Significant Bronchodilator Response Research Articles

Assessment of bronchodilator responsiveness to salbutamol or ipratropium using different criteria in treatment-naïve patients with asthma and COPD

ABSTRACT Background The criteria for significant bronchodilator responsiveness (BDR) were published in 2005 by the European Respiratory Society/American Thoracic Society, which were revised in 2021, however, data on the agreement between these two recommendations in untreated patients with airflow limitation are missing. Aims We aimed to study BDR to salbutamol (SABA) or ipratropium bromide (SAMA) in patients with suspected bronchial asthma or COPD at initial clinical presentation using the 2005 and 2021 criteria and explore clinical factors associated with BDR+. Methods Symptomatic, treatment-naïve patients with expiratory airflow limitation (n = 105, 57 men, age (mean ± standard deviation): 65 ± 10 years) underwent BDR testing with 400 mcg salbutamol (day 1) or 80 mcg ipratropium bromide (day 2) and BDR was measured after 15 and 30 minutes. Clinical factors with risk for BDR+ were assessed with binomial logistic regression analysis. Results We found a good agreement between the number of 2005-BDR+ and 2021-BDR+ patients at 15 and 30 minutes post-salbutamol and post-ipratropium (88.6–94.8%). More patients showed BDR+ after 30 minutes than following 15 minutes using either criterion. When results at 30 minutes are considered, the number of patients with 2005-BDR+ (82%) was higher than that of 2021-BDR+ (75%), with the proportion of SAMA+ patients being higher than that of SABA+ (2005: 70% vs. 49%, Fisher exact p < 0.01; 2021: 64% vs. 41%, p = 0.001). 2005-BDR+ and 2021-BDR+ to SABA were associated with decreasing pre-BD FEV1% predicted and the presence of cough. More patients with asthma were in the SABA+ group compared to the SAMA+ group (2005: 71% vs. 53%, Fischer exact p = 0.04; 2021: 77% vs. 52%, p = 0.02). Conclusions Fewer patients show BDR+ according to the 2021 criteria in comparison with the 2005 recommendations, and protocols for BDR testing may consider the assessment of response to both SABA and SAMA after 30 minutes.

APLICACIÓN DE LA FISIOLOGÍA RESPIRATORIA EN LOS EXÁMENES DE FUNCIÓN PULMONAR

Having an adequate understanding of respiratory physiology is useful to better interpret pulmonary function tests and thus optimize their clinical usefulness. In this review we will see some concepts that will allow us to better understand the most important tests in the evaluation of a child with chronic lung disease. Among the frequent examinations in pediatrics, spirometry provides good information to objectify airway obstruction and identify if there is a significant bronchodilator response. The flow-volume curve can suggest the location of the airway obstruction. To assess whether there is a restrictive, mixed or air trapping component, it is advisable to complement spirometry with tests that allow the measurement of lung volumes and capacities. Tests to quantify bronchial hyperreactivity are also common in pediatrics, mainly in children with suspected bronchial asthma. In less frequent clinical situations, it is necessary to evaluate the main function of the lung parenchyma, which corresponds to gas exchange, and in this case the diffusion capacity can be measured. It is recommended to review the series of articles on respiratory pathophysiology previously published in this journal. The technical details of the execution and interpretation of the exams can be reviewed in the specialized guides. Examinations in infants and preschoolers are not addressed in this review because they are not commonly used in clinical practice.

Oscillometry and spirometry are not interchangeable when assessing the bronchodilator response in children and young adults born preterm.

The European Respiratory Society Oscillometry Taskforce identified that clinical correlates of bronchodilator responses are needed to advance oscillometry in clinical practice. The understanding of bronchodilator-induced oscillometry changes in preterm lung disease is poor. Here we describe a comparison of bronchodilator assessments performed using oscillometry and spirometry in a population born very preterm and explore the relationship between bronchodilator-induced changes in respiratory function and clinical outcomes. Participants aged 6-23 born ≤32 (N = 288; 132 with bronchopulmonary dysplasia) and ≥37 weeks' gestation (N = 76, term-born controls) performed spirometry and oscillometry. A significant bronchodilator response (BDR) to 400 μg salbutamol was classified according to published criteria. A BDR was identified in 30.9% (n = 85) of preterm-born individuals via spirometry and/or oscillometry, with poor agreement between spirometry and oscillometry definitions (k = 0.26; 95% confidence interval [CI] 0.18-0.40, p < .001). Those born preterm with a BDR by oscillometry but not spirometry had increased wheeze (33% vs. 11%, p = .010) and baseline resistance (Rrs5 z-score mean difference (MD) = 0.86, 95% CI 0.07-1.65, p = .025), but similar baseline spirometry to the group without a BDR (forced expiratory volume in 1 s [FEV1 ] z-score MD = -0.01, 95% CI -0.66 to 0.68, p > .999). Oscillometry was more feasible than spirometry (95% success rate vs. 85% (FEV1 ), 69% (forced vital capacity) success rate, p < .001), however being born preterm did not affect test feasibility. In the preterm population, oscillometry is a feasible and clinically useful supportive test to assess the airway response to inhaled salbutamol. Changes measured by oscillometry reflect related but distinct physiological changes to those measured by spirometry, and thus these tests should not be used interchangeably.

Association of Absolute Eosinophil Count and Post-Bronchodilator Reversibility in the Chronic Obstructive Pulmonary Disease Patients

Objective: To look for the relationship between absolute eosinophil count and post-bronchodilator reversibility in chronic obstructive pulmonary disease patients at Pak Emirates Military Hospital, Rawalpindi Pakistan.&#x0D; Study Design: Cross sectional study.&#x0D; Place and During of Study: Pulmonology Department, Pak Emirates Military Hospital Rawalpindi (PEMH) from Jul to Dec 2019.&#x0D; Methodology: The study was conducted on 150 patients suffering from chronic obstructive pulmonary disease admitted in the Medical Ward or reporting in the Outpatient Department. Lung function was assessed using spirometry pre- and postbronchodilation. The presence and severity of chronic obstructive pulmonary disease were assessed using modified Global Obstructive Lung Disease (GOLD) criteria. The presence of significant bronchodilator responsiveness was taken as ≥12% improvement in the forced expiratory volume (FEV) (1) or the forced vital capacity.&#x0D; Results: Of 150 patients in the final analysis, 95 (63.3%) were male, and 55(36.7%) were female. The mean duration of COPD in our target population was 9.13±1.23 years. 68 (45.3%) had &gt;12% improvement after bronchodilator administration, while 82(54.7%) had &lt;12% improvement. The absolute eosinophilic count was &lt;2% in 49(32.7%), while it was raised in 101(67.3%) patients. &#x0D; Conclusion: Raised eosinophilic count emerged as a predictor of good response after administering bronchodilators among patients suffering from chronic obstructive airway disease. Screening patients for this simple blood component may predictresponse to the initial treatment and help in the tailoring of the treatment plan by the treating physician.Keywords: Chronic obstructive pulmonary disease, Eosinophils, Forced expiratory volume.

Nebulization versus metered-dose inhaler and spacer in bronchodilator responsiveness testing: a retrospective study

Background: The recommended delivery mode for bronchodilators in bronchodilator responsiveness (BDR) testing remains controversial. Objective: To compare the efficacy of salbutamol administration using a nebulizer versus a metered-dose inhaler (MDI) with spacer in BDR testing. Design: A retrospective study. Methods: This study examined the data of patients with chronic obstructive pulmonary disease who completed BDR testing between 1 December 2021 and 30 June 2022, at Xiangya Hospital, Central South University. After administering 400 μg of salbutamol through an MDI with spacer or 2.5 mg using a nebulizer, the changes in forced expiratory volume in one second (FEV1) and forced vital capacity (FVC) were analyzed in patients with moderate-to-very severe spirometric abnormalities [pre-bronchodilator FEV1 percentage predicted values (FEV1%pred) ⩽59%]. Significant responsiveness was assessed as &gt;12% and &gt;200 mL improvement in FEV1 and/or FVC or &gt;10% increase in FEV1%pred or FVC percentage predicted values (FVC%pred) from pre- to post-bronchodilator administration. Results: Of the enrolled 894 patients, 83.2% were male (median age, 63 years). After propensity score matching, 240 pairs of patients were selected. The increment in FEV1 and increased FEV1 relative to the predicted value (ΔFEV1%pred) were significantly higher in patients &lt;65 years and those with severe spirometric abnormalities in the nebulization group than patients in the MDI group (all p &lt; 0.05). Compared with MDI with spacer, patients who used nebulization had a 30 mL greater increase in ΔFEV1 (95% CI: 0.01–0.05, p = 0.004) and a 1.09% greater increase in ΔFEV1%pred (95% CI: 0.303–1.896, p = 0.007) from baseline. According to the &gt; 12% and &gt;200 mL increase criterion, the significant BDR rate with nebulization was 1.67 times higher than that with an MDI with spacer (OR = 1.67, 95% CI: 1.13–2.47, p = 0.009). Conclusion: Salbutamol delivered using a nebulizer may be preferable to an MDI with spacer in certain circumstances. Nebulization has the potential to increase responsiveness to salbutamol in BDR testing.

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.

The Prevalence of Bronchodilator Responsiveness "Asthma" Among Adult Indigenous Australians Referred for Lung Function Testing in the Top End Northern Territory of Australia.

BackgroundAmong Indigenous Australians, studies examining the clinical significance of airway bronchodilator responsiveness (BDR) are limited. In this retrospective study, we examined the nature of underlying lung disease in adult Indigenous patients with BDR referred for lung function testing (LFT) in the Top End Health Service region of the Northern Territory of Australia.MethodsPresence or absence of BDR as per usual (FVC or FEV1 change pre to post ≥12% and ≥0.2L) and updated (2021 “>10% predicted) ATS/ERS criteria among Indigenous and non-Indigenous Australians was determined. The radiological findings in the Indigenous study participants with and without BDR were next assessed for the presence of underlying chronic airway/lung disease.ResultsWe found that 123/742 (17%) Indigenous and 578/4579 (13%) non-Indigenous patients had a significant BDR. Indigenous patients with BDR were younger (mean difference 7 years), with a greater proportion of females (52 vs 32%), underweight (15 vs 4%) and current smokers (52 vs 25%). Indigenous patients with BDR displayed lower LFT values, and a higher proportion exhibited FVC BDR compared to non-Indigenous (34 vs 20%). Almost half (46%) of Indigenous patients with BDR had evidence of COPD and/or bronchiectasis on radiology. Adjusting for the presence of radiologic or spirometric evidence of COPD, the presence of BDR was similar between Indigenous and non-Indigenous patients (5–8 vs 7–11%), irrespective of which BDR criteria was used.ConclusionBDR was higher overall among Indigenous in comparison to non-Indigenous patients; however, a significant proportion of Indigenous patients demonstrating BDR had evidence of underlying COPD/bronchiectasis. This study highlights that although presence of BDR among Indigenous people may indicate asthma, it may also be observed among patients with COPD/bronchiectasis or could represent asthma/COPD/bronchiectasis overlap. Hence, a combination of clinical history, LFT and radiology should be considered for precise diagnosis of lung disease in this population.

Impaired exercise outcomes with significant bronchodilator responsiveness in children with prematurity-associated obstructive lung disease.

IntroductionPreterm‐born children have their normal in‐utero lung development interrupted, thus are at risk of short‐ and long‐term lung disease. Spirometry and exercise capacity impairments have been regularly reported in preterm‐born children especially those who developed chronic lung disease of prematurity (CLD) in infancy. However, specific phenotypes may be differentially associated with exercise capacity. We investigated exercise capacity associated with prematurity‐associated obstructive (POLD) or prematurity‐associated preserved ratio of impaired spirometry (pPRISm) when compared to preterm‐ and term‐controls with normal lung function.Materials and MethodsPreterm‐ and term‐born children identified through home screening underwent in‐depth lung function and cardiorespiratory exercise testing, including administration of postexercise bronchodilator, as part of the Respiratory Health Outcomes in Neonates (RHiNO) study.ResultsFrom 241 invited children, aged 7–12 years, 202 underwent exercise testing including 18 children with POLD (percent predicted (%)FEV1 and FEV1/FVC < LLN); 12 pPRISm (%FEV1 < LLN and FEV1/FVC ≥ LLN), 106 preterm‐controls (PTc, %FEV1 ≥ LLN) and 66 term‐controls (Tc, %FEV1 > 90%). POLD children had reduced relative workload, peak O2 uptake, CO2 production, and minute ventilation compared to Tc, and used a greater proportion of their breathing reserve compared to both control groups. pPRISm and PTc children also had lower O2 uptake compared to Tc. POLD children had the greatest response to postexercise bronchodilator, improving their %FEV1 by 19.4% (vs 6.3%, 6% 6.3% in pPRISm PTc,Tc, respectively; p < .001).ConclusionPreterm‐born children with obstructive airway disease had the greatest impairment in exercise capacity, and significantly greater response to postexercise bronchodilators. These classifications can be used to guide treatment in children with POLD.

Lung Health in the Solomon Islands: A Mixed Methods Study.

Background and ObjectivesDespite a population of 600,000 people from 900 islands, there is little published data on the prevalence of lung disease in the Solomon Islands. We sought to 1) estimate the prevalence of obstructive lung disease (OLD) in Gizo, Solomon Islands, 2) identify risk factors for respiratory disease in this population and 3) review current management practices for respiratory disease through an audit of local emergency department (ED) presentations.MethodsA two-part mixed methods study was performed between March and May 2019; the first was a population-based, cross-sectional study conducted in Gizo, Solomon Islands, with a random sample undergoing questionnaires and spirometry. The second was an audit of Gizo Hospital ED records to assess presentation numbers, diagnoses and outcomes.ResultsA total of 104 patients were randomly selected for spirometry. The mean age was 46.9 years. Current smoking rates were high (24.0% overall, 43.3% age < 40, 16.2% age ≥ 40) as was regular (>10h/week) exposure to indoor/enclosed wood fire ovens (51.5%). The prevalence of COPD was 3.2% overall. A further 9.7% of participants demonstrated significant bronchodilator responsiveness suggestive of possible asthma. Most patients seen in ED presented with a respiratory condition or fever/viral illness, but spirometry was not available. Only four outpatients were prescribed salbutamol and two patients inhaled corticosteroid.ConclusionThere appears to be a high burden of obstructive lung disease in the Solomon Islands with high smoking rates, indoor smoke exposure and bronchodilator responsiveness. Respiratory symptoms are common amongst hospital ED presentations; however, inhaled asthma treatments are infrequently prescribed to outpatients.

Asthma Phenotypes and Host Risk Factors Associated With Various Asthma-Related Outcomes in Health Workers.

Background: Work-related asthma phenotypes in health workers (HWs) exposed to cleaning agents have not been investigated extensively as other occupational exposures. This study aimed to describe asthma phenotypes and to identify important host risk factors associated with various asthma-related outcomes.Methods: A cross-sectional study of 699 HWs was conducted in two large tertiary hospitals. A total of 697 HWs completed questionnaire interviews. Sera collected from 682 HWs were analyzed for atopy (Phadiatop) and IgE to occupational allergens (NRL—Hev b5, Hev b6.02; chlorhexidine and ortho-phthalaldehyde—OPA). Methacholine (MCT), bronchodilator challenge (BDR) and fractional exhaled nitric oxide (FeNO) were performed. An asthma symptom score (ASS) used five asthma-related symptoms reported in the past 12 months. Current asthma was based on use of asthma medication or an asthma attack or being woken up by an attack of shortness of breath in the past 12 months. Nonspecific bronchial hyperresponsiveness (NSBH) was defined as having either a positive MCT or a significant bronchodilator response. Two continuous indices of NSBH [continuous index of responsiveness (CIR) and dose-response slope (DRS)] were calculated.Results: The prevalence of current asthma was 10%, atopic asthma (6%) and non-atopic asthma (4%). Overall, 2% of subjects had work-related asthma. There was a weak positive association between NSBH and FeNO [CIR: Beta coefficient (β) = 0.12; CI: 0.03–0.22 and DRS: β = 0.07; CI: 0.03–0.12]. Combining FeNO ≥ 50 ppb with a BDR [mean ratio (MR) = 5.89; CI: 1.02–34.14] or with NSBH (MR = 4.62; CI: 1.16–18.46) correlated better with ASS than FeNO alone (MR = 2.23; CI: 1.30–3.85). HWs with current asthma were twice as likely to be atopic. FeNO was positively associated with atopy (OR = 3.19; CI: 1.59–6.39) but negatively associated with smoking status (GMR = 0.76; CI: 0.62–0.94). Most HWs sensitized to occupational allergens were atopic.Conclusion: Atopic asthma was more prevalent than non-atopic asthma in HWs. Most asthma-related outcomes were positively associated with allergic predictors suggesting a dominant role for IgE mechanisms for work-related symptoms and asthma associated with sensitization to OPA or chlorhexidine.

A CALCIFIED CARCINOID TUMOR

TOPIC: Lung Cancer TYPE: Fellow Case Reports INTRODUCTION: Pulmonary carcinoid tumor is a neuroendocrine tumor of enterochromaffin cells representing about 1–5% of all lung malignancies. It usually presents in never smokers typically in proximal airways. Patients present with chronic cough, hemoptysis, and bronchial obstruction. These tumors show a low to moderate activity on PET scan. We present a case of a calcified carcinoid tumor. CASE PRESENTATION: A 49-year-old never-smoker male with medical history known for obesity, diabetes mellitus, hypothyroidism and exposure to welding presented complaining from progressive dyspnea with cough, wheezing and a history of mild hemoptysis. A Pulmonary function test (PFT) was performed which showed a FEV1/FVC ratio of 73% (post-bronchodilator), FEV1 77%, TLC 112%, RV 152% and DLCO of 77%. Findings were suggestive of a moderate obstructive lung defect and no significant bronchodilator response associated with decreased diffusion capacity and air trapping. The patient was started on umeclidium-vilanterol and a Chest X-ray was performed that showed atelectasis with prominence of the right hilum suggestive of pulmonary artery enlargement or potentially underlying lymphadenopathy/nodule. Thus, a Chest computer topography (CT) was scheduled. However, the patient developed an episode of hemoptysis and presented to the emergency department (ED) acutely prior to performing the chest CT. Chest CT was performed upon presentation to the ED which showed a calcified right hilar mass. Upon presentation the patient denied having any other complaints. He was started on antibiotics and steroids. A bronchoscopy with endobronchial ultrasound was performed that showed an endobronchial mass at the level of the secondary carina between the right upper lobe and bronchus intermedius bulging into the bronchus intermedius with about 85% obstruction of the bronchus intermedius not allowing the bronchoscope to pass distally with cobblestone mucosa. A transbronchial needle aspiration from the right hilar mass was performed as well as an endobronchial biopsy from right lung mass and lateral wall of the bronchus intermedius. Brushing from the right lung mass in the bronchus intermedius and bronchioalveolar lavage from bronchus intermedius was done. Pathology from the right upper lobe biopsy was positive for a neuroendocrine tumor (carcinoid). BAL, brushing, and lymph nodes were negative. A PET CT scan was done which confirmed the presence of a partially calcified right posterior hilar soft tissue mass with low FDG uptake and no definite metastatic disease. Patient underwent a right pneumonectomy. DISCUSSION: Calcifications has been reported in mesenteric carcinoid tumors, however, no prior cases of pulmonary carcinoid calcification were reported in the literature. This case describes an unusual presentation of pulmonary carcinoid tumor. CONCLUSIONS: This presentation highlights the importance of proper evaluation of a calcified mass. REFERENCE #1: https://pubmed.ncbi.nlm.nih.gov/7839976/ DISCLOSURES: No relevant relationships by Ahmad Albalbissi, source=Web Response No relevant relationships by Girendra Hoskere, source=Web Response No relevant relationships by AYA MASADEH, source=Web Response

Longitudinal Assessment of Pulmonary Function and Bronchodilator Response in Pediatric Patients With Post-infectious Bronchiolitis Obliterans.

Backgroud: Postinfectious bronchiolitis obliterans (PIBO) is a rare respiratory disease. In recent years, the disease has been recognized and diagnosed increasingly in children. Pulmonary function is important for diagnosis, identifying the severity of the PIBO and monitoring progression. But there have been only a few studies that followed the evolution of PIBO on the basis of pulmonary function tests (PFTs).Objective: The study targeted the evolution of pulmonary function and bronchodilator response in a case series of Chinese children with PIBO.Methods: Twelve children between the ages of 6–99 months with PIBO were studied retrospectively from 2009 to 2019. Forced vital capacity (FVC), forced expiratory volume in 1 s (FEV1), the FEV1/FVC ratio, and maximal midexpiratory flow velocity 25–75% (MMEF25−75%) were collected at each PFT, and bronchodilator responses were evaluated. Spirometric parameters were monitored over time, and generalized linear mixed models were used to analyze longitudinal panel data.Results: The median baseline PFT values for FVC, FEV1, the FEV1/FVC ratio, and MMEF25−75% were 41.6, 39.75, 90.7, and 22.2%, respectively. At the initial PFTs, 10 (83.3%) patients demonstrated a significant bronchodilator response. FVC and FEV1 increased by 8.212%/year and 5.007%/year, respectively, and the FEV1/FVC ratio decreased by an average of 3.537%/year. MMEF25−75% showed improvement at an average rate of 1.583% every year. Overall, FEV1 and MMEF25−75% showed different degrees of improvement after the use of inhaled bronchodilators at each PFT session for 10 patients, and FEV1 measures demonstrated significant (>12%) β2-bronchodilation in 56% of PFT sessions.Conclusions: Pediatric patients with PIBO showed an obstructive defect in pulmonary function. The FVC, FEV1, and MMEF25−75% improved as they grew older, while the FEV1/FVC ratio decreased. This may be due to the development of lung parenchyma more than airway growth. Airway obstruction in some patients improved with the use of β2 agonists.

Spirometric Response to Bronchodilator and Eucapnic Voluntary Hyperpnea in Adults With Asthma.

The spirometric response to fast-acting bronchodilator is used clinically to diagnose asthma and in clinical research to verify its presence. However, bronchodilator responsiveness does not correlate with airway hyper-responsiveness measured with the direct-acting stimulus of methacholine, demonstrating that bronchodilator responsiveness is a problematic method for diagnosing asthma. The relationship between bronchodilator responsiveness and airway hyper-responsiveness assessed with indirect-acting stimuli is not known. Retrospectively, the spirometric responses to inhaled bronchodilator and a eucapnic voluntary hyperpnea challenge (EVH) were compared in 39 non-smoking adult subjects with asthma (26 male, 13 female; mean ± SD age 26.9 ± 7.8 y; mean ± SD body mass index 26.3 ± 4.7 kg/m2). All subjects met one or both of 2 criteria: ≥ 12% and 200 mL increase in FEV1 after inhaled bronchodilator, and ≥ 10% decrease in FEV1 after an EVH challenge. Overall, FEV1 increased by 9.9 ± 7.9% after bronchodilator (3.93 ± 0.97 to 4.28 ± 0.91 L, P < .001) and decreased by 23.9 ± 15.0% after the EVH challenge (3.89 ± 0.89 to 2.96 ± 0.88 L, P < .001). However, the change in FEV1 after bronchodilator did not correlate with the change after EVH challenge (r = 0.062, P = .71). Significant bronchodilator responsiveness predicted a positive response to EVH challenge in 9 of 33 subjects (sensitivity 27%). Following EVH, the change in FEV1 strongly correlated with the change in FVC (FEV1 percent change vs FVC percent change, r = 0.831, P < .001; FEV1 ΔL vs FVC ΔL, r = 0.799, P < .001). These results extend previous findings that demonstrate a lack of association between bronchodilator responsiveness and methacholine responsiveness. Given the poor concordance between the spirometric response to fast-acting bronchodilator and the EVH challenge, these findings suggest that the airway response to inhaled β2-agonist must be interpreted with caution and in the context of its determinants and limitations.

Role of the Bronchodilator Test Defined by the Forced Vital Capacity in Chronic Obstructive Pulmonary Disease Phenotyping.

PurposeIn clinical practice, some chronic obstructive pulmonary disease (COPD) patients experienced a remarkable increase in forced vital capacity (FVC) after bronchodilator administration, whereas forced expiratory volume in the first second (FEV1) remains substantially unchanged. We assume this may relate to airway inflammatory type. We aim to analyze the clinical characteristics and explore the usefulness of the bronchodilator test, especially FVC, in this new COPD phenotype.Patients and MethodsA total of 346 COPD patients with exacerbation who underwent bronchodilator tests, fractional exhaled nitric oxide (FeNO) measurements and blood eosinophil counts were analyzed. The characteristics, FeNO levels, and blood eosinophil counts were compared between patients with and without significant bronchodilator responsiveness in terms of FVC.ResultsPatients with significant FVC responsiveness displayed poorer lung function and higher FeNO levels compared with those without considerable FVC responsiveness (Z= −5.042 to −0.375, p=0.000–0.022). There is a discernible linear relationship between FeNO levels and FVC responsiveness to bronchodilator use (r=0.251, P=0.001). The application of bronchodilator responsiveness of FVC for detecting high FeNO levels in COPD patients exhibited relatively high sensitivity (61.8%) and specificity (86.7%).ConclusionWe demonstrated that COPD patients with significant FVC responsiveness had higher FeNO levels than non-responders and established a simple method for detecting high FeNO values. FVC responders may be identified as a separate group of COPD patients.

Substantial variation exists in spirometry interpretation practices for airflow obstruction in accredited lung function laboratories across Australia and New Zealand

Spirometry forms the foundation investigation for the diagnosis and monitoring of common pulmonary conditions. However, potential variation in spirometry interpretation for airflow obstruction may impact subsequent clinical management. To audit spirometry interpretation practices for airflow obstruction in Thoracic Society of Australia and New Zealand accredited laboratories. Thirty-nine accredited complex lung function laboratories were invited to participate in an online survey. The survey enquired about demographics, definition of lower limit of normal range for spirometry parameters, spirometric parameters used for identifying airflow obstruction, spirometric definition of airflow obstruction, definition of significant bronchodilator response and chosen spirometry reference equations. Thirty-six laboratories provided complete responses (response rate, 92%). To define the lower limit of normal, 26 of 36 used the 5th percentile, 7 of 36 used a fixed cut-off and 3 used other. Twenty-nine laboratories utilised forced expiratory volume in 1 s/forced vital capacity (FEV1 /FVC) as the sole parameter to identify airflow obstruction, 3 of 36 used FEV1 /FVC and FEF25-75% , and 4 used other. To define airflow obstruction, 25 of 36 laboratories used FEV1 /FVC < 5th percentile, 9 of 36 used a fixed cut-off (FEV1 /FVC < 0.7, 6/36; FEV1 /FVC < 0.8, 2/36; FEV1 /FVC < 0.75, 1/36) and 2 of 36 used other. Twenty-six laboratories defined a significant bronchodilator response as an increase of at least 200 mL and 12% in FEV1 and/or FVC, 9 of 36 used ≥200 mL and ≥ 12% increase in FEV1 only, and 1 used other criteria. Reference equations utilised for interpretation of spirometry data included: Quanjer 2012 Global Lung Initiative (16/36), the third National Health and Nutritional Examination Survey (8/36), European Community of Coal and Steel (8/36) and other (4/36). Significant heterogeneity in spirometry interpretation for airflow obstruction exists across Australian and New Zealand accredited lung function laboratories. Lack of standardisation may translate into clinically appreciable differences for the diagnosis and management of common respiratory conditions. Ongoing discussion regarding formal standardisation is required.

Diagnostic Accuracy of Bronchodilator Response for Asthma in a Population of South China.

A significant bronchodilator response is commonly defined as a 12% or greater and 200ml or greater change in FEV1 from baseline according to the 2005 American Thoracic Society (ATS)/European Respiratory Society (ERS) criterion. A number of studies have shown that the ATS/ERS criterion has limitations in asthma diagnosis, and some experts have argued for correcting the criteria. The aim of this study is to investigate the diagnostic value of acute bronchodilator response for asthma in a Southern Chinese population. We prospectively evaluated 805 patients with obstructive lung disease (309 for asthma, 496 for non-asthma). Spirometry was performed according to the ATS/ERS guidelines. Data were analyzed by SPSS 18.0. The receiver-operating characteristic (ROC) curve was drawn to assess the diagnostic accuracy of the ATS/ERS criterion based on FEV1. Linear regression was used to analyze the factors of FEV1 change. The sensitivity and specificity of the acute bronchodilator test when judged by the ATS/ERS criteria (200ml or higher and 12% improvement) were 68.6% and 78.2%, respectively. For the ATS/ERS criteria, the Youden Index, which comprehensively reflects the authenticity of a diagnostic test, was 46.8%. The absolute change of FEV1 positively correlated with baseline FEV1 and weight and negatively with age, while the percentage change of FEV1 was negatively correlated with baseline FEV1, age and height and positively with weight. Compared with the different diagnostic values, when ∆FEV1 was 195ml and ∆FEV1i% was 14%, the Youden Index was the largest (48.2%) and the diagnostic capability of the test the biggest. The ATS/ERS criterion for acute bronchodilator response might not be completely suitable for asthma in the Chinese population. Chinese Clinical Trial Registry (Registry ID: ChiCTR-DDT-14004976). This work was supported by the National Natural Science Foundation of China (grant nos. 81670027, 81270080).

Bronchodilator responsiveness assessed by forced oscillometry and multiple breath washout techniques in preschool children.

ImportanceThe forced oscillation (FOT) and multiple breath washout (MBW) techniques are passive tests of lung function, and are reliable for preschool‐age children. There has not been comparison testing to determine which test could more accurately differentiate between healthy controls and poorly controlled asthmatics, or differentiate a response to bronchodilator administration.ObjectiveTo determine whether the MBW and/or FOT could differentiate between healthy controls and poorly controlled asthmatics, and whether the two tests could detect a response to bronchodilator administration.MethodsTwenty‐eight healthy controls and 23 poorly controlled asthmatics 3–6 years of age participated. All subjects were administered the MBW followed by the FOT. A bronchodilator was then administered and testing was repeated. Wilcoxon Rank Sum tests were used to compare the difference between healthy controls and poorly controlled asthmatics. Wilcoxon Signed Rank tests were used to compare the pre‐ and post‐bronchodilator values.ResultsNeither MBW nor FOT differentiated healthy controls from poorly controlled asthmatics (pre‐bronchodilator data); both groups had similar baseline gas mixing and airway mechanics. There was no improvement in any MBW outcomes post‐bronchodilator administration. FOT detected a significant and similar degree of improvement in the airway mechanics in both groups.InterpretationNeither MBW nor FOT differentiated between poorly controlled asthmatics (when well) and healthy controls. MBW did not detect a significant bronchodilator response in either subject group, whereas FOT detected a similar degree of bronchodilator responsiveness in both groups. This discrepancy may reflect differential changes in airway mechanics and gas mixing properties in response to bronchodilators.

Bronchodilator Response Assessment of the Small Airways Obstructive Pattern.

Background:A concomitant decrease in FEV1 and FVC with normal FEV1/FVC ratio and TLC defines small airways obstructive pattern (SAOP) and constitutes a classic pitfall of pulmonary-function-tests interpretation.Objective:To evaluate the prevalence of flow- (FEV1 increase≥12% and 200 mL), volume- (FVC or inspiratory capacity [IC] increase≥12% and 200 mL), flow and volume-, and non-response to bronchodilation in patients with SAOP. An additional objective was to assess whether impulse oscillometry (IOS) parameters allow the diagnosis of SAOP and its reversibility.Methods:Fifty consecutive adult patients with SAOP (FEV1 and FVC < lower limit of normal, FEV1/FVC and TLC > lower limit of normal) diagnosed on spirometry and plethysmography underwent the assessment of reversibility (400 µg salbutamol) on FEV1, FVC, IC and IOS parameters.Results:The diseases most frequently associated with SAOP were COPD and asthma (26 and 15 patients, respectively). Six patients were flow-responders, 20 were volume-responders, 9 were flow and volume-responders and 15 patients were non-responders. Overall, 26 patients had a significant improvement of IC, and 35 / 50 (70%, 95%CI: 57-83) exhibited a significant bronchodilator response. The difference between Rrs5Hz and Rrs20Hz was increased in 28/50 patients (56%, 95%CI: 42-70 with value higher than upper limit of normal) and its decrease after bronchodilator significantly correlated to FEV1 increase only, suggesting proximal airway assessment.Conclusion:A significant reversibility, mainly assessed on IC increase, is frequent in Small Airways Obstructive Pattern. Impulse oscillometry is of limited value in this context because of its low sensitivity.

Post-traumatic Stress Disorder, Bronchodilator Response, and Incident Asthma in World Trade Center Rescue and Recovery Workers.

Post-traumatic stress disorder (PTSD) has been associated with asthma in cross-sectional studies. Whether PTSD leads to clinically significant bronchodilator response (BDR) or new-onset asthma is unknown. We sought to determine the relationship between probable PTSD and both BDR and incident asthma in a high-risk cohort of World Trade Center workers in New York (NY). This study was conducted on data from a high-risk cohort of 11,481 World Trade Center workers in New York, including 6,133 never smokers without a previous diagnosis of asthma. Of the 6,133 never smokers without asthma, 3,757 (61.3%) completed a follow-up visit several years later (mean = 4.95 yr, interquartile range = 3.74-5.90 yr). At the baseline visit, probable PTSD was defined as a score 44 points or greater in the PTSD Checklist questionnaire, and BDR was defined as both a change of 12% or greater and an increment of 200 ml or greater in FEV1 after bronchodilator administration. Incident asthma was defined as a self-report of new physician-diagnosed asthma after the baseline visit. Multivariable logistic regression was used for the analysis of probable PTSD and baseline BDR or incident asthma. Measurements and Main and Results: At baseline, probable PTSD was associated with BDR among all participants (adjusted odds ratio = 1.43; 95% confidence interval = 1.19-1.72), with similar results among never smokers without asthma. Among 3,757 never smokers, probable PTSD at baseline was associated with incident asthma, even after adjustment for baseline BDR (odds ratio = 2.41; 95% confidence interval = 1.85-3.13). This association remained significant in a confirmatory analysis after excluding 195 subjects with baseline BDR. In a cohort of adult workers exposed to a severe traumatic event, probable PTSD is significantly associated with BDR at baseline and predicts incident asthma.

Bronchodilator effects of ipratropium bromide and albuterol sulfate among subjects with tetraplegia

Objective: In addition to lung volume restriction, persons with chronic tetraplegia demonstrate obstructive airway physiology evinced by pharmacologically-induced bronchodilation. We previously found independent evidence that anticholinergic agents (ipratropium bromide; IB) and beta-2 adrenergic agonists (albuterol sulfate; AS) were associated with significant bronchodilation in subjects with tetraplegia as determined via spirometry or body plethysmography. Direct comparison of these two classes of agents has received little attention.Methods: Twelve subjects with chronic tetraplegia completed single dose treatment on alternate days with nebulized IB or AS. Patients underwent pre- and 30-minute post-bronchodilator spirometry, body plethysmography, and impulse oscillation system (IOS) in accordance with established protocols.Results: Spirometry and specific airway conductance revealed significant bronchodilator responsiveness following both IB and AS. As determined by increases in specific airway conductance post-bronchodilator, IB tended toward greater bronchodilation than AS (71% vs. 47%). IOS revealed a greater reduction in central airway resistance (R20) following IB compared to AS (22% vs. 9%, P < 0.01). A greater number of subjects exhibited a clinically significant reduction in R20 following IB compared to AS (58% vs. 8%, P < 0.01).Conclusion: Among subjects with tetraplegia, both IB and AS elicit significant bronchodilation, although the magnitude of the bronchodilator response is greater following IB. This lends support to theory of overriding cholinergic airway tone in tetraplegia. The IOS findings further suggest that the predominant site of action of IB is upon the larger central airways congruent with findings in able-bodied subjects.