Incidence refers to the number of new cases of a disorder or condition identified in a specified time period.

Prevalence refers to the number of individuals who are living with the disorder or condition in a given time period.

Currently, there are no population-level studies investigating the incidence and prevalence of ILO. Incidence and prevalence estimates may additionally be impacted by frequent misdiagnoses, inconsistent diagnostic criteria and terminology, and an overall lack of awareness of ILO in the medical community (Halvorsen et al., 2017; Patel et al., 2015). As such, the following data should be interpreted with caution.

• ILO can occur across the lifespan and across the gender spectrum. However, it appears to be most common among females and more common in adolescence to young adulthood for both exercise- and irritant-based subtypes (Jeppesen et al., 2024; Walsted et al., 2021).
• Across multiple studies, ILO has been reported in approximately 2%–22% of patients with shortness of breath (Patel et al., 2015).
• In one German study, 4% of adults in rural settings reported ILO-like symptoms; however, diagnosis was not confirmed within this study (Bisdorff, 2014).
• It is estimated that 25% of adults with asthma have comorbid ILO (Lee et al., 2020).
• Exercise-based ILO (EILO) appears to be more common in athletes and individuals with high physical demands regardless of age (Fujiki et al., 2023; Jeppesen et al., 2024; Nielsen et al., 2013).
• Estimates suggest that 5% of adult elite athletes and 8.1% of adolescent athletes have symptoms consistent with EILO (Ersson et al., 2020; Rundell & Spiering, 2003).
• The estimated prevalence of EILO ranges from 5.7% to 7.5% in adolescents overall (Christensen et al., 2011; Johansson et al., 2015).

ILO may present with various signs and symptoms. Diagnosis is typically made with multidisciplinary input. SLPs play an instrumental role in the differential diagnosis of ILO and in determining the nature of ILO episodes and their potential triggers (Sandage et al., 2023).

Signs and symptoms may include the following:  

• A sudden and short closing of the vocal folds or nearby structures during breathing—either in or out. This can happen when triggered by things such as stress, irritants in the environment, or physical activity (exercise, in cases of EILO) and may be visible during a laryngoscopy.
• Cough or throat clearing during or after an episode of vocal fold adduction.
• Difficulty inhaling.
• Throat/neck tightness during episodes of breathing difficulty (chest tightness may suggest asthma).
• Intermittent episodes of shortness of breath typically triggered by a stimulus.
• Difficulty breathing that resolves quickly when triggers (i.e., exercise, strong odors, smoke, sudden changes in temperature or humidity) are removed.
• Lightheadedness.
• Noisy breathing.
  • Stridor (most common symptom)—high-pitched, turbulent sound due to a narrowing or obstruction of the upper airway. This may occur on inhalation or exhalation. Stridor for both inhalation and exhalation suggests laryngeal obstruction. Stridor on inhalation suggests only ILO.
  • Wheezing (rare symptom)—high-pitched, continuous, whistle-like sound that typically occurs on exhalation. This occurs at the level of the lower airway, below the level of the vocal folds.
  • Stertor (rare symptom)—rattling sound during breathing that typically sounds like “snoring” or nasal congestion. This occurs at the level of the naso- and oropharynx.

A change in vocal quality can possibly occur before or during an episode of vocal fold adduction but is not considered to be a sign/symptom.

The exact cause (or causes) of inducible laryngeal obstruction (ILO) is not known. However, some researchers suggest that these disorders may be related to changes in the responsiveness of laryngeal sensory nerve fibers, which result in the hypersensitivity of airway protective reflexes (e.g., laryngeal adductor reflex, laryngeal chemoreflex; Patel et al., 2015; Pathak et al., 2020). Although the etiology of ILO is not known, there may be identifiable triggers—events or situations that elicit an ILO event—such as the following:

• environmental irritants, such as
  • fumes, dust, smoke, pollen, or temperature/humidity change
• exercise or activity (exercise-based ILO)
• psychological stress
• gastroesophageal reflux/laryngopharyngeal reflux disease
• other sources of irritation, such as
  • upper respiratory infections or
  • some types of voicing (i.e., singing, laughing, shouting)
• a combination of any of the above factors

SLPs play a central role in the screening, assessment, diagnosis, and treatment of ILO. The SLP’s professional roles and activities include obtaining a comprehensive case history of the client as well as providing clinical/educational services (diagnosis, assessment, planning, and treatment); engaging in prevention and advocacy; and conducting education, administration, and research. See ASHA’s Scope of Practice in Speech-Language Pathology (ASHA, 2016).

Appropriate roles for SLPs include, but are not limited to, the following.

Screening and Assessment

• Screening individuals who present with signs and symptoms that are consistent with ILO and determining the need for further assessment and/or referral to other services.
• Assessing and diagnosing impairments of laryngeal function associated with ILO.
• Using laryngeal endoscopy for assessment (given proper training and/or certification).
• Making appropriate referrals to medical professionals for extensive medical workups.
• Serving on multidisciplinary teams to diagnose and differentially diagnose ILO.
• Referring individuals to otolaryngologists (ENTs), allergists, and/or pulmonary physicians who assist in differential diagnosis and care planning.

Treatment

• Adapting and developing person-centered treatment plans to accommodate patient/care partner preferences and values (see ASHA’s resource on focusing care on individuals and their care partners and ASHA’s Practice Portal page on Cultural Responsiveness).
• Making evidence-based recommendations about the management of ILO and exercise-based ILO.
• Serving as an integral member of a multidisciplinary team (see ASHA’s resources on collaboration and teaming and interprofessional education/interprofessional practice [IPE/IPP]).

Counseling and Education

• Educating and counseling people with ILO and their care partners on the signs, symptoms, and triggers for ILO and how these differ from the signs, symptoms, and triggers for asthma and other upper airway disorders.
• Educating other professionals on the needs of people with ILO and on the SLP’s role in diagnosis and treatment.

Other

• Advocating for individuals with ILO at the local, state, and national levels.
• Developing ILO programs.
• Ensuring the cultural and linguistic appropriateness of diagnostic and treatment procedures (see ASHA’s Practice Portal pages on Cultural Responsiveness; Multilingual Service Delivery in Audiology and Speech-Language Pathology and Collaborating With Interpreters, Transliterators, and Translators).
• Remaining informed of research and new developments relevant to ILO and helping to advance the knowledge base related to the nature and treatment of ILO.

As indicated in the ASHA Code of Ethics (ASHA, 2023), SLPs who serve this population should be specifically educated and appropriately trained to do so. This includes maintaining and documenting the highest level of competence in the areas of practice and recommending referrals to qualified professionals in areas outside of the SLP’s scope of practice.

ILO can have multiple triggers (see the Causes section), some of which may require a unique treatment approach. Such triggers can be accompanying disorders, such as

• refractory chronic cough (RCC)—a cough lasting over 8 weeks despite medical intervention (Chen et al., 2025)—and
• breathing pattern disorder (BPD) or dysfunctional breathing—a situation where an individual has inefficient or abnormal breathing patterns (e.g., upper chest breathing).

If disorders such as RCC and/or BPD trigger ILO, SLPs may directly treat those disorders to indirectly treat ILO. See ASHA’s Practice Portal page on Aerodigestive Disorders and Sandage et al. (2023) for further information on BPD.

EILO, by definition, occurs only during exercise (typically in peak physical exertion), with symptoms resolving when exercise stops. ILO also mimics other medical conditions, including asthma, swelling and other reactions secondary to allergies, BPD, and panic attack, among others. See Sandage et al. (2023) for a comprehensive tutorial of differential diagnosis for ILO. Charts related to differential diagnosis of ILO from Sandage et al. are also included (with permission) in the Differential Diagnosis section below.

Ideally, ILO is diagnosed with continuous laryngoscopy during provocation. Similarly, EILO can be diagnosed with continuous laryngoscopy during exercise (CLE; Hull et al., 2019). Data from pulmonary function testing can also be helpful for assessment and diagnosis (Christopher & Morris, 2010; Sterner et al., 2009).

A core multidisciplinary team may include

• an SLP,
• a pulmonologist,
• a laryngologist or otolaryngologist,
• a primary care provider,
• an allergist,
• a psychologist (general or performance, for EILO), and/or
• a respiratory therapist

Other professionals (e.g., neurologist, cardiologist, sports medicine physician) may also be included on the team.

SLPs make necessary referrals and collaborate with those professionals if a multidisciplinary team does not exist. See ASHA’s resources on interprofessional education/interprofessional practice (IPE/IPP) and collaboration and teaming.

Assessment and treatment of ILO may require the use of appropriate personal protective equipment and universal precautions.

Screening

An SLP may be the first health care professional to see an individual who is experiencing voice or breathing problems. See the Assessment section of ASHA’s Practice Portal page on Voice Disorders for specific screening information.

SLPs screen for the following changes:

• Respiratory factors, such as
  • the presence of stridor or labored breathing that affects breath support for voicing,
  • rapid respiratory rate,
  • BPD
  • chronic unproductive cough, and/or
  • neck tightness during inhalation
• Psychological and emotional factors
• Other conditions that can (a) affect voice or respiration or (b) signal an underlying medical condition, such as
  • vocal fold paralysis,
  • laryngomalacia,
  • fixed laryngeal stenosis, and/or
  • other neurologic conditions (e.g., abnormal sensorimotor function)

If screening results indicate anatomical or neurological difficulties that suggest an underlying disease process, referral is made to an appropriate medical professional.

Differential Diagnosis

ILO may involve the interaction of multiple systems and other disorders (e.g., BPD, RCC). Individuals may present with multiple complaints and varied symptoms. Due to these complexities, differential diagnosis is critical.

Differential diagnosis of ILO involves a multidisciplinary approach (Centeno-Saenz et al., 2025). The SLP plays an essential role in diagnosis. They obtain a detailed case history, assess breathing patterns, perform skilled fiberoptic laryngoscopy, and synthesize test information from all other team members (Reitz et al., 2014). See Sandage et al. (2023) for further information on differential diagnosis.

Thorough case histories and sign/symptom assessments facilitate differential diagnosis. Case histories may include the following.

Areas of Concern

• Presenting concern (see the Signs and Symptoms section)
• Patterns and progression of symptoms, both across time and within an episode (e.g., antecedent behaviors, recovery patterns, variability of symptoms)
• Patient or care partner perception of symptom severity
• Report of variability in symptoms (e.g., intermittent voice change, intermittent reflux)
• Report of environmental or activity-based triggers, including exercise
• Voice concerns/changes

Case History

The following are suggested case history questions to assist in differential diagnosis.

Reprinted, with permission, from “Inducible Laryngeal Obstruction Differential Diagnosis in Adolescents and Adults: A Tutorial,” by M. J. Sandage, C. F. Milstein, and E. Nauman, 2023, American Journal of Speech-Language Pathology, 32(1), 1–17 (https://doi.org/10.1044/2022_AJSLP-22-00187).

Common Symptom Comparison (Adult)

The following chart supports differential diagnosis by explaining the presentation of variables (e.g., symptoms, triggers) across disorders that commonly co-occur with ILO.

Note. ADLs = activities of daily living; GERD = gastroesophageal reflux disease; LPR = laryngopharyngeal reflux; SLP = speech-language pathologist. Reprinted, with permission, from “Inducible Laryngeal Obstruction Differential Diagnosis in Adolescents and Adults: A Tutorial,” by M. J. Sandage, C. F. Milstein, and E. Nauman, 2023, American Journal of Speech-Language Pathology, 32(1), 1–17 (https://doi.org/10.1044/2022_AJSLP-22-00187).

Rare Symptom Comparison (Adult)

The following chart supports differential diagnosis by explaining the presentation of variables (e.g., symptoms, triggers) across disorders that rarely co-occur with ILO.

Note. ADLs = activities of daily living; GERD = gastroesophageal reflux disease; LPR = laryngopharyngeal reflux; SLP = speech-language pathologist. Reprinted, with permission, from “Inducible Laryngeal Obstruction Differential Diagnosis in Adolescents and Adults: A Tutorial,” by M. J. Sandage, C. F. Milstein, and E. Nauman, 2023, American Journal of Speech-Language Pathology, 32(1), 1–17 (https://doi.org/10.1044/2022_AJSLP-22-00187).

Physical and System Assessment

Oral Mechanism and Cranial Nerve Examination

• Symmetry and movement of structures of the face, oral cavity, oropharynx, head, and neck during rest, nonspeech tasks, and speech/swallowing tasks
• Sensory response to mechanical stimulation of the face, oral structures, and pharyngeal structures
• Sensory response to taste, smell, and temperature
• Review of reported laryngeal sensations (e.g., dryness, tickling, burning, pain)

Respiration

• Respiratory pattern (abdominal, thoracic, clavicular), rate, and rhythm
• Coordination of respiration with triggers (e.g., exercise, irritants)
• Phrase length and other speech signs of impaired respiratory rate or tidal volume
• Strength of volitional cough

Respiration may be assessed under varied conditions, including at rest and during physical activity (e.g., walking, running), and in the presence of patient-identified triggers (e.g., strong smells). At times, clinicians may need to rely on client and care partner report for triggers that are difficult to create in a clinical environment.

Fiberoptic Laryngoscopy

Fiberoptic laryngoscopy (nasendoscopy is the preferable form of laryngoscopy) allows a clinician to see the entire larynx and pharynx during breathing. Fiberoptic laryngoscopy can allow a clinician to assess

• patency of the airway;
• the presence of any upper airway obstructive conditions (i.e., bilateral vocal fold paralysis, large vocal fold granuloma, stenosis);
• the structural and functional integrity of the vocal folds and supralaryngeal structures;
• laryngeal/supralaryngeal dynamics across a range of activities;
• breathing patterns at rest;
• breathing patterns during dyspnea, noting any abnormal adduction of the vocal cords and/or supraglottic structures during the inspiratory or expiratory phases; and
• the presence of paradoxical adduction of the true vocal folds with or without the involvement of supraglottic structures during inhalation and exhalation.

Please see Chiang et al. (2012) for further reading on fiberoptic laryngoscopy for assessment of EILO.

Note: It may be possible to meet the criteria for ILO even when laryngeal adduction upon inhalation is mild or does not occur (Olin et al., 2014). For further reading, please see Halvorsen et al. (2017), Centeno-Saenz et al. (2025), Hull et al. (2016), Olin et al. (2016), and Heimdal et al. (2006).

Cultural and Individual Considerations

SLPs conduct assessments in a manner that is responsive to each individual’s cultural background, personal beliefs/practices/habits, and preferences for medical intervention.

Ethnographic interviewing strategies can help in gathering useful information (Westby et al., 2003). Collaboration with other professionals (e.g., cultural broker, mental health provider, registered dietitian) may be beneficial. See ASHA’s Practice Portal pages on Cultural Responsiveness and Collaborating With Interpreters, Transliterators, and Translators for more information.

Decisions about goals and treatment options are made in partnership with the client, their care partners, and other professionals. As part of a multidisciplinary team, the SLP is involved in assessing the individual’s response to medical treatment and in implementing both indirect and direct strategies during or following medical treatment. See ASHA’s resources on interprofessional education/interprofessional practice (IPE/IPP) and focusing care on individuals and their care partners

Speech therapy is the primary treatment for ILO. Comprehensive multidisciplinary treatment of the upper airway may include

• medical management (including pharmacotherapy);
• behavioral treatment by an SLP;
• environmental management, such as avoiding triggers (e.g., environmental pollutants, strenuous exercise); and
• dietary and lifestyle modifications.

Behavioral Treatment

SLPs provide behavioral treatment to address ILO. The nature, scope, and duration of speech-language therapy depends on

• the severity of ILO symptoms,
• the length of time the client has experienced ILO events, and
• the need for medical treatment to address any underlying factors (e.g., reflux, anxiety).

The goal of treatment is to establish a consistent pattern of vocal fold abduction during the breathing cycle to maintain a patent airway. This affirms that breathing is consistently achievable, even in the presence of environmental or activity-related triggers.

During treatment, the SLP focuses on behavioral changes/strategies (Reitz et al., 2014). Other disciplines may also be involved in treatment (e.g., medical intervention to treat reflux or allergy triggers, when present).

SLPs may teach strategies to individuals with ILO; such strategies are individualized based on triggers or other factors (Drake et al., 2017; Fujiki et al., 2023; Johnston et al., 2018; Mathers-Schmidt, 2001; Sandage & Zelazny, 2004; Vreim et al., 2025). One such strategy that may help individuals manage their ILO is respiratory retraining, which uses a variety of techniques (discussed below).

Respiratory Retraining

Many of the techniques listed below use a semi-occluded vocal tract to promote laryngeal abduction through negative back pressure.

• Lower torso breathing (also known as “diaphragmatic breathing”): focuses on expanding the rib cage in the lateral and anterior–posterior planes during inhalation to avoid clavicular breathing patterns and shoulder/neck tension. Care should be taken not to emphasize too much abdominal muscle activity, as this can cause laryngeal tension. Laryngeal tightness and breath-holding should be avoided for patients with ILO and EILO.
• Olin EILO biphasic inspiratory breathing technique (EILOBT): a set of three laryngeal control and breathing activities (see Johnson et al. [2018] for a further explanation). This breathing technique is designed to
  • prevent inappropriate closure of the larynx/supralaryngeal structures during inhalation;
  • improve airflow during exercise; and
  • reduce symptoms of throat tightness, dyspnea, and stridor.
• Pursed-lip breathing: involves slowly breathing in through the nose, puckering the lips, and then slowly exhaling through pursed lips (Hicks et al., 2008). 
• Relaxed throat breathing: trains the vocal folds to abduct and remain abducted throughout the breathing cycle. This may include exhalation through pursed lips or the production of a strident sound such as /s/. 
• Sniff inhalation: involves sniffing in quickly through the nose with the tongue relaxed on the floor of the mouth and the lips gently touching, followed by exhalation through pursed lips or the production of a strident sound such as /s/.

Once the individual has identified their most effective breathing technique, the SLP may introduce challenges (triggers) while using the technique. These include the following:

• Sports-specific or exercise-specific training (relevant to EILO)—implementing breathing techniques during a routine exercise activity or competitive sports training. Biofeedback may be effective for individuals with EILO (Olin et al., 2017).
• Training in the presence of environmental triggers (if applicable)—implementing breathing techniques during exposure to odors or other environmental triggers, beginning with non-noxious stimuli and progressing through noxious stimuli.

For additional reading on therapeutic techniques, see Shaffer et al. (2018).

Prognosis depends on the appropriate identification of underlying causes and triggers as well as the individual’s ability to avoid noted triggers.

Billing for ILO Services

Providing appropriate procedure and diagnosis codes for evaluation and treatment is an important aspect of successfully billing for services. Payer policies often outline specific coverage guidelines relevant to procedure codes from the Current Procedural Terminology (CPT®; American Medical Association, 2018) and diagnosis codes from the International Classification of Diseases and Related Health Problems, 10th Revision, Clinical Modification (ICD-10-CM; World Health Organization, 2015).

ILO does not always present as a disorder of the respiratory and laryngeal systems that leads to voice, upper airway, or swallowing disorder. Coverage depends on how ILO directly relates to any of these conditions. Therefore, SLP documentation should clearly illustrate the effect of ILO on voice, the upper airway, and communication.

When billing for these services, SLPs use diagnosis and procedure codes for the assessment and treatment of voice and upper airway disorders. Payer policies regarding the coverage of ILO vary. Therefore, SLPs should verify coverage for each individual prior to billing for these services.

For more information about coding, see the following ASHA resources:

• New CPT Evaluation Codes for SLPs
• Medicare CPT Coding Rules for Speech-Language Pathology Services
• Coding for Reimbursement Frequently Asked Questions: Speech-Language Pathology
• ICD-10-CM Diagnosis Codes Related to Speech, Language, and Swallowing Disorders [PDF]

Service Delivery

In addition to determining the type of treatment that is optimal for individuals with ILO, SLPs consider other service delivery variables—including format, provider, dosage, timing, and setting—that may affect treatment outcomes.

• Format—whether a person is seen for treatment one-on-one (i.e., individual) or as part of a group. The format of service delivery for this population can include in-person and telepractice models.
• Provider—the person administering the treatment (e.g., SLP, trained volunteer, caregiver).
• Dosage—the frequency, intensity, and duration of service.
• Timing—when intervention occurs relative to the diagnosis. This includes the timing of behavioral intervention in relation to surgical/physical management.
• Setting—the location of treatment (e.g., inpatient, outpatient, home, community based, sports venue).

ASHA Resources

• Aerosol Generating Procedures (AGPs)
• Collaboration and Teaming
• Focusing Care on Individuals and Their Care Partners
• ILO/VCD Toolkit
• Interprofessional Education/Interprofessional Practice (IPE/IPP)
• Person-Centered Focus on Function: Voice [PDF]
• Sniffs, Gasps, and Coughs: Irritable Larynx Syndrome Across the Lifespan

Other Resources

• Aerodigestive Society
• American Academy of Allergy, Asthma & Immunology
• American Society of Pediatric Otolaryngology
• Global Initiative for Inducible Laryngeal Obstruction (GILO)
• The National Center for Voice & Speech
• The North American Airway Collaborative

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American Speech-Language-Hearing Association. (2023). Code of ethics [Ethics]. https://www.asha.org/policy/

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Acknowledgments

Content for ASHA’s Practice Portal is developed through a comprehensive process that includes multiple rounds of subject-matter expert input and review. ASHA extends its gratitude to the following subject-matter experts who were involved in the development of the Inducible Laryngeal Obstruction page:

• Robert Fujiki, PhD, CCC-SLP
• Emily Nauman, MA, CCC-SLP
• Rita Patel, PhD, CCC-SLP
• Mary Sandage, PhD, CCC-SLP

ASHA seeks input from subject matter experts representing differing perspectives and backgrounds. At times a subject matter expert may request to have their name removed from our acknowledgment. We continue to appreciate their work.

Citing Practice Portal Pages

The recommended citation for this Practice Portal page is:

American Speech-Language-Hearing Association. (n.d.). Inducible Laryngeal Obstruction (ILO). [Practice Portal]. https://www.asha.org/practice-portal/clinical-topics/Inducible Laryngeal Obstruction (ILO)/.