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Fujiki RB, Thibeault SL. Diagnostic utility of spirometry for children with induced laryngeal obstruction or chronic non-specific cough. Am J Otolaryngol 2024; 45:104316. [PMID: 38677150 PMCID: PMC11168868 DOI: 10.1016/j.amjoto.2024.104316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2024] [Accepted: 04/15/2024] [Indexed: 04/29/2024]
Abstract
PURPOSE To determine the diagnostic utility of spirometry in distinguishing children with Induced Laryngeal Obstruction (ILO) or chronic non-specific cough (a.k.a. tic cough) from those with mild or moderate to severe asthma. METHODS Retrospective cross sectional design. Children diagnosed with ILO (N = 70), chronic non-specific cough (N = 70), mild asthma (N = 60), or moderate to severe asthma (N = 60) were identified from the electronic medical record of a large children's hospital. Spirometry was completed before ILO, non-specific cough, or asthma diagnoses were made by pediatric laryngologists or pulmonologists. Spirometry was performed following American Thoracic Society guidelines and was interpreted by a pediatric pulmonologist. Forced Vital Capacity (FVC), Forced Expiratory Volume in 1 Second (FEV1), FEV1/FVC Ratio (FEV1/FVC), Forced Mid-Expiratory Flow 25--75 % (FEF25-75%), pulmonologist interpretation of flow volume loops, and overall exam findings were extracted from the medical record. RESULTS Ninety seven percent of children with ILO or chronic non-specific cough presented with spirometry values within normative range. Patients with ILO, non-specific cough, and mild asthma presented with FVC, FEV1, FEV1/FVC, and FEF25-75% values in statistically similar range. Children with moderate to severe asthma presented with significantly reduced FVC (p < .001), FEV1 (p < .001), FEV1/FVC (p < .001), and FEF25-75% (p < .001) values when compared with patients in the other groups. Flow volume loops were predominantly normal for children with ILO and non-specific cough. CONCLUSIONS Findings indicate that ILO and chronic non-specific cough can neither be diagnosed nor differentiated from mild asthma using spirometry alone. Spirometry should therefore be used judiciously with this population, bearing in mind the limitations of the procedure. Future research should determine the most effective and efficient ways of delineating ILO and non-specific cough from other respiratory conditions in children.
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Affiliation(s)
- Robert Brinton Fujiki
- Department of Surgery, University of Wisconsin - Madison, Madison, WI, United States of America
| | - Susan L Thibeault
- Department of Surgery, University of Wisconsin - Madison, Madison, WI, United States of America.
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2
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Beasley R, Hughes R, Agusti A, Calverley P, Chipps B, del Olmo R, Papi A, Price D, Reddel H, Müllerová H, Rapsomaniki E. Prevalence, Diagnostic Utility and Associated Characteristics of Bronchodilator Responsiveness. Am J Respir Crit Care Med 2024; 209:390-401. [PMID: 38029294 PMCID: PMC10878375 DOI: 10.1164/rccm.202308-1436oc] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 11/29/2023] [Indexed: 12/01/2023] Open
Abstract
Rationale: The prevalence and diagnostic utility of bronchodilator responsiveness (BDR) in a real-life setting is unclear. Objective: To explore this uncertainty in patients aged ⩾12 years with physician-assigned diagnoses of asthma, asthma and chronic obstructive pulmonary disease (COPD), or COPD in NOVELTY, a prospective cohort study in primary and secondary care in 18 countries. Methods: The proportion of patients with a positive BDR test in each diagnostic category was calculated using 2005 (ΔFEV1 or ΔFVC ⩾12% and ⩾200 ml) and 2021 (ΔFEV1 or ΔFVC >10% predicted) European Respiratory Society/American Thoracic Society criteria. Measurements and Main Results: We studied 3,519 patients with a physician-assigned diagnosis of asthma, 833 with a diagnosis of asthma + COPD, and 2,436 with a diagnosis of COPD. The prevalence of BDR was 19.7% (asthma), 29.6% (asthma + COPD), and 24.7% (COPD) using 2005 criteria and 18.1%, 23.3%, and 18.0%, respectively, using 2021 criteria. Using 2021 criteria in patients diagnosed with asthma, BDR was associated with higher fractional exhaled nitric oxide; lower lung function; higher symptom burden; more frequent hospital admissions; and greater use of triple therapy, oral corticosteroids, or biologics. In patients diagnosed with COPD, BDR (2021) was associated with lower lung function and higher symptom burden. Conclusions: BDR prevalence in patients with chronic airway diseases receiving treatment ranges from 18% to 30%, being modestly lower with the 2021 than with the 2005 European Respiratory Society/American Thoracic Society criteria, and it is associated with lower lung function and greater symptom burden. These observations question the validity of BDR as a key diagnostic tool for asthma managed in clinical practice or as a standard inclusion criterion for clinical trials of asthma and instead suggest that BDR be considered a treatable trait for chronic airway disease.
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Affiliation(s)
- Richard Beasley
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Rod Hughes
- Research and Early Development, Respiratory and Immunology, Clinical, AstraZeneca, Cambridge, United Kingdom
| | - Alvar Agusti
- University of Barcelona, Respiratory Institute, Clinic Barcelona, IDIBAPS, and CIBERES, Barcelona, Spain
| | - Peter Calverley
- University of Liverpool Institute of Life Course and Medical Sciences, Liverpool, United Kingdom
| | - Bradley Chipps
- Capital Allergy & Respiratory Disease Center, Sacramento, California
| | - Ricardo del Olmo
- Diagnostic and Treatment Department of María Ferrer Hospital & IDIM CR, Buenos Aires, Argentina
| | - Alberto Papi
- Research Centre on Asthma and Chronic Obstructive Pulmonary Disease, University of Ferrara, Ferrara, Italy
| | - David Price
- Observational and Pragmatic Research Institute, Singapore
- Centre of Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, United Kingdom
| | - Helen Reddel
- Woolcock Institute of Medical Research, Macquarie Medical School, Faculty of Medicine, Health and Human Sciences, Macquarie University
- Sydney Local Health District, Sydney, Australia; and
| | - Hana Müllerová
- BioPharmaceuticals Medical, AstraZeneca, Cambridge, United Kingdom
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3
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Shin S, Whitmore GA, Boulet LP, Boulay MÈ, Côté A, Bergeron C, Lemière C, Lougheed MD, Vandemheen KL, Alvarez GG, Mulpuru S, Aaron SD. Anticipating undiagnosed asthma in symptomatic adults with normal pre- and post-bronchodilator spirometry: a decision tool for bronchial challenge testing. BMC Pulm Med 2023; 23:496. [PMID: 38071285 PMCID: PMC10709915 DOI: 10.1186/s12890-023-02806-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Accepted: 12/05/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Some patients with asthma demonstrate normal spirometry and remain undiagnosed without further testing. OBJECTIVE To determine clinical predictors of asthma in symptomatic adults with normal spirometry, and to generate a tool to help clinicians decide who should undergo bronchial challenge testing (BCT). METHODS Using random-digit dialling and population-based case-finding, we recruited adults from the community with respiratory symptoms and no previous history of diagnosed lung disease. Participants with normal pre- and post-bronchodilator spirometry subsequently underwent BCT. Asthma was diagnosed in those with symptoms and a methacholine provocative concentration (PC20) of < 8 mg/ml. Sputum and blood eosinophils, and exhaled nitric oxide were measured. Univariate analyses identified potentially predictive variables, which were then used to construct a multivariable logistic regression model to predict asthma. Model sensitivity, specificity, and area under the receiver operating curve (AUC) were calculated. RESULTS Of 132 symptomatic individuals with normal spirometry, 34 (26%) had asthma. Of those ultimately diagnosed with asthma, 33 (97%) answered 'yes' to a question asking whether they experienced cough, chest tightness or wheezing provoked by exercise or cold air. Other univariate predictors of asthma included female sex, pre-bronchodilator FEV1 percentage predicted, and percent positive change in FEV1 post bronchodilator. A multivariable model containing these predictive variables yielded an AUC of 0.82 (95% CI: 0.72-0.91), a sensitivity of 82%, and a specificity of 66%. The model was used to construct a nomogram to advise clinicians which patients should be prioritized for BCT. CONCLUSIONS Four readily available patient characteristics demonstrated a high sensitivity and AUC for predicting undiagnosed asthma in symptomatic adults with normal pre- and post-bronchodilator spirometry. These characteristics can potentially help clinicians to decide which individuals with normal spirometry should be investigated with bronchial challenge testing. However, further prospective validation of our decision tool is required.
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Affiliation(s)
- Sheojung Shin
- The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Canada
| | | | - Louis-Philippe Boulet
- Institut universitaire de cardiologie et de pneumologie de Québec-Université Laval, Québec, QC, Canada
| | - Marie-Ève Boulay
- Institut universitaire de cardiologie et de pneumologie de Québec-Université Laval, Québec, QC, Canada
| | - Andréanne Côté
- Institut universitaire de cardiologie et de pneumologie de Québec-Université Laval, Québec, QC, Canada
| | - Céline Bergeron
- The Lung Center, Vancouver General Hospital, Vancouver, BC, Canada
| | | | | | | | - Gonzalo G Alvarez
- The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Canada
| | - Sunita Mulpuru
- The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Canada
| | - Shawn D Aaron
- The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Canada.
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4
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Gupta S, Thériault G. Do not diagnose or routinely treat asthma or chronic obstructive pulmonary disease without pulmonary function testing. BMJ 2023; 380:e072834. [PMID: 36940980 DOI: 10.1136/bmj-2022-072834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/22/2023]
Affiliation(s)
- Samir Gupta
- Li Ka Shing Knowledge Institute of St. Michael's Hospital, Unity Health, Toronto, Canada
- Division of Respirology, Department of Medicine, University of Toronto, Toronto, Canada
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5
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Cherian M, Magner KMA, Whitmore GA, Vandemheen KL, FitzGerald JM, Bergeron C, Boulet LP, Cote A, Field SK, Penz E, McIvor RA, Lemière C, Gupta S, Mayers I, Bhutani M, Hernandez P, Lougheed MD, Licskai CJ, Azher T, Ainslie M, Ezer N, Mulpuru S, Aaron SD. Patient and physician factors associated with symptomatic undiagnosed asthma or COPD. Eur Respir J 2023; 61:13993003.01721-2022. [PMID: 36328359 DOI: 10.1183/13993003.01721-2022] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 10/05/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND It remains unclear why some symptomatic individuals with asthma or COPD remain undiagnosed. Here, we compare patient and physician characteristics between symptomatic individuals with obstructive lung disease (OLD) who are undiagnosed and individuals with physician-diagnosed OLD. METHODS Using random-digit dialling and population-based case finding, we recruited 451 participants with symptomatic undiagnosed OLD and 205 symptomatic control participants with physician-diagnosed OLD. Data on symptoms, quality of life and healthcare utilisation were analysed. We surveyed family physicians of participants in both groups to elucidate differences in physician practices that could contribute to undiagnosed OLD. RESULTS Participants with undiagnosed OLD had lower mean pre-bronchodilator forced expiratory volume in 1 s percentage predicted compared with those who were diagnosed (75.2% versus 80.8%; OR 0.975, 95% CI 0.963-0.987). They reported greater psychosocial impacts due to symptoms and worse energy and fatigue than those with diagnosed OLD. Undiagnosed OLD was more common in participants whose family physicians were practising for >15 years and in those whose physicians reported that they were likely to prescribe respiratory medications without doing spirometry. Undiagnosed OLD was more common among participants who had never undergone spirometry (OR 10.83, 95% CI 6.18-18.98) or who were never referred to a specialist (OR 5.92, 95% CI 3.58-9.77). Undiagnosed OLD was less common among participants who had required emergency department care (OR 0.44, 95% CI 0.20-0.97). CONCLUSIONS Individuals with symptomatic undiagnosed OLD have worse pre-bronchodilator lung function and present with greater psychosocial impacts on quality of life compared with their diagnosed counterparts. They were less likely to have received appropriate investigations and specialist referral for their respiratory symptoms.
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Affiliation(s)
- Mathew Cherian
- The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Kate M A Magner
- The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - G A Whitmore
- Desautels Faculty of Management, McGill University, Montreal, QC, Canada
| | | | - J Mark FitzGerald
- Department of Medicine, The University of British Columbia, Vancouver, BC, Canada.,Deceased
| | - Celine Bergeron
- Department of Medicine, The University of British Columbia, Vancouver, BC, Canada
| | | | - Andreanne Cote
- Centre de Recherche, Hôpital Laval, Université Laval, Quebec City, QC, Canada
| | - Stephen K Field
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Erika Penz
- Department of Medicine, University of Saskatchewan, Saskatoon, SK, Canada
| | - R Andrew McIvor
- Firestone Institute for Respiratory Health, McMaster University, Hamilton, ON, Canada
| | - Catherine Lemière
- Department of Medicine, Université de Montréal, Montreal, QC, Canada
| | - Samir Gupta
- Department of Medicine and Li Ka Shing Knowledge Institute of St Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Irvin Mayers
- Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Mohit Bhutani
- Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Paul Hernandez
- Department of Medicine, Dalhousie University, Halifax, NS, Canada
| | - M Diane Lougheed
- Department of Medicine, Queen's University, Kingston, ON, Canada
| | | | - Tanweer Azher
- Department of Medicine, Memorial University, St John's, NL, Canada
| | - Martha Ainslie
- Department of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Nicole Ezer
- Department of Medicine, McGill University, Montreal, QC, Canada
| | - Sunita Mulpuru
- The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Shawn D Aaron
- The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
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Antimisiaris DE, Folz RJ, Cavallazzi RS, Polivka BJ. Polypharmacy Interactions Impacting Methacholine Challenge Testing for Asthma Assessment in Older People. Sr Care Pharm 2023; 38:29-40. [PMID: 36751917 DOI: 10.4140/tcp.n.2023.29] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Objective To investigate potential reasons for unusually high incidence of negative Methacholine Challenge Tests (MCT), following standardized MCT medication-hold protocol, in older people with physician-diagnosed asthma. Design An analysis of a longitudinal observational parent study of asthma. Setting Community-dwelling participants were evaluated in an outpatient clinic and at home. Participants Screening inclusion criteria for the parent study included 60 years of age or older, physician diagnosis of asthma, and a positive response to at least one of six asthma screening questions. Participants were enrolled in the study if they also demonstrate either: (1) a postbronchodilator administration response showing an increase of at least 12% and 200 mL in forced expiratory volume or an increase of at least 12% and 200 mL in forced vital capacity, or (2) an MCT result of PC20 ≤ 16 mg/mL (indicating bronchial hyper-responsiveness, MCT positive). Exclusion criteria included diagnosis of cognitive impairment or dementia, residing in a long-term care facility, more than 20 pack/ year smoking history or a history of smoking within the previous five years, inability to perform pulmonary function testing maneuvers, and a Prognostic Index score of greater than 10. Interventions Analysis of participant data for non-medication- and medication-exposure factors for association with negative MCT results. Results Anticholinergic burden and statin use were positively associated with negative MCT. Conclusion Medications not accounted for in medication-hold protocols, and concurrently in use, may impact clinical tests and outcomes.
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Affiliation(s)
- Demetra E Antimisiaris
- 1 Department of Health Management and Systems Sciences, Department of Neurology, University of Louisville, Louisville, Kentucky
| | - Rodney J Folz
- 3 Jerald B. Katz Academy, Houston Methodist Research Institute, Houston, Texas
| | - Rodrigo S Cavallazzi
- 5 Department of Pulmonary and Critical Care Medicine, University of Louisville, Louisville, Kentucky
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7
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Parker J, Tzeng A, Wayne S, Haynes JM, Irvin CG, Kaminsky DA. Validation of the clinical utility of
sGaw
as a response variable in methacholine challenge testing. Respirology 2022; 28:437-444. [PMID: 36478621 DOI: 10.1111/resp.14431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 11/16/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND OBJECTIVE Airway hyperresponsiveness (AHR) is commonly assessed by a methacholine challenge test (MCT), during which a provocative concentration causing a 20% reduction in forced expiratory volume in 1 second (FEV1 ) (PC20 ) < 8 mg/ml is considered a positive response. However, a fall in specific airway conductance (sGaw) may also have clinical significance. The purpose of this study was to assess whether AHR determined by a provocative concentration causing a 40% reduction in sGaw (PC40 ) < 8 mg/ml corresponds to a clinical diagnosis of asthma. METHODS We analysed the changes in spirometry, lung volumes and sGaw during MCT in 211 randomly selected patients being evaluated for AHR to support a clinical diagnosis of asthma. RESULTS The mean (SD) age of the group was 53 (15) years, with 141 women (67%). Overall lung function was normal, with FEV1 = 92 (15) % predicted, total lung capacity = 97 (13) % predicted and sGaw = 0.19 (0.15-0.23) L/s/cm H2 O/L, (median, 25-75 IQR). There were many more patients who responded by PC40 only (n = 120) than who responded by PC20 (n = 52). There was no significant difference in asthma diagnosis between the PC20 (98%) and PC40 (93%) groups, and we estimate 34% of patients with a diagnosis of asthma would have been classified as having no AHR if only the FEV1 criterion was used. CONCLUSION Changes in sGaw during MCT indicate clinically significant AHR in support of a clinical diagnosis of asthma among patients being evaluated for asthma.
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Affiliation(s)
| | - Allison Tzeng
- University of Vermont Larner College of Medicine Burlington Vermont USA
| | - Shawn Wayne
- Pulmonary and Critical Care University of Vermont Larner College of Medicine Burlington Vermont USA
| | | | - Charles G. Irvin
- Pulmonary and Critical Care University of Vermont Larner College of Medicine Burlington Vermont USA
| | - David A. Kaminsky
- Pulmonary and Critical Care University of Vermont Larner College of Medicine Burlington Vermont USA
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Al Busaidi N, Alweqayyan A, Al Zaabi A, Mahboub B, Al-Huraish F, Hameed M, Al-Ahmad M, Khadadah M, Al Lawati N, Behbehani N, Al Jabri O, Salman R, Al Mubaihsi S, Al Raisi S. Gulf Asthma Diagnosis and Management in Adults: Expert Review and Recommendations. Open Respir Med J 2022. [DOI: 10.2174/18743064-v16-e2205230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The prevalence and incidence of asthma are increasing globally because of genetic and environmental influences. Prevalence of asthma in the Gulf has been reported to range from 4.7% to 32.0% and has a substantial economic burden. In this paper, we summarize current asthma management guidance for adults, present insights, and recommendations by key opinion leaders (KOLs) in the Gulf region, and key performance indicators for guiding clinical practice for asthma diagnosis, management, and treatment in the Gulf. While it is recommended that the Global Initiative for Asthma (GINA) guidelines should be followed wherever possible for the management of asthma, KOLs in the Gulf region have presented additional recommendations based on regional challenges and insights. There is a need for better diagnosis using objective testing, increased efforts in tackling the burden of comorbidities in the region, and greater provision of the necessary tools for phenotyping severe asthma. Furthermore, there is a need for greater education for physicians regarding asthma treatment, including the importance of inhaled-corticosteroid-containing controller medication. Regionally, there is also a need for specialist asthma clinics and asthma educators, which would serve to educate physicians and their patients as well as to improve the management of patients. Finally, the use of asthma registries, digital devices, and electronic templates would be of benefit in the management of asthma patients in the region.
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Asthma diagnosis using patient-reported outcome measures and objective diagnostic tests: now and into the future. Curr Opin Pulm Med 2022; 28:251-257. [PMID: 35256554 DOI: 10.1097/mcp.0000000000000871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
PURPOSE OF REVIEW The global prevalence of asthma continues to increase; however, asthma remains under-diagnosed and under-treated. This results in a significant burden on the healthcare system and preventable patient morbidity and mortality. Over-diagnosis of asthma based on clinical history alone also complicates patient management. This heightens the importance of a prompt and accurate asthma diagnosis. Therefore, a review of the literature was performed regarding both objective diagnostic testing for asthma and using patient-reported outcome measures. RECENT FINDINGS The cornerstone of asthma diagnosis remains spirometry with testing for bronchodilator reversibility testing for pediatric and adult populations. This test may need to be repeated at multiple time points due to its low sensitivity. Peak flow measurement, fractional exhaled nitric oxide testing, and allergy testing are useful adjuncts to the diagnosis and phenotyping of asthma. Bronchoprovocation testing is reserved for people with high clinical suspicion for asthma, but negative spirometry. Novel noninvasive testing modalities may play a diagnostic role in the future. The advent of remote digital health monitoring technology has resulted in revisiting patient-reported outcome measures for the diagnosis and monitoring of asthma. SUMMARY Overall, improved diagnostic tools for asthma are crucial for earlier recognition and treatment of the disease and improved patient care outcomes worldwide.
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10
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Yawn BP. Developing and Disseminating Evidence to Support Enhanced Spirometry Use in Primary Care Diagnosis of Asthma and COPD. Chest 2022; 161:865-866. [DOI: 10.1016/j.chest.2021.11.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 11/27/2021] [Indexed: 10/18/2022] Open
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Raherison-Semjen C, Guilleminault L, Billiart I, Chenivesse C, De Oliveira A, Izadifar A, Lorenzo A, Nocent C, Oster JP, Padovani M, Perez T, Russier M, Steinecker M, Didier A. [Update of the 2021 recommendations for the management and follow-up of adult asthmatic patients under the guidance of the French Society of Pulmonology and the Paediatric Society of Pulmonology and Allergology. Long version]. Rev Mal Respir 2021; 38:1048-1083. [PMID: 34799211 DOI: 10.1016/j.rmr.2021.08.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 06/17/2021] [Indexed: 11/22/2022]
Affiliation(s)
- C Raherison-Semjen
- Université de Bordeaux, INSERM UMR 1219, Epicene Team, Bordeaux, France.
| | - L Guilleminault
- Pôle des voies respiratoires, CHU de Toulouse, Toulouse, France; Institut toulousain des maladies infectieuses et inflammatoires (Infinity), INSERM, UMR1291, CNRS UMR5051, université Toulouse III, CRISALIS F-CRIN, Toulouse, France
| | | | - C Chenivesse
- CHRU de Lille, service de pneumo-allergologie, 59000 Lille, France
| | - A De Oliveira
- Sorbonne université, département de médecine générale, Paris, France
| | - A Izadifar
- Département de pneumologie, centre cardiologique du Nord, Saint-Denis, France
| | - A Lorenzo
- Sorbonne université, département de médecine générale, Paris, France
| | - C Nocent
- CHG Côte Basque, Bayonne, France
| | - J P Oster
- Service de pneumologie, centre hospitalier Louis-Pasteur, Colmar, France
| | - M Padovani
- Espace Santé Ii, La Seyne-sur-Mer, France
| | - T Perez
- CHRU de Lille, service d'explorations fonctionnelles, 59000 Lille, France
| | - M Russier
- Service de pneumo-allergologie, CHR Orléans, Orléans, France
| | - M Steinecker
- Sorbonne université, département de médecine générale, Paris, France
| | - A Didier
- Université de Bordeaux, INSERM UMR 1219, Epicene Team, Bordeaux, France; Pôle des voies respiratoires, CHU de Toulouse, Toulouse, France
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12
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Barriers and Enablers to Objective Testing for Asthma and COPD in Primary Care: A Systematic Review Using the Theoretical Domains Framework. Chest 2021; 161:888-905. [PMID: 34740591 DOI: 10.1016/j.chest.2021.10.030] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 10/03/2021] [Accepted: 10/22/2021] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Although guidelines have long recommended objective pulmonary function testing to diagnose asthma and chronic obstructive lung disease (COPD), many primary care patients receive a clinical diagnosis of asthma or COPD without objective testing. This often leads to unnecessary treatment with associated incremental costs and side-effects, and delays actual diagnosis. RESEARCH QUESTION What are the barriers and enablers to lung function testing for asthma and/or COPD in primary care? STUDY DESIGN AND METHODS We searched the literature for qualitative and quantitative studies reporting barriers and/or enablers to in-office or out-of-office lung function testing for diagnosing asthma and/or COPD, in primary care. Two reviewers independently screened abstracts and full texts; assessed methodological quality using the Mixed Methods Appraisal Tool; and extracted data from included studies. Identified barriers and enablers were categorized using the Theoretical Domains Framework (TDF), applying a pre-established coding manual. RESULTS We identified 7988 unique articles, reviewed 336 full-text articles, and included 18 studies in this systematic review. Of these 18, 12 were quantitative, 3 were qualitative, and 3 used mixed methods. All 18 addressed in-office testing and 11 also addressed out-of-office testing. Barriers and enablers overlapped for asthma and COPD, and in- and out-of-office settings. We identified more reported barriers (e.g. lack of knowledge of the usefulness of spirometry) than enablers (e.g. skills for performing reliable spirometry). Barriers mapped to 9 (of a possible 14) TDF domains (for both in- and out-of-office settings). Enablers mapped to three domains for in-office testing and five domains for out-of-office testing. INTERPRETATION Barriers to objective testing for airways disease in primary care are complex and span many theoretical domains. Correspondingly, a successful intervention must leverage multiple behaviour change techniques. A theory-based, multifaceted intervention to address underuse of diagnostic testing for asthma or COPD should now be developed and tested.
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13
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Ciprandi G, Tosca MA. Turbinate Hypertrophy, Allergic Rhinitis, and Otitis Media. Curr Allergy Asthma Rep 2021; 21:44. [PMID: 34591196 DOI: 10.1007/s11882-021-01021-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/04/2021] [Indexed: 11/29/2022]
Abstract
PURPOSE OF REVIEW Otitis media (OM) is a disease with high prevalence in infancy; it has a substantial burden on healthcare resources, and a relevant impact on the quality of life of families. The link between OM and allergic rhinitis (AR) is still debated. However, there is agreement about the relevance of type 2 inflammation on turbinate hypertrophy (TH) generation. There is also evidence that TH is associated with middle ear dysventilation: a pathogenic factor promoting OM. Therefore, a vicious circle among AR, TH, and OM may occur. RECENT FINDINGS There are some recent studies exploring this issue through different approaches, such as epidemiological, mechanistic, and therapeutic. Identifying allergy as a pathogenic factor for OM could improve the management of OM patients. Vice versa, suspecting AR in OM patients, could be reasonable in selected patients. The current narrative review provides an overview of the evidence concerning the potential role of AR, and associated TH, in OM patients.
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Ciprandi G, Tosca MA. Turbinate Hypertrophy, Allergic Rhinitis, and Otitis Media. Curr Allergy Asthma Rep 2021; 21:40. [PMID: 34390424 DOI: 10.1007/s11882-021-01016-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/04/2021] [Indexed: 11/29/2022]
Abstract
PURPOSE OF REVIEW Otitis media (OM) is a disease with high prevalence in infancy; it has a substantial burden on healthcare resources and a relevant impact on the quality of life of families. The link between OM and allergic rhinitis (AR) is still debated. However, there is agreement about the relevance of type 2 inflammation on turbinate hypertrophy (TH) generation. There is also evidence that TH is associated with middle ear dysventilation: a pathogenic factor promoting OM. Therefore, a vicious circle among AR, TH, and OM may occur. RECENT FINDINGS There are some recent studies exploring this issue through different approaches, such as epidemiological, mechanistic, and therapeutic. Identifying allergy as a pathogenic factor for OM could improve the management of OM patients. Vice versa, suspecting AR in OM patients could be reasonable in selected patients. The current narrative review provides an overview of the evidence concerning the potential role of AR, and associated TH, in OM patients.
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Affiliation(s)
- Giorgio Ciprandi
- , Allergy Clinic, Casa di Cura Villa MontallegroVia P. Boselli 5, 16146, Genoa, Italy.
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15
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How I do it. Work-up of severe asthma. Chest 2021; 160:2019-2029. [PMID: 34265308 DOI: 10.1016/j.chest.2021.07.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 07/03/2021] [Accepted: 07/06/2021] [Indexed: 11/22/2022] Open
Abstract
CASE EXAMPLE A 56-year-old gentleman has difficult to control asthma and a history of four exacerbations in the prior 12 months despite high-dose inhaled corticosteroids (ICS) and additional controller therapies. Is he suitable for more advanced therapeutic options? SCOPE OF REVIEW We herein review the clinical assessment of a patient with suspected severe asthma, discuss factors contributing to poor asthma control and how biomarkers assist in disease investigation and stratification. HOW I DO IT The key components of our multidisciplinary approach are to confirm an asthma diagnosis and adherence to treatment, to assess any contributing comorbidities or confounding factors, and to stratify what type of asthma our patient has. The combination of spirometry and repeated measures of key biomarkers of type-2 airway inflammation - the blood eosinophil count and fractional exhaled nitric oxide - identifies whether poor disease control is driven by uncontrolled, ICS-resistant type-2 airway inflammation or ongoing airflow obstruction. A failure to elicit evidence of either suggests an alternative driver for the patient's symptoms including chronic airway infection and non-asthma causes. Each phenotype represents a treatable trait that requires a specific targeted approach. Critically, steroids can cause harm and their use should be guided by objective evidence of inflammation rather than symptoms alone. CASE CONCLUSION After assessment of treatment adherence and exclusion of relevant comorbidities, the patient was found to have severe asthma with ICS-resistant type-2 airway inflammation. We will consider additional treatment options at our next appointment (Part 2/2 of this How I Do It series).
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16
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Wang R, Murray CS, Fowler SJ, Simpson A, Durrington HJ. Asthma diagnosis: into the fourth dimension. Thorax 2021; 76:624-631. [PMID: 33504564 PMCID: PMC8223645 DOI: 10.1136/thoraxjnl-2020-216421] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 12/18/2020] [Accepted: 12/31/2020] [Indexed: 02/06/2023]
Abstract
Asthma is the most common chronic respiratory disease in the UK; however, the misdiagnosis rate is substantial. The lack of consistency in national guidelines and the paucity of data on the performance of diagnostic algorithms compound the challenges in asthma diagnosis. Asthma is a highly rhythmic disease, characterised by diurnal variability in clinical symptoms and pathogenesis. Asthma also varies day to day, seasonally and from year to year. As much as it is a hallmark for asthma, this variability also poses significant challenges to asthma diagnosis. Almost all established asthma diagnostic tools demonstrate diurnal variation, yet few are performed with standardised timing of measurements. The dichotomous interpretation of diagnostic outcomes using fixed cut-off values may further limit the accuracy of the tests, particularly when diurnal variability straddles cut-off values within a day, and careful interpretation beyond the 'positive' and 'negative' outcome is needed. The day-to-day and more long-term variations are less predictable and it is unclear whether performing asthma diagnostic tests during asymptomatic periods may influence diagnostic sensitivities. With the evolution of asthma diagnostic tools, home monitoring and digital apps, novel strategies are needed to bridge these gaps in knowledge, and circadian variability should be considered during the standardisation process. This review summarises the biological mechanisms of circadian rhythms in asthma and highlights novel data on the significance of time (the fourth dimension) in asthma diagnosis.
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Affiliation(s)
- Ran Wang
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK,Manchester Academic Health Science Centre and NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester, UK
| | - Clare S Murray
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK,Manchester Academic Health Science Centre and NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester, UK
| | - Stephen J Fowler
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK,Manchester Academic Health Science Centre and NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester, UK
| | - Angela Simpson
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK,Manchester Academic Health Science Centre and NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester, UK
| | - Hannah Jane Durrington
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK .,Manchester Academic Health Science Centre and NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester, UK
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17
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Cockcroft DW. Methacholine Challenge Testing in the Diagnosis of Asthma. Chest 2021; 158:433-434. [PMID: 32768054 DOI: 10.1016/j.chest.2020.04.034] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 04/24/2020] [Indexed: 11/28/2022] Open
Affiliation(s)
- Donald W Cockcroft
- Department of Respirology, University of Saskatchewan, Royal University Hospital, Saskatoon, SK, Canada.
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18
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Peled M, Ovadya D, Cohn J, Seluk L, Pullerits T, Segel MJ, Onn A. Baseline spirometry parameters as predictors of airway hyperreactivity in adults with suspected asthma. BMC Pulm Med 2021; 21:153. [PMID: 33957916 PMCID: PMC8101108 DOI: 10.1186/s12890-021-01506-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 04/13/2021] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Methacholine challenge tests (MCTs) are used to diagnose airway hyperresponsiveness (AHR) in patients with suspected asthma where previous diagnostic testing has been inconclusive. The test is time consuming and usually requires referral to specialized centers. Simple methods to predict AHR could help determine which patients should be referred to MCTs, thus avoiding unnecessary testing. Here we investigated the potential use of baseline spirometry variables as surrogate markers for AHR in adults with suspected asthma. METHODS Baseline spirometry and MCTs performed between 2013 and 2019 in a large tertiary center were retrospectively evaluated. Receiver-operating characteristic curves for the maximal expiratory flow-volume curve indices (angle β, FEV1, FVC, FEV1/FVC, FEF50%, FEF25-75%) were constructed to assess their overall accuracy in predicting AHR and optimal cutoff values were identified. RESULTS A total of 2983 tests were analyzed in adults aged 18-40 years. In total, 14% of all MCTs were positive (PC20 ≤ 16 mg/ml). All baseline spirometry parameters were significantly lower in the positive group (p < 0.001). FEF50% showed the best overall accuracy (AUC = 0.688) and proved to be useful as a negative predictor when applying FEF50% ≥ 110% as a cutoff level. CONCLUSIONS This study highlights the role of FEF50% in predicting AHR in patients with suspected asthma. A value of ≥ 110% for baseline FEF50% could be used to exclude AHR and would lead to a substantial decrease in MCT referrals.
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Affiliation(s)
- Michael Peled
- Institute of Pulmonary Medicine, Chaim Sheba Medical Center, Derech Sheba st. 2, 52621, Ramat Gan, Israel. .,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.
| | - David Ovadya
- Institute of Pulmonary Medicine, Chaim Sheba Medical Center, Derech Sheba st. 2, 52621, Ramat Gan, Israel.,Department of Respiratory Care and Rehabilitation, Chaim Sheba Medical Center, Ramat Gan, Israel
| | - Jennifer Cohn
- Faculty of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Lior Seluk
- Institute of Pulmonary Medicine, Chaim Sheba Medical Center, Derech Sheba st. 2, 52621, Ramat Gan, Israel
| | - Teet Pullerits
- Department of Asthma and Allergology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Michael J Segel
- Institute of Pulmonary Medicine, Chaim Sheba Medical Center, Derech Sheba st. 2, 52621, Ramat Gan, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Amir Onn
- Institute of Pulmonary Medicine, Chaim Sheba Medical Center, Derech Sheba st. 2, 52621, Ramat Gan, Israel
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19
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Neder JA. Functional respiratory assessment: some key misconceptions and their clinical implications. Thorax 2021; 76:644-646. [PMID: 33859052 DOI: 10.1136/thoraxjnl-2020-215287] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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20
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Kouri A, Gupta S, Yadollahi A, Ryan CM, Gershon AS, To T, Tarlo SM, Goldstein RS, Chapman KR, Chow CW. Addressing Reduced Laboratory-Based Pulmonary Function Testing During a Pandemic. Chest 2020; 158:2502-2510. [PMID: 32652095 PMCID: PMC7345485 DOI: 10.1016/j.chest.2020.06.065] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 06/23/2020] [Accepted: 06/27/2020] [Indexed: 01/04/2023] Open
Abstract
To reduce the spread of the severe acute respiratory syndrome coronavirus 2, many pulmonary function testing (PFT) laboratories have been closed or have significantly reduced their testing capacity. Because these mitigation strategies may be necessary for the next 6 to 18 months to prevent recurrent peaks in disease prevalence, fewer objective measurements of lung function will alter the diagnosis and care of patients with chronic respiratory diseases. PFT, which includes spirometry, lung volume, and diffusion capacity measurement, is essential to the diagnosis and management of patients with asthma, COPD, and other chronic lung conditions. Both traditional and innovative alternatives to conventional testing must now be explored. These may include peak expiratory flow devices, electronic portable spirometers, portable exhaled nitric oxide measurement, airwave oscillometry devices, and novel digital health tools such as smartphone microphone spirometers and mobile health technologies along with integration of machine learning approaches. The adoption of some novel approaches may not merely replace but could improve existing management strategies and alter common diagnostic paradigms. With these options comes important technical, privacy, ethical, financial, and medicolegal barriers that must be addressed. However, the coronavirus disease 19 pandemic also presents a unique opportunity to augment conventional testing by including innovative and emerging approaches to measuring lung function remotely in patients with respiratory disease. The benefits of such an approach have the potential to enhance respiratory care and empower patient self-management well beyond the current global pandemic.
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Affiliation(s)
- Andrew Kouri
- Division of Respirology, Department of Medicine, St. Michael's Hospital, Unity Health Toronto, Toronto, ON.
| | - Samir Gupta
- Division of Respirology, Department of Medicine, St. Michael's Hospital, Unity Health Toronto, Toronto, ON,Department of Medicine, University of Toronto, Toronto, ON
| | - Azadeh Yadollahi
- Institute of Biomaterials and Biomedical Engineering, University of Toronto, Toronto, ON,KITE-Toronto Rehabilitation Institute, University Health Network, Toronto, ON
| | - Clodagh M. Ryan
- Department of Medicine, University of Toronto, Toronto, ON,Division of Respirology, Department of Medicine, Toronto General Hospital, University Health Network, Toronto, ON
| | - Andrea S. Gershon
- Department of Medicine, University of Toronto, Toronto, ON,Division of Respirology, Department of Medicine, Sunnybrook Health Sciences Center, Toronto, ON
| | - Teresa To
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, ON,Dalla Lana Graduate School of Public Health, University of Toronto, Toronto, ON
| | - Susan M. Tarlo
- Department of Medicine, University of Toronto, Toronto, ON,Division of Respirology, Department of Medicine, Toronto Western Hospital, University Health Network, Toronto, ON
| | - Roger S. Goldstein
- Department of Medicine, University of Toronto, Toronto, ON,Division of Respiratory Medicine, West Part Healthcare Centre, Toronto, ON, Canada
| | - Kenneth R. Chapman
- Department of Medicine, University of Toronto, Toronto, ON,Division of Respirology, Department of Medicine, Toronto Western Hospital, University Health Network, Toronto, ON
| | - Chung-Wai Chow
- Department of Medicine, University of Toronto, Toronto, ON,Division of Respirology, Department of Medicine, Toronto General Hospital, University Health Network, Toronto, ON
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