea may respond to different coaching techniques. For example, for respiratory conditions such as asthma, warm up and cool down periods may be effective coaching adjustments [39]. There is a paucity of data examining whether this technique would be beneficial for patients with EILO, however, this would be unlikely to address the physiology underlying the condition. In the current study, when working with athletes with EILO, coaches were significantly less likely to recommend inhaler use or to tell athletes to “push through” symptoms. These are likely appropriate adjustments given that inhaler use is generally ineffective for EILO [40] and pushing through symptoms without the use of rescue breathing techniques is unlikely to resolve EILO symptoms.

The findings of the current study underscore a major factor in supporting young athletes with EILO—communication. Although athletic coaches strongly indicated that EID in general should not prevent athletes from taking part in sports, they expressed concern that athletes frequently did not communicate with them regarding dyspnea etiology [41]. Coaches indicated that successful athletic performance could be achieved despite dyspnea symptoms if athletes communicate with their coaches regarding their needs. This supports past study indicating that 80% of athletes who experience acute respiratory illness do not miss days of training or competition for their symptoms [42]. Clinicians may want to consider advising patients about the potential advantages of communicating with athletic coaches regarding dyspnea etiology—particularly as coaches were willing to adapt training to help athletes with EILO succeed. Facilitating these conversations may be important given the high prevalence of behavioral health comorbidities in individuals with EILO [43], which may render these conversations more difficult.

Coaches reported little medical training with regard to respiratory conditions, and many indicated they desired more information regarding EILO and conditions that cause dyspnea in athletes. The most efficient way to mitigate the lack of EILO awareness among athletic coaches might be to integrate the condition into exercise science pedagogy. The high prevalence of EILO in athletes would justify covering the condition in physical education curricula; however, content related to health promotion is limited in most programs [44]. Interdisciplinary communication could be key to familiarizing coaches with EID generally and EILO specifically. It is also possible that better outreach from SLPs, and physicians might enable coaches to employ more effective and condition‐specific strategies. This could reduce the frequency of athletes being removed from games and training—a practice that is both detrimental to long‐term athletic training and unlikely to produce lasting improvements in EILO symptoms. Unfortunately there is a paucity of data addressing the effects of physician‐coach communication. Further studies are needed to examine whether medical professionals may be able to instruct athletic coaches to increase EILO awareness. EILO content incorporated into physical education curricula could improve diagnostic efficiency and expedite appropriate referrals. Better communication between young athletes, their families, coaches, SLPs, and medical providers could facilitate EILO management, support athletic performance, and enhance quality of life.

There are some considerations which should be remembered when interpreting the current data. First, surveys like the one utilized in this study are susceptible to recall bias. Thus, longitudinal work examining athletic coach practice patterns over time may be useful. Additionally, the survey was designed to allow comparisons across individuals and sports. For this reason, limited open‐response questions were posed. Qualitative work might elucidate athletic coach thought processes and experiences more thoroughly. Future research should also probe how coaching patterns might differ across various levels of competition (i.e., regional, state, national, etc.). Finally, as social media was one of the methods used for survey distribution, it may be that the survey reached a greater proportion of coaches familiar with EILO due to the location and contacts of the research team. Thus, the current data may actually overestimate the number of coaches aware of the condition. Multiple methods of survey distribution were employed, however, the majority of which had no connection to the research team. Therefore, these findings are considered to be valid.

Conclusion

Overall, only 22.5% of athletic coaches indicated that they were familiar with EILO. Twelve percent of coaches reported that they had directly worked with an athlete with EILO. Coaches indicated that EID of unknown etiology was common in their athletes, but athletes often did not disclose the etiology of dyspnea symptoms. Coaches utilized more condition‐specific strategies to help athletes with dyspnea when they were aware EILO was the etiology of symptoms. Increased interdisciplinary communication may enhance awareness of EILO and promote more efficient identification and management of EILO symptoms in athletes. Future work should examine how EILO awareness can be improved in this population and determine how increased coordination of care could improve EILO treatment outcomes.

Author Contributions

Robert Brinton Fujiki: conceptualization, investigation, writing – original draft, methodology, visualization, formal analysis, data curation, supervision. Kayla Lewis: investigation, writing – review and editing, conceptualization. Susan L Thibeault: conceptualization, investigation, funding acquisition, supervision, writing – review and editing.

Conflicts of Interest

The authors declare no conflicts of interest.

Supporting information