Positive Bronchodilator Response Research Articles

Changes in the Functional Classification of Spirometry Using the New Interpretation Standard 2022: A Multicenter Study

IntroductionPulmonary function tests are vital for diagnosing lung diseases, assessing treatment responses, and monitoring respiratory health. Recent updates to interpretive standards by the European Respiratory and American Thoracic Societies (ERS/ATS) in 2022 introduced significant changes compared to the 2005 standards. They include incorporating lung volume measurements, non-specific and mixed disorders, introducing z-scores for functional abnormality assessment, reducing severity categories from five to three, and revising criteria for positive bronchodilator responses. MethodsWe conducted a retrospective, multi-center study across four centers using spirometric data spanning from 2002 to 2022. We categorized spirometry results using both the 2005 and 2022 ATS/ERS standards and calculated predicted values following the GLI 2012 equation (Caucasian subset). ResultsAmong 79,039 subjects, we observed that 23% shifted from an obstructive diagnosis under the 2005 standard to a mixed pattern diagnosis under the 2022 standard, necessitating lung volume assessments. In the evaluation of bronchodilator responses among 59,203 tests, 12.3% of those initially classified as responders were reclassified as non-responders with the new standards. We found variations in severity categorization across age groups, with older patients tending to receive milder severity classifications and younger individuals receiving greater severity classifications under the 2022 standards. ConclusionsThe 2022 document emphasizes early lung volume assessment, potentially leading to increased utilization of more complex tests. Furthermore, the bronchodilator response was predominant in extreme age groups and among individuals with milder spirometric impairments. This shift may impact treatment decisions, potentially initiating medication in milder cases and de-escalating treatment in more severe cases.

Pulmonary function assessments and clinical correlates in children with sickle cell disease in Cape Town, South Africa

Objectives: Among children with sickle cell disease (SCD) in Africa, there are varied reports on pulmonary function assessments. Restrictive pulmonary function is common in children with SCD in Africa; however, reports from Africa are few. We aimed to describe pulmonary function and its clinical correlates in children with SCD in Cape Town, South Africa. Materials and Methods: A prospective cross-sectional study was carried out over seven months from October 2018 to April 2019 in children 6–16 years with SCD. Children with hemoglobin (Hb) genotypes, homozygous for the BS globin mutation, and sickle-beta0-thalassemia Hb were included in the study. Children were excluded if they had acute complications. Medical record review clinical, laboratory, and pulmonary function assessments were done. Data were entered into Excel and exported to Stata Version 16.0 statistical software for analysis. Results: A total of 25 participants were recruited, mean (standard deviation) age of 10 ± (3.0) years. Thirteen (53%) children were under ten years and 15 (60%) were male. The median/interquartile range age at diagnosis was 1.7 [0.8–3.0] years. SCD-related complications were common. A review of the medical records showed a third of the patients (32%) had at least one previous episode of acute chest syndrome, 20 (80%) had a history of vaso-occlusive crisis, and 15 (76%) had required at least one blood transfusion. Spirometry was performed on 19 (76%) of the participants 9 (47%) had abnormal lung function. The most common spirometry abnormality was a restrictive pattern (forced vital capacity (FVC) < lower limit of normal (LLN)). No participant had a positive bronchodilator response. Older age was associated with a decrease in forced expiratory volume in the first second (FEV1) Z-score (−0.16, 95% confidence interval [CI] −0.31, −0.01; P = 0.04). Children on hydroxyurea similarly had reduced FEV1 Z-score (−1.5, 95%CI −2.88, −0.12; P = 0.04) and reduced FVC Z-score (−2.21, 95%CI −3.64, −0.79; P < 0.001). Conclusion: Lung function abnormalities were common among children with SCD, with restrictive abnormality predominating. Asthma and obstructive airway abnormalities were uncommon in children with SCD in South Africa.

Impulse oscillometry bronchodilator response in preschool children.

In preschoolers, performing an acceptable spirometry and measuring bronchodilator response (BDR) is challenging; in this context, impulse oscillometry (IOS) represents a valid alternative. However, more studies on the standardization of BDR for IOS in young children are required. The objective of the study was to identify optimal thresholds to define a positive BDR test with IOS in preschoolers with suspected asthma. Children aged 3-6 years with suspected asthma and their lung function investigated with both IOS and spirometry pre- and post-BDR were retrospectively analyzed. The spirometric BDR was defined as positive when the change of FEV1 was ≥12% or ≥200 mL. The oscillometric BDR was defined as positive in case of change of at least -40% in R5, +50% in X5, and -80% in AX. Among 72 patients, 36 (age 5.2 ± 1 years; 64% boys) were selected for the subsequent analysis according to ATS/ERS quality criteria of measurements; specifically, 19 patients did not meet IOS and 36 did not meet spirometry criteria. The spirometric BDR was found positive in seven subjects (19.4%); conversely, a positive oscillometric BDR was identified in four patients (11.1%). No patient presented a positive BDR response with both methods. In IOS, the mean decrease in R5 and AX was 19.9% ± 10% and 44% ± 22.1%, and the mean increase in X5 was 23.3% ± 17.8%, respectively. A decrease in R5 of 25.7% (AUC 0.77, p = .03) and an increase in X5 of 25.7% (AUC 0.75, p = .04) showed the best combination of sensitivity and specificity to detect an increase of FEV1 ≥ 12% and/or ≥200 mL. The IOS represents a valid alternative to spirometry to measure BDR in preschool children and should be the gold standard in this age group. We are considering a decrease of 26% in R5 and an increase of 26% in X5 as diagnostic threshold for BDR.

A comparative study of bronchodilator response: utilizing pre-bronchodilator versus predicted normal values

BackgroundA positive bronchodilator response has been defined as a 12% increase in the forced expiratory volume in one second (FEV1) or forced vital capacity (FVC) from their respective pre-bronchodilator values, combined with at least a 0.2 L absolute change. Recent recommendations suggested the use of the percent change in FEV1 and FVC relative to their predicted normal values without having applied them in patients with airflow obstruction. The aim of the current study was to compare the two approaches over a wide range of pre-bronchodilator FEV1 and FVC values.MethodsA retrospective review of consecutive patients undergoing spirometry and bronchodilator testing was completed. The change in FEV1 and FVC with a bronchodilator was expressed relative to the pre-bronchodilator and predicted normal FEV1 and FVC.ResultsIn 1,040 patients with a non-paradoxical change in FEV1, 19.0% had a ≥ 12% change in FEV1 using their pre-bronchodilator value compared to 5.7% using their predicted normal value. For FVC, the respective values were 12.7% vs. 5.8%. The difference was retained in patients with a ≥ 0.2 L change in FEV1 or FVC. In unobstructed patients, the upper threshold (two standard deviations above the mean) of the bronchodilator response was 14% for FEV1 and 10% for FVC using predicted normal values.ConclusionsExpressing the percent change in FEV1 and FVC relative to predicted normal values reduces the over-estimation of the bronchodilator response, especially in patients with a very low pre-bronchodilator FEV1, including in those with a ≥ 0.2 L change in FEV1. Irrespective of pre-bronchodilator values, a ≥ 14% change in FEV1 and ≥ 10% change in FVC relative to the predicted normal values could be considered a positive bronchodilator response.

Bronchodilator responsiveness in children with primary ciliary dyskinesia.

Reversible airway obstruction is common in children with primary ciliary dyskinesia. However, the diagnostic value of adding bronchodilator (BD) response testing to routine spirometry is unclear. This is a retrospective analysis of pulmonary function test results obtained from children with primary ciliary dyskinesia seen as outpatients at the Hospital for Sick Children, Toronto. Spirometry results were collected for every appointment with BD response testing ("Visit", with pre-BD and post-BD measurements) as well as for the previous ("Baseline") and following ("Follow-up") encounters. A positive BD response was seen in 86 out of 474 (18.1%) of the pulmonary function tests from 82 children with primary ciliary dyskinesia. BD responsiveness was associated with a significant absolute change (±sd) in % predicted forced expiratory volume in 1 s (FEV1) from Baseline to Visit pre-BD (-6.5±10.3%, p<0.001), but not from Baseline to Follow-up (0.4±10.8, p=0.757). Antimicrobial therapy was initiated more commonly following a Visit with a positive BD response (OR 3.8, 95% CI 2.2-6.6) compared to no BD response. Children with a positive BD response had a greater annual decline in FEV1 % predicted compared to those with no BD response (-0.9% per year versus -0.5% per year, p<0.001). The annual decline in FEV1 % predicted was greater in children with multiple compared to one measured positive BD responses (-1.3% per year versus -0.6% per year, p<0.001) and in those not treated with antibiotic therapy following a positive BD response compared to those treated with antibiotics (-1.1% versus -0.6%, p<0.001). A positive BD response in children with primary ciliary dyskinesia may help identify those at risk for accelerated lung disease progression.

Bronchodilator response by interrupter technique to guide management of preschool wheeze

ObjectiveWe examined relationships between clinical features and pulmonary function before and after inhaled corticosteroid (ICS) treatment in wheezy preschool children, and specifically, whether measuring bronchodilator response (BDR) could predict benefit...

Oscillometry helps assess treatment responsiveness in adults with asthma exacerbations

BackgroundIt is necessary to evaluate the severity of asthma exacerbations for subjective symptoms and objective indicators. When patients cannot perform spirometry, oscillometry is a surrogate test. ObjectiveWe assessed the usefulness of oscillometry for the evaluation of treatment responsiveness in patients with asthma exacerbations. MethodsThe subjects included 21 consecutive patients with asthma exacerbations. Symptomatic responses, oscillometry, and spirometry (if possible) were assessed before and after treatment with corticosteroids and aminophylline. ResultsAfter treatment, all of the patients were allowed to return home and had no hospital visits. Oscillometry was feasible in all patients; however, spirometry could not be performed in 9 patients. Overall, there was a significant improvement in wheezing scores and oscillometric parameters, but not in FEV1 after treatment. The thresholds for a positive bronchodilator response in oscillometry were observed in 4 or more patients, while the minimal clinically important differences in FEV1 were observed in one patient. ConclusionOscillometry can detect improvements that cannot

Clinical predictors of treatment response to tiotropium add-on therapy in adult asthmatic patients: From multicenter real-world cohort data in Korea

BackgroundTiotropium, a long-acting muscarinic antagonist, is recommended for add-on therapy to inhaled corticosteroids (ICS)-long-acting beta 2 agonists (LABA) for severe asthma. However, real-world studies on the predictors of response to tiotropium are limited. We investigated the real-world use of tiotropium in asthmatic adult patients in Korea and we identified predictors of positive response to tiotropium add-on. MethodsWe performed a multicenter, retrospective, cohort study using data from the Cohort for Reality and Evolution of Adult Asthma in Korea (COREA). We enrolled asthmatic participants who took ICS-LABA with at least 2 consecutive lung function tests at 3-month intervals. We compared tiotropium users and non-users, as well as tiotropium responders and non-responders to predict positive responses to tiotropium, defined as 1) increase in forced expiratory volume in 1 s (FEV1) ≥ 10% or 100 mL; and 2) increase in asthma control test (ACT) score ≥3 after 3 months of treatment. ResultsThe study included 413 tiotropium users and 1756 tiotropium non-users. Tiotropium users had low baseline lung function and high exacerbation rate, suggesting more severe asthma. Clinical predictors for positive response to tiotropium add-on were 1) positive bronchodilator response (BDR) [odds ratio (OR) = 6.8, 95% confidence interval (CI): 1.6–47.4, P = 0.021] for FEV1 responders; 2) doctor-diagnosed asthma-chronic obstructive pulmonary disease overlap (ACO) [OR = 12.6, 95% CI: 1.8–161.5, P = 0.024], and 3) initial ACT score <20 [OR = 24.1, 95% CI: 5.45–158.8, P < 0.001] for ACT responders. FEV1 responders also showed a longer exacerbation-free period than those with no FEV1 increase (P = 0.014), yielding a hazard ratio for the first asthma exacerbation of 0.5 (95% CI: 0.3–0.9, P = 0.016). ConclusionsThe results of this study suggest that tiotropium add-on for uncontrolled asthma with ICS-LABA would be more effective in patients with positive BDR or ACO. Additionally, an increase in FEV1 following tiotropium may predict a lower risk of asthma exacerbation.

Effects of Aeroallergen Sensitization on Symptom Severity, Pulmonary Function, and Bronchodilator Response in Children With Bronchial Asthma

Background: Allergen sensitization, symptom severity, pulmonary function test, and bronchodilator response are important in the diagnosis and treatment of asthma. However, the relationship between these factors remains unclear. Objective: The objective of this study was to investigate the relationship between aeroallergen sensitization and asthma severity, pulmonary function, and bronchodilator response among pediatric patients with bronchial asthma. Methods: This was a prospective study where 155 pediatric patients aged 7–18 years old with bronchial asthma were recruited from Outpatient Clinics. Patients who met the inclusion criteria proceeded with spirometry and aeroallergen skin prick test. Results: There was a significant degree of sensitization, wherein 100% of the patients had sensitization to one or more aeroallergens. Among these children, 106 (68%) were polysensitized. The polysensitized group had more severe and persistent asthma severity profile (p&lt;0.001) and worse pulmonary function (p&lt;0.001). The frequency of abnormal pre-bronchodilator lung function of the polysensitized group was higher than the monosensitized group (p&lt;0.001). A positive bronchodilator response was higher among polysensitized children as compared to monosensitized children (p&lt;0.001). Sensitization to Dermatophagoides farinae, Dermatophagoides pteronyssinus and dog correlated with impairment of both the large airways and distal small airways while sensitization to cat, cockroach, and horse correlated only with impairment of the large airways (p&lt;0.05). Patients sensitized to D. farinae, D. pteronyssinus, cat and dog had significant bronchodilator response (p&lt;0.05). Conclusion: Polysensitized asthmatic children had a more persistent and severe asthma profile, worse pulmonary function, and higher bronchodilator reversibility compared to the monosensitized group.

Airwave oscillometry and spirometry in children with asthma or wheeze

Objective Lung function testing is used in diagnosing asthma and assessing asthma control. Spirometry is most commonly used, but younger children can find performing this test challenging. Non-volitional tests such as airwave oscillometry (AOS) may be helpful in that population. We compared the success of spirometry and AOS in assessing bronchodilator responsiveness in children. Methods AOS was conducted alongside routine lung function testing. Resistance at 5 Hz (R5), the difference between the resistance at 5 and 20 Hz (R5-20) and the area under the reactance curve (AX) were assessed. Patients between 5 and 16 years old attending clinic with wheeze or asthma were assessed. Patients performed AOS, followed by spirometry and were then given 400 µg salbutamol; the tests were repeated 15 minutes later. Results Lung function testing was performed in 47 children of whom 46 (98%) and 32 (68%) performed acceptable baseline oscillometry and spirometry, respectively (p < 0.001). Children unable to perform acceptable spirometry were younger (7.35, range: 5.4–10.3 years) than those who could (10.4, range: 5.5–16.9 years), p < 0.001. The baseline z-scores of AOS R5 correlated with FEV1 (r = 0.499, p = 0.004), FEF75 (r = 0.617, p < 0.001), and FEV1/FVC (r = 0.618, p < 0.001). There was a positive bronchodilator response assessed by spirometry (change in FEV1 ≥ 12%) in eight children which corresponded to a change in R5 of 36% (range: 30%–50%) and a change in X5 of 39% (range: 15%–54%). Conclusions Oscillometry is a useful adjunct to spirometry in assessing young asthmatic children’s lung function. The degree of airway obstruction, however, might affect the comparability of the results of the two techniques.

Bronchodilator Responsiveness Defined by the 2005 and 2021 ERS/ATS Criteria in Patients with Asthma as Well as Chronic Obstructive Pulmonary Disease.

BackgroundIn the 2021 ERS/ATS interpretive strategies for routine lung function tests, a positive bronchodilator response (BDR) was updated as a change of >10% relative to the predicted value in forced expiratory volume in 1 second (FEV1) or forced vital capacity (FVC). We aimed to explore the differences between the 2005 and 2021 ERS/ATS criteria applied to patients with asthma as well as chronic obstructive pulmonary disease (COPD).MethodsBDR test data about asthma patients aged 6–80 years and COPD patients aged 18–80 years were derived from the National Respiratory Medicine Center, First Affiliated Hospital of Guangzhou Medical University, from January 2017 to March 2022. BDR results defined by the 2005 and 2021 ERS/ATS criteria were named 2005-BDR and 2021-BDR, respectively. We compared differences between 2005-BDR and 2021-BDR and analyzed the trend in the proportion of positive BDR (BDR+) with the level of airflow obstruction.ResultsA total of 4457 patients with asthma and 7764 patients with COPD were included in the analysis. The percentages of 2005-BDR+ and 2021-BDR+ were 63.32% and 52.84% for asthma, 30.92% and 22.94% for COPD, respectively. Of patients with 2005-BDR+, 81.86% for asthma and 70.18% for COPD showed 2021-BDR+ results, and these patients had higher FEV1%pred, FVC%pred (all P<0.05). Whichever BDR criterion was adopted, the proportion of BDR+ had an upward linear trend with the increased degree of airflow obstruction in COPD, but exhibited an approximate inverted U-shaped curve in asthma. In COPD, the proportion of BDRFEV1 was negatively associated with the degree of airflow obstruction, while BDRFVC was positively associated (all P<0.05).ConclusionCompared with 2005-BDR+, the proportion of 2021-BDR+ reduced markedly in patients with asthma and COPD, but their trends with the degree of airflow obstruction did not change. Patients with consistent BDR+ had higher initial FEV1%pred and FVC%pred.

Long-term pulmonary sequelae in adolescents post-SARS-CoV-2 infection.

RationaleSevere acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) causes long‐term pulmonary sequelae in adults, but little is known about pulmonary outcomes in pediatrics.Objective(s)The aim of this study was to describe long‐term subjective and objective pulmonary abnormalities after SARS‐CoV‐2 infection in pediatric populations.MethodsSingle‐center, retrospective cohort of patients seen in post‐coronavirus disease 2019 (COVID‐19) pulmonary clinic in 2021. Subjects evaluated had persistent pulmonary symptoms 4 weeks or more after initial infection. Clinical testing included a 6‐min walk test (6MWT), chest X‐ray, pre‐ and postbronchodilator spirometry, plethysmography, and diffusion capacity. Patients were followed 2‐to‐3‐months after the initial visit with repeat testing. The primary outcome was the presence of abnormal pulmonary function testing. Secondary measures included variables associated with pulmonary outcomes.ResultsEighty‐two adolescents were seen at a median of 3.5 months postinfection, with approximately 80% reporting two or more symptoms at clinic presentation (cough, chest pain, dyspnea at rest, and exertional dyspnea). At follow‐up (~6.5 months) exertional dyspnea persisted for most (67%). Spirometry was normal in 77% of patients, but 31% had a positive bronchodilator response. No abnormalities were noted on plethysmography or diffusion capacity. Clinical phenotypes identified included inhaled corticosteroid responsiveness, paradoxical vocal fold motion disorder, deconditioning, and dysautonomia. Multivariable modeling demonstrated that obesity, anxiety, and resting dyspnea were associated with reduced 6MWT, while female sex and resting dyspnea were associated with higher Borg Dyspnea and Fatigues scores.ConclusionsThis is the largest study to date of pediatric patients with long‐term pulmonary sequelae post‐COVID‐19. Identified clinical phenotypes and risk factors warrant further study and treatment.

EXTENSIVE CYSTIC LUNG DISEASE IN EXTRANODAL MARGINAL ZONE B CELL LYMPHOMA (MALT LYMPHOMA) OF THE LUNG WITH LIGHT CHAIN DEPOSITION DISEASE

TOPIC: Diffuse Lung Disease TYPE: Fellow Case Reports INTRODUCTION: Extranodal marginal zone lymphoma of mucosa associated lymphoid tissue (MALT Lymphoma) is a rare disorder, but is the most common cause of primary pulmonary lymphoma involvement. Cystic changes along with nodularity has been previously reported in MALT lymphomas along with light chain deposition disease (LCDD). CASE PRESENTATION: A 44 y/o previously smoking female patient presented with a 3-year history of progressive dyspnea in the setting of extensive cystic lung disease. Her extensive lung cysts had previously raised concern for lymphangioleiomyomatosis (LAM) and she had undergone an open lung biopsy (OLB) about 2 years prior. She also had a 10-year history of Rheumatoid Arthritis (RA) for which she had previously received methotrexate, adalimumab and leflunomide. The OLB was negative for LAM, but no alternative diagnosis was made based on the biopsy results. Due to progressive dyspnea, she presented to our facility where a fresh evaluation of her case was undertaken. A repeat CT Chest again confirmed extensive cystic lung changes that were not present 12 years ago and had minimally progressed from the time of OLB two years ago (figure 1). Pulmonary function testing (PFTs) showed a severe obstructive pattern with a positive bronchodilator response. Laboratory testing confirmed positive results for rheumatoid factor, CCP, ANA as well as SSA & SSB antibodies. A review of the OLB confirmed the presence of an atypical lymphoplasmacytic infiltrate associated with nodular kappa light chain deposition disease (LCDD). The overall pattern was consistent with extranodal marginal zone lymphoma of mucosa associated lymphoid tissue (MALT lymphoma). The biopsy confirmed the presence of cystic changes within the nodular light chain deposits. PET scan was negative for extrathoracic lymphoma and the patient was started on Rituximab. DISCUSSION: We present a case of pulmonary MALT Lymphoma with LCDD presenting with extensive cystic lung disease and severe airflow obstruction. The case was initially mistaken for LAM and appropriate therapy was delayed for 2 years. MALT lymphomas with LCDD are rare causes of pulmonary cystic disease and generally have a good prognosis with an overall 5-year survival rate exceeding 80% and a median survival over 10 years. Given the positive Sjogren's antibodies and the presence of lung cysts; lymphocytic interstitial pneumonia (LIP) was also considered in the differential diagnosis. The presence of severe airflow obstruction on lung function was somewhat atypical in this case and a component of bronchiolitis obliterans from RA could not be entirely excluded. CONCLUSIONS: Extranodal marginal zone B cell lymphoma of the lung can present with extensive cystic lung disease that can mimic other common causes of cystic lung disease such as LAM, LIP and Birt Hogg Dube disease and PLCH. Prognosis is generally good and Rituximab is the most commonly used initial treatment approach. REFERENCE #1: pulmonary and nodular cystic light chain deposition disease: a retrospective review of 10 cases. Baqir M et al. Respir Med. 2020 Apr; 164:105896. REFERENCE #2: Nodular pulmonary light chain deposition disease: an entity associated with Sjögren syndrome or marginal zone lymphoma. Arrossi AV et al. J Clin Pathol. 2016 Jun; 69(6): 490-6. REFERENCE #3: Pulmonary mucosa-associated lymphoidtissue lymphoma revisited. Borie R et al. Eur Respir J 2016; 47: 1244-1260. DISCLOSURES: No relevant relationships by Vaibhav Ahluwalia, source=Web Response No relevant relationships by Hasan Ahmad Hasan Albitar, source=Web Response No relevant relationships by Vivek Iyer, source=Web Response

Normal limits for oscillometric bronchodilator responses and relationships with clinical factors.

IntroductionWe aimed to determine normal thresholds for positive bronchodilator responses for oscillometry in an Australian general population sample aged ≥40 years, to guide clinical interpretation. We also examined relationships between bronchodilator responses and respiratory symptoms, asthma diagnosis, smoking and baseline lung function.MethodsSubjects recruited from Sydney, Melbourne and Busselton, Australia, underwent measurements of spirometry, resistance (Rrs6) and reactance (Xrs6) at 6 Hz, before and after inhalation of salbutamol 200 μg. Respiratory symptoms and/or medication use, asthma diagnosis, and smoking were recorded. Threshold bronchodilator responses were defined as the fifth percentile of decrease in Rrs6 and 95th percentile increase in Xrs6 in a healthy subgroup.ResultsOf 1318 participants, 1145 (570 female) were analysed. The lower threshold for ΔRrs6 was −1.38 cmH2O·s·L−1 (−30.0% or −1.42 Z-scores) and upper threshold for ΔXrs6 was 0.57 cmH2O·s·L−1 (1.36 Z-scores). Respiratory symptoms and/or medication use, asthma diagnosis, and smoking all predicted bronchodilator response, as did baseline oscillometry and spirometry. When categorised into clinically relevant groups according to those predictors, ΔXrs6 was more sensitive than spirometry in smokers without current asthma or chronic obstructive pulmonary disease (COPD), ∼20% having a positive response. Using absolute or Z-score change provided similar prevalences of responsiveness, except in COPD, in which responsiveness measured by absolute change was twice that for Z-score.DiscussionThis study describes normative thresholds for bronchodilator responses in oscillometry parameters, including intra-breath parameters, as determined by absolute, relative and Z-score changes. Positive bronchodilator response by oscillometry correlated with clinical factors and baseline function, which may inform the clinical interpretation of oscillometry.

A Case series on Asthma-COPD overlap (ACO) is independent from other chronic obstructive diseases (COPD and Asthma)

As we know that, Asthma and chronic obstructive pulmonary diseases are well characterized diseases, they can co-exist as asthma-COPD overlap (ACO). The co-existence of asthma-chronic obstructive pulmonary disease overlap (ACO) in chronic obstructive pulmonary disease (COPD) patients is often unrecognized. In patients with a primary diagnosis of COPD or Asthma, the identification of ACO has got implication for better prognosis and treatment. Such patients experience frequent exacerbations, poor quality of life, rapid decline in lung function and high mortality than COPD or Asthma alone. Inhalational steroids provide significant alleviation of symptoms in such patients and some studies suggest that the most severe patients may respond to biological agents indicated for severe asthma. Patients who have asthma with a COPD component tend to present with severe hypoxia because of Irreversible/fixed airway obstruction and impairment of the alveolar diffusion capacity by emphysematous changes. In contrast, patients with COPD who have an asthma component not only have exertional dyspnoea but also develop paroxysmal wheezing or dyspnoea at night or in the early morning. The criteria to diagnose asthma-COPD overlap (ACO) include positive bronchodilator response, sputum eosinophilia or previous diagnosis of asthma, high IgE and/or history of atopy. There is scarcity of literature available in country like India. We highlight the importance of identification of Asthma COPD overlap as different phenotype from COPD or asthma alone as it is challenging to diagnose ACO in India. We report 3 cases having both the features of asthma and COPD, later diagnosed with Asthma-COPD overlap.

Airwave oscillometry to measure lung function in children with Down syndrome.

Children with Down syndrome are at risk for significant pulmonary co-morbidities, including recurrent respiratory infections, dysphagia, obstructive sleep apnea, and pulmonary vascular disease. Because the gold standard metric of lung function, spirometry, may not be feasible in children with intellectual disabilities, we sought to assess the feasibility of both airwave oscillometry and spirometry in children with Down syndrome. Thirty-four children with Down syndrome aged 5-17 years were recruited. Participants performed airwave oscillometry and spirometry before and 10 min after albuterol. Outcomes include success rates, airway resistance and reactance pre- and post-bronchodilator, and bronchodilator response. Participants were median age 9.2 years (interquartile range 7.2, 12.0) and 47% male. Airwave oscillometry was successful in 26 participants (76.5%) and 4 (11.8%) were successful with spirometry. No abnormalities in airway resistance were detected, and 16/26 (61.5%) had decreased reactance. A positive bronchodilator response by oscillometry was observed in 5/23 (21.7%) of those with successful pre- and post-bronchodilator testing. Measures of pulmonary function were successfully obtained using airwave oscillometry in children with Down syndrome, which supports its use in this high-risk population. Children with Down syndrome are at risk for significant pulmonary co-morbidities, but the gold standard metric of lung function, spirometry, may not be feasible in children with intellectual disabilities. This may limit the population's enrollment in clinical trials and in standardized clinical care. In this prospective study of lung function in children with Down syndrome, airwave oscillometry was successful in 76% of participants but spirometry was successful in only 12%. This study reinforces that measures of pulmonary function can be obtained successfully using airwave oscillometry in children with Down syndrome, which supports its use in this high-risk population.

Asthma-like symptom or "cystic fibrosis asthma"?

The diagnosis of asthma is still a difficult problem in cystic fibrosis. There is no consensus on how to define "CF asthma". The aim of this study was to determine the role of bronchodilator response and laboratory evidence of allergy in "CF asthma". Patients aged ≥6 years with evaluated bronchodilator response and characteristics of atopy were included in the study. Patients diagnosed with Allergic Bronchopulmonary Aspergillosis or pulmonary exacerbation were excluded. A total of 204 CF patients were evaluated, and 40 who met the criteria were included. Asthma had been diagnosed in ten patients. A positive bronchodilator response was present in 47.3% of the patients tested. Aeroallergen sensitization was present in 52.5% of the patients. While the frequency of recurrent/history of wheezing, family history of atopy and elevated total immunoglobulin E were similar (p> 0.05), the frequencies of inhaled medication use and coexistence of asthma were statistically higher in the group with positive allergen sensitization (p<0.05). The frequencies of positive bronchodilator response (77.7% versus 37.9%) and a family history of asthma/atopy (40% versus. 23%) were found to be similar in CF asthma and CF. There were significant increases in total IgE and allergen-specific IgE and an increase in the frequency of aeroallergen sensitization in CF asthma compared to CF (p<0.05). Although not routinely used in the evaluation of patients, allergen specific-IgE and skin prick test for aeroallergen sensitization may be used as an adjunctive test in patients with suspected clinical findings. The recognition of CF asthma may facilitate the development of targeted therapies.

Dietary phenotype and advanced glycation end-products predict WTC-obstructive airways disease: a longitudinal observational study

BackgroundDiet is a modifier of metabolic syndrome which in turn is associated with World Trade Center obstructive airways disease (WTC-OAD). We have designed this study to (1) assess the dietary phenotype (food types, physical activity, and dietary habits) of the Fire Department of New York (FDNY) WTC-Health Program (WTC-HP) cohort and (2) quantify the association of dietary quality and its advanced glycation end product (AGE) content with the development of WTC-OAD.MethodsWTC-OAD, defined as developing WTC-Lung Injury (WTC-LI; FEV1 < LLN) and/or airway hyperreactivity (AHR; positive methacholine and/or positive bronchodilator response). Rapid Eating and Activity Assessment for Participants-Short Version (REAP-S) deployed on 3/1/2018 in the WTC-HP annual monitoring assessment. Clinical and REAP-S data of consented subjects was extracted (7/17/2019). Diet quality [low-(15–19), moderate-(20–29), and high-(30–39)] and AGE content per REAP-S questionnaire were assessed for association with WTC-OAD. Regression models adjusted for smoking, hyperglycemia, hypertension, age on 9/11, WTC-exposure, BMI, and job description.ResultsN = 9508 completed the annual questionnaire, while N = 4015 completed REAP-S and had spirometry. WTC-OAD developed in N = 921, while N = 3094 never developed WTC-OAD. Low- and moderate-dietary quality, eating more (processed meats, fried foods, sugary drinks), fewer (vegetables, whole-grains),and having a diet abundant in AGEs were significantly associated with WTC-OAD. Smoking was not a significant risk factor of WTC-OAD.ConclusionsREAP-S was successfully implemented in the FDNY WTC-HP monitoring questionnaire and produced valuable dietary phenotyping. Our observational study has identified low dietary quality and AGE abundant dietary habits as risk factors for pulmonary disease in the context of WTC-exposure. Dietary phenotyping, not only focuses our metabolomic/biomarker profiling but also further informs future dietary interventions that may positively impact particulate matter associated lung disease.

Multimodal longitudinal respiratory function assessment in very low birth weight 7-year-old children

PurposePreterm birth is associated with adverse pulmonary outcomes. We aimed to evaluate respiratory morbidities and lung function of very low birth weight (VLBW) Polish children followed up at the age of 7 years old, and to compare with electrical impedance segmentography (EIS) results recorded at 4 years of age. Materials and methodsVLBW children were compared with term controls using impulse oscillometry and spirometry. Perinatal data and current respiratory morbidities were analyzed and pulmonary function test results were compared with previous EIS results. ResultsWe included 40 VLBW children and 30 controls in the analysis. Elevated total airway resistance and forced expiratory volume in the first second below the lower limit of normal were more prevalent in VLBW children compared with term controls (15 vs 0%; 18 vs 0%). A positive bronchodilator response was more common in VLBW children (R5 Hz: 46 vs 13.3%; R5–20 ​Hz: 65 vs 36.7%). Children with bronchopulmonary dysplasia (BPD) had higher total airway resistance (R5 Hz/R5 Hz pred: 1.35 vs 0.95; p ​< ​0.001), large airway resistance (R20 Hz/R20 Hz pred: 0.89 vs 0.66; p ​= ​0.001), small airway resistance (R5–20 ​Hz: 0.57 vs 0.34 ​kPa ​L−1 ​s−1; p ​= ​0.009), than controls. Strong correlation between BDR in EIS and R5 Hz/R5 Hz pred was observed in children with BPD (r ​= ​0.7). ConclusionVLBW school-aged children with BPD presented with substantial respiratory morbidity and persistent reduction of lung function, affecting small and large airways and lung parenchyma. EIS may be an alternative tool for lung function assessment in children with BPD.

Small-airway disease and its reversibility in human immunodeficiency virus-infected children on highly active antiretroviral therapy: A cross-sectional study in an African setting.

BACKGROUND:Lung function abnormalities may occur in children with human immunodeficiency virus (HIV) infection. Small-airway disease (SAD) precedes abnormalities in forced expiratory volume in 1 s (FEV 1).OBJECTIVE:This study aims to assess the presence and reversibility of SAD in HIV-infected children using the Global Lung Function Initiative standards.METHODS:A cross-sectional study was conducted over 6 months at the Paediatric HIV Clinic of the University of Nigeria Teaching Hospital in Enugu, Southeast Nigeria. Eligible consenting children with HIV infection were recruited. Lung function was measured, and the reversibility of FEV1 and forced vital capacity (FVC) was assessed at 12% while that of forced expiratory flow between 25% and 75% (FEF25-75) was assessed at 12%, 15%, and 20%. Predictors of abnormal Z-score values were determined by multivariate linear and logistic regressions. Statistically significant values were set at P < 0.05.RESULTS:The mean Z-score for FEV1, FVC, and FEF25-75 was − 2.19, −1.86, and − 1.60, respectively. Most patients (73%) had abnormal FEV1, while 52% had abnormal FEF25-75. Significant changes in FEV1 (P = 0.001) and FEF25-75 (P < 0.001) occurred after the bronchodilator response (BDR) test. Of the children whose FEV1 showed positive BDR, 70.9% had low zFEV1; 50% had low zFEF25-75, while all had low FEV1. Nutritional status (Z-score for body mass index) was significantly associated with low FEV1.CONCLUSIONS:Abnormal FEF25-75 as a marker of SAD and FEV1 with a positive BDR are common in HIV-infected children. These lung function abnormalities justify long-term follow-up for these patients.