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Background: Ultrasound (US) is not widely used as part of the speech and language therapy (SLT) clinical toolkit The COVID-19 pandemic has intensified interest in US as an alternative to SLT instrumental tools such as the videofluoroscopic swallowing study (VFSS), fibreoptic endoscopic evaluation of swallowing (FEES) and endoscopic evaluation of the larynx (EEL) as a non-invasive, non-aerosol-generating procedure that can be delivered at the bedside to assess swallowing and/or laryngeal function To establish the appropriacy of routine US use, and in response to a national professional body request for a position statement, a group of expert SLTs conducted a rapid review of the literature Aim: To explore critically the clinical utility of US as an assessment tool for swallowing and laryngeal function in adults Methods & Procedures: A rapid review of four databases was completed to identify articles using US to assess swallowing and/or laryngeal function in adults compared with reference tests (VFSS/FEES/EEL/validated outcome measure) Screening was completed according to predefined inclusion/exclusion criteria and 10% of abstracts were rescreened to assess reliability Data were extracted from full texts using a predeveloped form The QUADAS-2 tool was used for quality ratings Information from included studies was summarized using narrative synthesis and visual illustration Outcomes & Results: Ten papers used US to assess swallowing, and 13 to assess laryngeal function All were peer-reviewed primary studies across a range of clinical populations and with a wide geographical spread Four papers had an overall low risk of bias, but the remaining 19 had at least one domain where risk of bias was judged as high or unclear Applicability concerns were identified in all papers The papers that used US to assess swallowing varied widely in terms of the anatomical structures assessed and methodology employed The papers assessing laryngeal function were more homogenous in their methodology Sensitivity and specificity data were provided for 12 of the laryngeal function papers with ranges of 64 3–100% and 48 5–100%, respectively Conclusions & Implications: There is burgeoning evidence to support the use of US as an adjunct to SLT clinical assessment of swallowing and laryngeal function However, the current literature does not support its use as a tool in isolation Further research is required to establish reliability in US assessment as well as clear SLT-driven protocols and training What this paper adds What is already known on the subject US has demonstrated potential as an assessment tool for objective parameters of swallowing Its use for laryngeal assessment (gross vocal fold movement) is also widely recognized within the literature This review appraised the literature related to US as an alternative or adjunctive tool for the assessment of swallowing and laryngeal function What this paper adds to existing knowledge This paper identifies that the current evidence base for US as a swallowing or laryngeal assessment tool is heterogenous and of variable quality No study combined the assessment of swallowing and laryngeal function, and only two studies assessed more than one parameter of swallowing, limiting the clinical application of the results What are the potential or actual clinical implications of this work? This review shows that US is a non-invasive accessible tool that can offer a detailed focal assessment of swallowing and laryngeal function, such as hyoid displacement and vocal fold mobility With the development of protocols, training packages and competency standards, US has the potential to be used as an adjunct to SLT assessment of swallowing and laryngeal function There is not currently enough evidence to support the use of US as a stand-alone tool for SLT assessment of swallowing or laryngeal function © 2020 Royal College of Speech and Language Therapists

Prior to the COVID‐19 pandemic, laryngoscopy was the mandatory gold standard for the accurate assessment and diagnosis of inducible laryngeal obstruction. However, upper airway endoscopy is considered an aerosol‐generating procedure in professional guidelines, meaning routine procedures are highly challenging and the availability of laryngoscopy is reduced. In response, we have convened a multidisciplinary panel with broad experience in managing this disease and agreed a recommended strategy for presumptive diagnosis in patients who cannot have laryngoscopy performed due to pandemic restrictions. To maintain clinical standards whilst ensuring patient safety, we discuss the importance of triage, information gathering, symptom assessment and early review of response to treatment. The consensus recommendations will also be potentially relevant to other future situations where access to laryngoscopy is restricted, although we emphasize that this investigation remains the gold standard.

Background Inducible laryngeal obstruction (ILO) is often misdiagnosed as, or may coexist with, asthma. Identifying differences in triggering factors may assist clinicians to differentiate between the two conditions, and could give mechanistic insights. Objective To identify and compare patient‐reported triggers in ILO and asthma. Methods This was a two‐part study. Initially we conducted a retrospective case note review of the triggers of ILO from endoscopically‐confirmed ILO patients to generate a Breathlessness Triggers Survey (BrTS). Triggers were categorised as: scents, environmental factors, temperature, emotions, mechanical factors and daily activities. Secondly, ILO and/or asthma patients completed the BrTS prospectively, rating the likelihood of each item triggering their symptoms using a five‐point Likert scale (strongly disagree to strongly agree). Chi‐square testing was performed to compare responses by cohort. Results Data from 202 patients with ILO [73% female, mean (SD) age 53(16) years] were included in the case note review. For the prospective study, 38 patients with ILO‐only [63% females, age 57(16) years], 39 patients with asthma‐only [(56% female, age 53(13) years] and 12 patients with both ILO and asthma [83% female, mean age, 57 (14) years)] completed the BrTS. The triggers identified in the case note review were confirmed in the independent sample of patients with ILO and/or asthma and identified several difference in prevalence of the triggers between disease types. Mechanical factors [talking (p

BACKGROUND: Cough both protects and clears the airway. Cough has three phases: breathing in (inspiration), closure of the glottis, and a forced expiratory effort. Chronic cough has a negative, far‐reaching impact on quality of life. Few effective medical treatments for individuals with unexplained (idiopathic/refractory) chronic cough (UCC) are known. For this group, current guidelines advocate the use of gabapentin. Speech and language therapy (SLT) has been considered as a non‐pharmacological option for managing UCC without the risks and side effects associated with pharmacological agents, and this review considers the evidence from randomised controlled trials (RCTs) evaluating the effectiveness of SLT in this context. OBJECTIVES: To evaluate the effectiveness of speech and language therapy for treatment of people with unexplained (idiopathic/refractory) chronic cough. SEARCH METHODS: We searched the Cochrane Airways Trials Register, CENTRAL, MEDLINE, Embase, CINAHL, trials registries, and reference lists of included studies. Our most recent search was 8 February 2019. SELECTION CRITERIA: We included RCTs in which participants had a diagnosis of UCC having undergone a full diagnostic workup to exclude an underlying cause, as per published guidelines or local protocols, and where the intervention included speech and language therapy techniques for UCC. DATA COLLECTION AND ANALYSIS: Two review authors independently screened the titles and abstracts of 94 records. Two clinical trials, represented in 10 study reports, met our predefined inclusion criteria. Two review authors independently assessed risk of bias for each study and extracted outcome data. We analysed dichotomous data as odds ratios (ORs), and continuous data as mean differences (MDs) or geometric mean differences. We used standard methods recommended by Cochrane. Our primary outcomes were health‐related quality of life (HRQoL) and serious adverse events (SAEs). MAIN RESULTS: We found two studies involving 162 adults that met our inclusion criteria. Neither of the two studies included children. The duration of treatment and length of sessions varied between studies from four sessions delivered weekly, to four sessions over two months. Similarly, length of sessions varied slightly from one 60‐minute session and three 45‐minute sessions to four 30‐minute sessions. The control interventions were healthy lifestyle advice in both studies. One study contributed HRQoL data, using the Leicester Cough Questionnaire (LCQ), and we judged the quality of the evidence to be low using the GRADE approach. Data were reported as between‐group difference from baseline to four weeks (MD 1.53, 95% confidence interval (CI) 0.21 to 2.85; participants = 71), revealing a statistically significant benefit for people receiving a physiotherapy and speech and language therapy intervention (PSALTI) versus control. However, the difference between PSALTI and control was not observed between week four and three months. The same study provided information on SAEs, and there were no SAEs in either the PSALTI or control arms. Using the GRADE approach we judged the quality of evidence for this outcome to be low. Data were also available for our prespecified secondary outcomes. In each case data were provided by only one study, therefore there were no opportunities for aggregation; we judged the quality of this evidence to be low for each outcome. A significant difference favouring therapy was demonstrated for: objective cough counts (ratio for mean coughs per hour on treatment was 59% (95% CI 37% to 95%) relative to control; participants = 71); symptom score (MD 9.80, 95% CI 4.50 to 15.10; participants = 87); and clinical improvement as defined by trialists (OR 48.13, 95% CI 13.53 to 171.25; participants = 87). There was no significant difference between therapy and control regarding subjective measures of cough (MD on visual analogue scale of cough severity: −9.72, 95% CI −20.80 to 1.36; participants = 71) and cough reflex sensitivity (capsaicin concentration to induce five coughs: 1.11 (95% CI 0.80 to 1.54; participants = 49) times higher on treatment than on control). One study reported data on adverse events, and there were no adverse events reported in either the therapy or control arms of the study. AUTHORS' CONCLUSIONS: The paucity of data in this review highlights the need for more controlled trial data examining the efficacy of SLT interventions in the management of UCC. Although a large number of studies were found in the initial search as per protocol, we could include only two studies in the review. In addition, this review highlights that endpoints vary between published studies. The improvements in HRQoL (LCQ) and reduction in 24‐hour cough frequency seen with the PSALTI intervention were statistically significant but short‐lived, with the between‐group difference lasting up to four weeks only. Further studies are required to replicate these findings and to investigate the effects of SLT interventions over time. It is clear that SLT interventions vary between studies. Further research is needed to understand which aspects of SLT interventions are most effective in reducing cough (both objective cough frequency and subjective measures of cough) and improving HRQoL. We consider these endpoints to be clinically important. It is also important for future studies to report information on adverse events. Because of the paucity of data, we can draw no robust conclusions regarding the efficacy of SLT interventions for improving outcomes in unexplained chronic cough. Our review identifies the need for further high‐quality research, with comparable endpoints to inform robust conclusions.

Introduction and Objectives Inducible Laryngeal Obstruction (Ilo) is poorly understood, in terms of aetiology and onset by patients and clinicians. Patients presenting to our Tertiary Airways service commonly seek an understanding of the causes and triggers of their Ilo episodes. This study aims to develop a taxonomy of categories of patient-reported onset factors for Ilo from a sample of patients with confirmed Ilo on laryngoscopy, referred to our service. Method Within a nine month period, 103 patients referred to the Airways service (76% female, 24% male; age range 15–86 years (median=52)) with endoscopically-confirmed Ilo were asked to report historical factors contemporaneous with the initial onset of Ilo symptoms. A retrospective analysis of patient notes was also conducted to identify co-morbidities and additional onset factors. Single or multiple onset factors for each patient were collected, which were coded into initial themes. From these themes, second-order onset categories were developed which incorporated factors reported by all participants. Results Thirteen initial onset themes were developed. These included psychological factors (25% of patients), upper respiratory tract infections (23%), reflux (17%), chest infections (14%), medical conditions (12%) and surgery (10%). These were then refined into a taxonomy of five categories of onset factors: Respiratory Tract Infections and Viruses (40% of patients) Underlying Medical Conditions, e.g., rhinitis with post nasal drip, reflux (34%) Psychological difficulties (25%) Irritants, e.g., medication (23%) Exercise (7%) Only one patient had onset factors in multiple categories, indicating that these categories are largely independent of each other. The prevalence of certain onset factors was mediated to some degree by age, e.g., medical conditions were more frequent factors for older participants, whereas exercise was a more common factor in younger participants. Conclusions This study demonstrates patient-reported onset factors for Ilo can be usefully translated into a detailed taxonomy based on specific conditions/triggers. This understanding may be useful in furthering our understanding, both of common trigger and onset factors that can be communicated to patients, and may help to inform therapeutic interventions aimed at the active self-management of Ilo.

Background Vocal cord dysfunction (VCD) is often initially misdiagnosed as, or may coexist with, asthma. Identifying the differences between the types of triggers for each condition may help differentiate between these two conditions, and could give mechanistic insights. Aim The aim of this study is to identify and compare patient-reported triggers in VCD and asthma. Methods This was a two-part study. Part A – A retrospective case note review of the triggers of VCD from endoscopically-confirmed VCD patients was conducted. This information was used to generate a Breathlessness Triggers Survey with triggers recorded under the categories: scents, environmental factors, temperature, emotions, mechanical factors and daily activities. Part B – A prospective study which involved patients with VCD and/or asthma completing the Breathlessness Triggers Survey, rating the likelihood of each item triggering their symptoms using a five-point Linkert scale (strongly disagree to strongly agree). Chi-square test was performed to compare responses by cohort. Results Part A – Data from 202 patients with VCD (73.3% female, mean age 53.1yrs) were included in the retrospective study. The findings were used to create a 23-item Breathlessness Triggers Survey for Part B of the study. Part B – 38 patients with VCD-only (63.2% females, mean age 56.8 yrs), 39 patients with asthma-only (56.4% female, mean age 53.3 yrs) and 12 patients with both VCD and asthma (83.3% female, mean age, 56.8yrs) were recruited. The mean number of patient-reported triggers in the VCD and asthma cohort was 11 and 13 respectively. Mechanical factors such as talking (p ≤ 0.001), shouting (p = 0.004) and swallowing (p ≤ 0.001) were more common in the VCD cohort, whilst environmental factors such as pollen/flowers (p = 0.002) and damp air (p = 0.039) were more common in asthma. There were no differences between groups in frequency of reporting scents as triggers (except for vinegar, more common in VCD), temperature, emotions or daily activities. Conclusion There were notable differences and overlaps between patient-reported triggers of VCD and asthma, which could give clues to diagnosis during clinical assessment. Future work should focus on the mechanisms underlying these findings.

Introduction Vocal cord dysfunction (VCD) typically involves abnormal vocal cord movement during inspiration. The recognised gold standard for diagnosis is fibreoptic laryngoscopy (FOL) during a symptomatic attack. Despite this there are no reported VCD FOL assessment scales to facilitate agreement in presentation, disease severity and treatment monitoring. Our VCD tertiary airways clinic receives over 300 referrals a year. We run a weekly diagnostic FOL list and identified the need for a VCD FOL classification for optimal care. Aims To gain consensus for a VCD FOL appearance scale and identify its interrater reliability. Methods An expert consensus group was convened comprising two respiratory consultant physicians and two respiratory speech and language therapists (SLTs). All have significant experience in VCD FOL interpretation. The group met, discussed and agreed on the VCD FOL appearance scale (Table 1). Two assessment teams were identified, each comprising a respiratory physician and a respiratory SLT. Each team rated patients, referred for FOL with a clinical suspicion of VCD, in three consecutive diagnostic FOL lists. All procedures were recorded and then blindly re-rated during playback by the other assessment team. Results Eighteen patients received ratings; the mean (range) age was 51(19–80) and 78% were female. The assessing teams agreed on the rating for seven patients. For nine patients there was disagreement but adjacent classifications. Interrater agreement was performed using a weighted kappa (1 = complete agreement in classification; 0.5 = disagreement but adjacent classifications; 0 = disagreement and non-adjacent classifications). There was moderate agreement between the teams; 0.44 with a 95% confidence interval of 0.18–0.70. There was no bias between the assessment teams, as each had mean ratings for all patients of 2.4. Conclusions The VCD FOL appearance scale is a promising clinical assessment tool for the VCD population. We expected further interrater agreement; interestingly the majority of disagreement would not have changed management as classification still yielded a positive diagnosis. The differential maybe attributed to whether ratings were performed live or in playback, and this should be investigated. With further development, standardisation of application and robust validation it will be a useful assessment to direct appropriate management and facilitate accurate and consistent diagnosis.

Introduction Heliox21 reduces the work of breathing in patients with extra-thoracic airway obstruction, is not curative or intended to replace other treatments. In our specialist service we have significant numbers of patients whom have history of regular hospitalisations, relating to poorly controlled vocal cord dysfunction (VCD). The gold standard for treatment is respiratory speech and language therapy (rSLT). We increasingly value Heliox21 as an early adjunct to rSLT in severe patients who are establishing management strategies. Aims To assess the impact of Heliox21 on patient admission rate and self-reported experience, for patients with severe VCD. Methods We retrospectively reviewed the rSLT caseload from June–December 2014. All patients with endoscopically confirmed VCD, greater than five VCD related hospitalisations prior to the commencement of VCD treatment and who were prescribed Heliox21 for use in the community were included. We requested hospital admission data (from patient’s GP and secondary care physicians) between June 2013–June 2015, and reviewed medical and rSLT notes for demographic information/co-morbidity data/opinions of Heliox21. Results Five patients met the inclusion criteria, three were available for analysis; one male and two female (aged 23,43,57 years). All had treated co-morbidities of asthma (BTS step 5) and reflux. One patient had treated nasal disease. Six-months prior to community Heliox21 administration the mean (range) number of hospital admissions was 11 (8–13); after instigation, during the same follow-up period, this reduced by 81% (2 admissions) and two patients had no hospitalisations. In all patients rSLT occurred simultaneously. Patient opinions included, ‘heliox gives me time to start my therapy and means I don’t ring 999 straight away,’ and, ‘heliox stops me from going to A&E all the time.’ Two patients, who had completed rSLT, had Heliox21 removed as it was no longer needed. Conclusions Heliox21 has a positive impact on reducing VCD hospital admissions and is a low cost short-term solution (£160 set-up, £8.50 month). This retrospective review has limitations; the impact of rSLT alone on admission rates needs to be compared. Further investigation is needed to examine the worth of Heliox21 as an initial adjunct to rSLT, with consideration of how to prevent reliance.

Introduction Our specialist service manages patients with vocal cord dysfunction (VCD), chronic cough (CC) and dysfunctional breathing (DB), and referrals have grown exponentially since we introduced this novel multi-disciplinary (MDT) model in 2006. The team comprises two severe asthma specialist physicians, two respiratory speech and language therapists (rSLT), a severe asthma nurse specialist, respiratory physiotherapist and clinical psychologist. Aims To describe the clinical characteristics of those referred and assess utilisation of the multi-disciplinary structure. Methods Patient demographics and clinical data were retrospectively collated from clinical records of patients referred between January and December 2014. Results The service received 249 referrals. Excluding patients still in treatment or who failed to attend initial assessment, 141 complete data sets were available for analysis: 71% female; mean (range) age 55 (18–79) years. Assessment requests were for VCD (71%), CC (28%) or both (1%) and over half were from NW severe asthma centres or extra-regional specialist centres. The majority of referrals were from hospital consultants (72%), with the remainder from GPs (17%) and AHPs (11%). For VCD there was 73% agreement between the clinical suspicion on referral and nasendoscopic assessment. Approximately half had evidence of co-existent reflux (52%) and a third (29%) had nasal disease. The majority were seen by more than one member of the MDT team; all by a specialist physician and a rSLT, 43% by respiratory physiotherapy, and 7% clinical psychology. In the VCD cohort 64% had a previous asthma diagnosis and this was confirmed in the majority (93%) – 49(82%) were ≥Step 3 on BTS/SIGN guidelines; 43% were additionally referred for DB assessment; 78 flow volume loops were available and 31 (40%) were suggestive of extra thoracic inspiratory airway obstruction. Sixty-seven patients (48%) received rSLT management [median (range) 4(1–8) sessions] with a further 16(11%) scheduled to receive it post medical intervention. Of those who completed treatment, 63% had clinically improved presentation on discharge nasendoscopy. Conclusions A large proportion of patients referred to a specialist service for patients with complex breathlessness require multi-disciplinary intervention. There is a significant incidence of VCD and DB in patients with severe complex asthma. Of those receiving rSLT interventions, outcome was extremely effective at reducing symptoms.