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Bill Klaproth (Host): Many people struggle with shortness of breath during exercise and are often given a diagnosis of asthma. But is that the real cause? Hmmm. Joining me right now, is Dr. Andrew Getzin, Clinical Director of Sports Medicine at Cayuga Medical Center and Director of Cayuga Medical Center’s Shortness of Breath with Exercise Clinic. Dr. Getzin, thanks for being here.

Andrew Getzin, MD (Guest): It’s a pleasure to be here Bill. Thanks for inviting me.

Host: Yeah, looking forward to talking with you. So, Dr. Getzin, how big of an issue is this? Is shortness of breath with exercise common?

Dr. Getzin: Well, we do have a clinic specifically designed to evaluate these people and we wouldn’t have that if it wasn’t common. About 50% of athletes suffer from some sort of breathlessness with exercise and the real challenge is these people often don’t get an accurate diagnosis. And they wound up seeing multiple physicians and never really figuring out the cause and consequently, really can’t get it better.

Host: So, when people are referred to your clinic, they usually come with a diagnosis of asthma. Is that correct?

Dr. Getzin: You know I think that anybody who has shortness of breath kind of gets this knee jerk that they must have asthma. I kind of describe it as someone being hit in the knee with a reflex hammer just shortness of breath, it must be asthma. And in fairness to my providers that see these people, sometimes it’s tough to kind of sift through it all and so they often will be empirically started on an inhaler which may or may not help. And the reality is, there’s been multiple high quality studies that have evaluated individuals with breathing tests called spirometry before exercise and then measuring their airway function after exercise and it doesn’t really correlate with a diagnosis of asthma. So, the history, unlike most medicine, really doesn’t help us much.

Host: Absolutely. So, they come to you then, they need answers, so, what is your process to diagnose the cause and come up with a clear answer for them?

Dr. Getzin: Anybody with shortness of breath with exercise, you need to obtain objective evidence to determine the cause. So, we will initially when we see somebody, in addition to doing a history which may or may not provide us with the information we need. We do a clear exam to see if there is anything that we can find on their physical exam that can give us the answer. And then we do a chest x-ray. We do some bloodwork. But what’s really important is to do a breathing test called spirometry and spirometry is very simple inexpensive test that measures the amount of air people breathe in and out and how rapidly they can expire that air.

And then what we do is we – we will do the breathing test and then we will treat them as if they had asthma and then we will measure lung function again and those who have baseline asthma, they of course get improvement when you treat their asthma. Now the majority of people who come to see us are fine at rest. It’s really only with exercise.

And like any problem with exercise, you need to be able to see what happens when you exercise that person. Right? So, one of the nice things about our clinic is I’m a sports medicine physician, I’m the head team doctor for USA triathlon and experienced triathlete if one competed in Kona Hawaii Ironman and such so I get exercise and my exercise physiologist and I, we work with an otolaryngologist, ear, notes and throat doctor. What we do is we take our athlete or people who are having problems breathing. We put them on the treadmill, and we see what happens. So, we measure the lung function first and then we exercise them at a sufficient exercise provocation.

Now asthma is provoked by cold dry air. So, when you think asthma, you think like a cross country skier it’s actually an occupational hazard because they are breathing in high workloads, high pulmonary stress and cold dry air. So, we follow the American Thoracic Society Guidelines where we make our room cold and dry. We give them a certain ventilatory load and then we measure the lung function afterwards and see was there a change.

Now, most of the people we see actually don’t have a change. And they might have been diagnosed with asthma. Those people we’re actually able to take off their medication they were put on so, an inhaled corticosteroid which is the mainstay of asthma treatment, it’s $200 a month plus there are negative effects for being on medication you don’t need. We can take a lot of these people off their medications.

What we find more commonly is people have an under-recognized problem, something called exercise induced laryngeal obstruction. So, the larynx is the conduit of the mouth to the lungs. It brings the air from the mouth down to the lungs and what we find in some individuals is that larynx in that upper airway actually narrows down when they are breathing in. It’s pretty dramatic when this happens. When they have an attack of this, it’s usually on inspiration and people are pretty freaked out. They feel like they are drowning. They can’t breathe. And it’s really rapid on and rapid off.

Now, we are one of the few clinics in the world that can actually diagnose this. We realized and we kind of figured this out sort of back and forth because Dr. Strominger who is an otolaryngologist would – he would scope these people where he put a laryngoscope, a little camera that’s on the end of a tube. He would put it into their nose and look at their airway. He would then send them out in the parking lot and have them run and then bring them back and scope them again.

Now we realized there was a group in Norway that had figured out how to look at upper airway with exercise. So, we basically looked at their design and kind of made a similar version here where we have a headgear and one of my athletic trainers is a welder and welded something. And then we went a couple of years ago actually and visited them.

So, now we do a technique that’s called continuous laryngoscopy with exercise, where we look at people’s airway as they are exercising. It’s very safe. We’ve been successful in using this technique in people as young as 9. There was a study out of Sweden that showed that in sixth and seventh graders, they were 99% successful in visualizing. And again, just like in an objective evidence for the asthma test, this objective test we can visualize if the airway is narrowing. So, we are one of the few places that can diagnose EILO or exercise induced laryngeal obstruction.

Host: And Dr. Getzin, you are one of the few clinics that offer the continuous laryngoscopy, that’s correct?

Dr. Getzin: We are. Yeah, we are only aware of one other clinic in the United States that’s doing this right now. There are about 10 clinics in the world. I think you need to have a lot of things fall into place successfully to be able to do this clinic. You need to have somebody who has the expertise to do a laryngoscope. You need to have the equipment that we were able to fabricate, and you need to have somebody with expertise on exercising the patient. So, I’m a sports medicine physician and we have exercise physiologists and we also have an otolaryngologist. So, we kind of have this perfect storm.

You know it’s interesting how things kind of go full circle in that this technique was first discovered with race horses because it’s the second most common problem with race horses to have a poor performance which is dynamic upper airway problems. So, there was a group of at Cornell University here in Ithaca, New York and a group in Norway that were doing it. Then this group in Norway of human doctors, said heh let’s do what we are doing in race horses and now currently we are starting to collaborate with our Cornell colleagues who have done some of work with the race horses.

Host: Very interesting. So, what you usually find is many people don’t actually have asthma, they have exercise induced laryngeal obstruction. So, then what is the normal treatment for that?

Dr. Getzin: You know the great thing about making the diagnosis is the treatment is usually pretty straightforward. Most people with EILO or exercise induced laryngeal obstruction respond very well to treatment with speech therapy. They are taught how to breathe through this. They are taught techniques to modify the pressure in their upper airway. Many of our patients are just overjoyed because they’ve been seeking care from multiple different providers and not getting an answer and people started thinking they were crazy.

And when you tell them, it’s really motivational. We’ve had people – we see this more commonly in adolescent females, but we see it in people all ages and we have seen people who are adults who cannot exercise, and they used to fake injury as kids because they would struggle with breathing, that we figured this process out and they are now able to exercise for their health. So, it’s really dramatic in some people.

Host: I can see where that really would be beneficial and eye opening to someone who thought they had asthma and it turns out they don’t. Last question Dr. Getzin. So, tell us about the Shortness of Breath Clinic. Why was that developed?

Dr. Getzin: That’s a great question. So, I’m the Head team doctor for USA triathlon and I’ve also been a head team physician for a division three college, Ithaca College here in Ithaca, New York. And I’ve seen people – athletes that would come to be seen on their screening or I’d see them in the clinic, or I’d see them at international events that the rate-limiting step for their exercise is their breathing. Now in almost everybody, what limits them is our heart’s ability to pump out blood. It really shouldn’t be limited by breathing. And many of these people have just struggled not getting answers.

So, it sort of pulled me in to try and solve these people’s problems and just been fortunate to have this collaboration with my colleague Dr. Strominger and being in an area with exercise physiologists as part of our team. So, we were able to get this multidisciplinary approach to assess these problems. And that’s the key for many complex problems, right, is getting different people with different expertise together to collaborate to come up with one solution.

Host: So great for the community to have this clinic right in their backyard. Dr. Getzin, thank you so much for your time today. We appreciate it. For more information, please visit www.cayugahealthsystem.org, that’s www.cayugahealthsystem.org. This is To Your Health from Cayuga Medical Center. I’m Bill Klaproth. Thanks for listening.