A Commonly Misdiagnosed Condition, EILO Makes Breathing Difficult During Exercise
Some cyclists push themselves to full exertion, then, unexpectedly, gasp for air and wheeze while breathing. Often times, this might cause riders to pull back on training and eventually start to think that maybe they can’t improve. But it’s possible this gasping and wheezing is actually exercise-induced laryngeal obstruction, also known as EILO.
A lesser known and frequently misdiagnosed condition, EILO typically affects young people who exercise intensely and frequently, according to a February 2022 paper published in the British Journal of Sports Medicine. And it’s often misdiagnosed as asthma, among other conditions.
However, people with asthma have more trouble breathing out during intense bouts of exercise, whereas the primary symptom of EILO is being unable to take a strong inhale and feeling as if there is a blockage in the throat, neck, or vocal chords, Craig Zalvan, M.D., medical director at the Institute for Voice and Swallowing Disorders and chief of the otolaryngology service at Phelps Hospital, Northwell Health in Tarrytown, New York, explains to Bicycling.
To help you recognize EILO, here’s what to know.
What’s the difference between EILO and asthma?
EILO occurs when vocal chords spasm during breathing while inflamed lungs and airways are the cause of troubled breathing with asthma. Nevertheless, a 2021 study published in the Journal of Voice found that many athletes—typically younger females—are misdiagnosed with asthma when the condition is actually EILO, explains Zalvan, one author of the study.
In this study, over half of the young athletes had normal pulmonary (lung) function tests and thus did not have asthma, yet all were treated for asthma for months to years and often saw no improvement, Zalvan says. This is a common misdiagnosis, though, because like EILO cases, an asthma diagnosis usually comes after athletes exert themselves in competition and have trouble breathing. Because they are more familiar with asthma, they visit their primary care doctor for the issue when it would be most helpful to see a specialist.
So how can a cyclist tell the difference? Asthma is identified as inflammation in airways, which blocks the flow of air out, and ends up building up pressure and volume so a person feels short of breath. It’s often accompanied by a high-pitched wheeze and trouble breathing out. EILO, on the other hand, is when someone has trouble taking breaths in and feels more like a blockage in the throat, neck, or vocal chords, Zalvan explains.
Athletes with EILO are often fine at first, then start to breathe a little heavier as they exercise. As they struggle for breath, they get more anxious, which exacerbates the problem. Typically, if they rest a couple of minutes, their breathing returns to normal and there is no residual shortness of breath, Zalvan adds. An asthma attack tends to persist and the difficult breathing doesn’t go away on its own. Also, it doesn't come on suddenly, and is likely to happen at a variety of times, not just during exercise.
Another difference? EILO can come on because of external stress not necessarily related to competition, acid reflux, and viruses or upper respiratory infection. Finally, EILO tends to be most prevalent in a younger, female athlete population; 16-year-old females are the majority of Zalvan’s patients, but he also works with older athletes and even Olympians. In older athletes, vocal chord spams, viruses, and acid reflux can cause EILO.
Therefore, cyclists who experience breathing issues on their inhale and feel a problem in their throat or vocal chords rather than their lungs, should see an otolarynologist rather than an pulmonologist or allergist. This is especially true if they are being treated for asthma and their medication isn't working.
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Exercise-Induced Laryngeal Obstruction Treatment
Although the current belief is that EILO goes away by late high school or college, experts, including Zalvan, are concerned that the decrease occurs because so many young woman don’t continue with organized competitive sports, which is unfortunate. However, he says, it's also possible that as they mature, these young athletes develop a change in stress alleviation, breathing technique, and diet which may lesson the symptoms. Right now, the research on this hasn't been definitive.
Significantly, though, when those who suffer from EILO see a laryngologist, who is specifically trained to diagnose and treat issues in the vocal cords and throat, they begin to practic breathing techniques can improve or alleviate symptoms. Likewise, psychotherapy to help pinpoint and work through stress triggers, and decreasing acid reflux through diet have also been shown to be effective treatments.
In fact, a 2017 study published in the Journal of Voice identified three breathing techniques that change airflow as a person breathes in, called Olin Exercise-Induced Laryngeal Obstruction Biphasic Inspiration Techniques, that may help reduce EILO. They are a “tongue variant,” where a person breathes in evenly between the nose and mouth; a “tooth variant,” that requires a person to forcefully breathe in through their teeth, then quickly open their mouth, which allows air to flow freely; and a “lip variant,” where air is inhaled through pursed lips, then the person quickly opens their mouth to allow air to rush in through the mouth to make breathing harder then suddenly easy.
As for helping negate acid reflux, following a plant-heavy diet, like the Mediterranean diet, and drinking alkaline water with a pH greater than 8 can help because plant-based diets contain fewer amino acids, which can decrease pepsin (an enzyme in the stomach that can trigger acid reflux) levels previous research published in JAMA found.
H2: Simon Clarke’s diagnosis and winning seasons
A few years ago, WorldTour pro Clarke was dealing with breathing troubles that resembled asthma, and he struggled most during the hardest moments in races. Having been a pro since 2006, in 2018, he was diagnosed with ILO. After seeing a specialist, he learned the prescribed breathing technique that helped him manage the condition. He then rode strong to a stage win in the 2018 Vuelta a España. The next year was his career-best at the time, and Clarke, known as a climber, has continued to excel. His improvements continued so much that he was the Stage 5 winner of the 2022 Tour de France.
A strong case for learning how to breathe properly even during the hardest rides.
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