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Background It is estimated that one in four individuals report exercise-related respiratory symptoms, including shortness of breath, cough and/or wheeze. 1 Untreated symptoms result in reduced participation in exercise activity or exercise avoidance, particularly in adolescents, with symptoms usually treated as exercise-induced bronchoconstriction (EIB) or asthma.2 It is now widely accepted that differential diagnoses such as exercise-induced laryngeal obstruction (EILO) and dysfunctional breathing (DB) should be considered, due to their high prevalence.1Considered the gold standard to confirm a diagnosis of EILO, continuous laryngoscopy during exercise (CLE) has limited availability in UK paediatric hospitals, likely exacerbating misdiagnosis of exercise-related respiratory symptoms in children and young people and leading to unnecessary treatments, in particular inhaled corticosteroids. Cardiopulmonary exercise testing (CPET) is an established objective test, but again is only available at tertiary level, such that differential diagnoses including DB may be missed in paediatric primary and secondary-level care.Study source This case describes the successful diagnosis and treatment of EILO, DB and asthma overlap in a symptomatic 14-year old child.Primary results A 14-year old girl was referred to a tertiary children’s respiratory clinic with a 7-month history of exercise-related respiratory symptoms. Despite increasing, burdensome levels of inhaled treatments, symptoms continued to worsen and exercise avoidance ensued. Reported symptoms included inhalation difficulty with accompanying audible, noisy breathing. Diagnoses included exclusion of poorly-controlled asthma (fractional expired Nitric Oxide (FeNO) and bronchodilator response), exclusion of EIB from poorly-controlled asthma (exercise-induced bronchoprovocation fully-medicated), confirmation of DB and suspicion of EILO (CPET), and confirmation of underlying asthma (FeNO and exercise-induced bronchoprovocation off-treatment). Subsequent referral for CLE led to surgical intervention (supraglottoplasty), therapeutic intervention (physiotherapy) for DB and reduction of inhaled therapies.Conclusion This case describes successful approaches to diagnosing and treating overlapping EILO, DB and asthma, with resolution of all exercise-related symptoms for this child. The improvement in patient well-being, reduction in treatment burden and return to exercise following successful management highlights the importance of synergy in clinical assessment, objective testing, treatment optimisation and effective interventions (surgical, medical and behavioural).References Hull JH, et al. Thorax 2022;77:540–551.Johansson H, et al. Thorax 2015;70:57–63.