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Bradding P, Porsbjerg C, Côté A, Dahlén SE, Hallstrand TS, Brightling CE. Airway hyperresponsiveness in asthma: The role of the epithelium. J Allergy Clin Immunol 2024; 153:1181-1193. [PMID: 38395082 DOI: 10.1016/j.jaci.2024.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Revised: 02/02/2024] [Accepted: 02/20/2024] [Indexed: 02/25/2024]
Abstract
Airway hyperresponsiveness (AHR) is a key clinical feature of asthma. The presence of AHR in people with asthma provides the substrate for bronchoconstriction in response to numerous diverse stimuli, contributing to airflow limitation and symptoms including breathlessness, wheeze, and chest tightness. Dysfunctional airway smooth muscle significantly contributes to AHR and is displayed as increased sensitivity to direct pharmacologic bronchoconstrictor stimuli, such as inhaled histamine and methacholine (direct AHR), or to endogenous mediators released by activated airway cells such as mast cells (indirect AHR). Research in in vivo human models has shown that the disrupted airway epithelium plays an important role in driving inflammation that mediates indirect AHR in asthma through the release of cytokines such as thymic stromal lymphopoietin and IL-33. These cytokines upregulate type 2 cytokines promoting airway eosinophilia and induce the release of bronchoconstrictor mediators from mast cells such as histamine, prostaglandin D2, and cysteinyl leukotrienes. While bronchoconstriction is largely due to airway smooth muscle contraction, airway structural changes known as remodeling, likely mediated in part by epithelial-derived mediators, also lead to airflow obstruction and may enhance AHR. In this review, we outline the current knowledge of the role of the airway epithelium in AHR in asthma and its implications on the wider disease. Increased understanding of airway epithelial biology may contribute to better treatment options, particularly in precision medicine.
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Affiliation(s)
- Peter Bradding
- Department of Respiratory Sciences, Leicester Respiratory National Institute for Health and Care Research Biomedical Research Centre, Glenfield Hospital, University of Leicester, Leicester, United Kingdom
| | - Celeste Porsbjerg
- Department of Respiratory Medicine and Infectious Diseases, Copenhagen University Hospital Bispebjerg, Copenhagen, Denmark
| | - Andréanne Côté
- Quebec Heart and Lung Institute, Université Laval, Laval, Quebec, Canada; Department of Medicine, Université Laval, Laval, Quebec, Canada
| | - Sven-Erik Dahlén
- Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden; Department of Respiratory Medicine and Allergy, Karolinska University Hospital, Stockholm, Sweden
| | - Teal S Hallstrand
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, Wash; Center for Lung Biology, University of Washington, Seattle, Wash.
| | - Christopher E Brightling
- Department of Respiratory Sciences, Leicester Respiratory National Institute for Health and Care Research Biomedical Research Centre, Glenfield Hospital, University of Leicester, Leicester, United Kingdom.
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Murphy RC, Lai Y, Liu M, Al-Shaikhly T, Altman MC, Altemeier WA, Frevert CW, Debley JS, Piliponsky AM, Ziegler SF, Gharib SA, Hallstrand TS. Distinct Epithelial-Innate Immune Cell Transcriptional Circuits Underlie Airway Hyperresponsiveness in Asthma. Am J Respir Crit Care Med 2023; 207:1565-1575. [PMID: 37212596 PMCID: PMC10273121 DOI: 10.1164/rccm.202209-1707oc] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Accepted: 03/02/2023] [Indexed: 05/23/2023] Open
Abstract
Rationale: Indirect airway hyperresponsiveness (AHR) is a highly specific feature of asthma, but the underlying mechanisms responsible for driving indirect AHR remain incompletely understood. Objectives: To identify differences in gene expression in epithelial brushings obtained from individuals with asthma who were characterized for indirect AHR in the form of exercise-induced bronchoconstriction (EIB). Methods: RNA-sequencing analysis was performed on epithelial brushings obtained from individuals with asthma with EIB (n = 11) and without EIB (n = 9). Differentially expressed genes (DEGs) between the groups were correlated with measures of airway physiology, sputum inflammatory markers, and airway wall immunopathology. On the basis of these relationships, we examined the effects of primary airway epithelial cells (AECs) and specific epithelial cell-derived cytokines on both mast cells (MCs) and eosinophils (EOS). Measurements and Main Results: We identified 120 DEGs in individuals with and without EIB. Network analyses suggested critical roles for IL-33-, IL-18-, and IFN-γ-related signaling among these DEGs. IL1RL1 expression was positively correlated with the density of MCs in the epithelial compartment, and IL1RL1, IL18R1, and IFNG were positively correlated with the density of intraepithelial EOS. Subsequent ex vivo modeling demonstrated that AECs promote sustained type 2 (T2) inflammation in MCs and enhance IL-33-induced T2 gene expression. Furthermore, EOS increase the expression of IFNG and IL13 in response to both IL-18 and IL-33 as well as exposure to AECs. Conclusions: Circuits involving epithelial interactions with MCs and EOS are closely associated with indirect AHR. Ex vivo modeling indicates that epithelial-dependent regulation of these innate cells may be critical in indirect AHR and modulating T2 and non-T2 inflammation in asthma.
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Affiliation(s)
- Ryan C. Murphy
- Division of Pulmonary, Critical Care and Sleep
- Center for Lung Biology
| | - Ying Lai
- Division of Pulmonary, Critical Care and Sleep
- Center for Lung Biology
| | - Matthew Liu
- Division of Pulmonary, Critical Care and Sleep
- Center for Lung Biology
| | - Taha Al-Shaikhly
- Division of Allergy and Infectious Diseases, Department of Medicine
- Center for Lung Biology
| | - Matthew C. Altman
- Division of Allergy and Infectious Diseases, Department of Medicine
- Immunology Program, Benaroya Research Institute, Seattle, Washington
| | | | | | - Jason S. Debley
- Division of Pulmonary and Sleep Medicine, Department of Pediatrics, Seattle Children’s Hospital, University of Washington, Seattle, Washington
- Center for Immunity and Immunotherapies, Seattle Children’s Research Institute, Seattle, Washington
| | - Adrian M. Piliponsky
- Center for Immunity and Immunotherapies, Seattle Children’s Research Institute, Seattle, Washington
| | - Steven F. Ziegler
- Immunology Program, Benaroya Research Institute, Seattle, Washington
| | - Sina A. Gharib
- Division of Pulmonary, Critical Care and Sleep
- Center for Lung Biology
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Salameh M, Pini L, Quadri F, Spreafico F, Bottone D, Tantucci C. Predictors of exercise-induced bronchoconstriction in subjects with mild asthma. Allergy Asthma Clin Immunol 2021; 17:84. [PMID: 34391448 PMCID: PMC8364109 DOI: 10.1186/s13223-021-00585-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 08/03/2021] [Indexed: 11/26/2022] Open
Abstract
Background Physical effort is capable of triggering airway obstruction in asthmatics, the so-called exercise-induced bronchoconstriction in asthma (EIBa). This study was performed in subjects with mild persistent asthma, aiming to find predictors for developing EIBa. Methods In 20 subjects with mild asthma, measurements of baseline functional respiratory parameters and airways responsiveness by a methacholine challenge were obtained on the first day. A maximal, symptom-limited incremental cardiopulmonary exercise test (CPExT) was performed the day after, with subsequent, repeated maneuvers of maximal full forced expiration to monitor the FEV1 change at 1,3,5,7,10 and 15 min after the end of the exercise. Results 19 subjects completed the two-days protocol. No functional parameters both at rest and during effort were useful to predict EIBa after stopping exercise. In asthmatics with EIBa, mean Inspiratory Capacity (IC) did not increase with increasing ventilatory requirements during CPExT because 6 of them (50%) displayed dynamic pulmonary hyperinflation (DH), as documented by their progressive increase of end-expiratory lung volume. This subgroup, showing earlier post-exercise FEV1 fall, had significantly lower forced mean expiratory flow between 25% and 75% of forced vital capacity (FEF25-75%) at rest (p < 0.05) and higher airways responsiveness, expressed as PD20FEV1 (p < 0.05) as compared with other asthmatics with EIBa. Conclusions No functional respiratory parameters seem to predict EIBa in mild asthmatics. However, in those with EIBa, a subgroup developed DH during exercise, and this was associated with a baseline reduced forced expiratory flow rates at lower lung volumes and higher airway hyperresponsiveness, suggesting a prominent small airways impairment.
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Affiliation(s)
- Maroon Salameh
- Respiratory Medicine Unit, Spedali Civili, Brescia, Piazzale Spedali Civili 1, Italy.,Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Laura Pini
- Respiratory Medicine Unit, Spedali Civili, Brescia, Piazzale Spedali Civili 1, Italy. .,Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy.
| | - Federico Quadri
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Fabio Spreafico
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Damiano Bottone
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Claudio Tantucci
- Respiratory Medicine Unit, Spedali Civili, Brescia, Piazzale Spedali Civili 1, Italy.,Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
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Murphy RC, Lai Y, Nolin JD, Aguillon Prada RA, Chakrabarti A, Novotny MV, Seeds MC, Altemeier WA, Gelb MH, Hite RD, Hallstrand TS. Exercise-induced alterations in phospholipid hydrolysis, airway surfactant, and eicosanoids and their role in airway hyperresponsiveness in asthma. Am J Physiol Lung Cell Mol Physiol 2021; 320:L705-L714. [PMID: 33533300 DOI: 10.1152/ajplung.00546.2020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The mechanisms responsible for driving endogenous airway hyperresponsiveness (AHR) in the form of exercise-induced bronchoconstriction (EIB) are not fully understood. We examined alterations in airway phospholipid hydrolysis, surfactant degradation, and lipid mediator release in relation to AHR severity and changes induced by exercise challenge. Paired induced sputum (n = 18) and bronchoalveolar lavage (BAL) fluid (n = 11) were obtained before and after exercise challenge in asthmatic subjects. Samples were analyzed for phospholipid structure, surfactant function, and levels of eicosanoids and secreted phospholipase A2 group 10 (sPLA2-X). A primary epithelial cell culture model was used to model effects of osmotic stress on sPLA2-X. Exercise challenge resulted in increased surfactant degradation, phospholipase activity, and eicosanoid production in sputum samples of all patients. Subjects with EIB had higher levels of surfactant degradation and phospholipase activity in BAL fluid. Higher basal sputum levels of cysteinyl leukotrienes (CysLTs) and prostaglandin D2 (PGD2) were associated with direct AHR, and both the postexercise and absolute change in CysLTs and PGD2 levels were associated with EIB severity. Surfactant function either was abnormal at baseline or became abnormal after exercise challenge. Baseline levels of sPLA2-X in sputum and the absolute change in amount of sPLA2-X with exercise were positively correlated with EIB severity. Osmotic stress ex vivo resulted in movement of water and release of sPLA2-X to the apical surface. In summary, exercise challenge promotes changes in phospholipid structure and eicosanoid release in asthma, providing two mechanisms that promote bronchoconstriction, particularly in individuals with EIB who have higher basal levels of phospholipid turnover.
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Affiliation(s)
- Ryan C Murphy
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington.,Center for Lung Biology, University of Washington, Seattle, Washington
| | - Ying Lai
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington.,Center for Lung Biology, University of Washington, Seattle, Washington
| | - James D Nolin
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington.,Center for Lung Biology, University of Washington, Seattle, Washington
| | - Robier A Aguillon Prada
- Department of Critical Care, Cleveland Clinic, Cleveland, Ohio.,Department of Pathobiology, Cleveland Clinic, Cleveland, Ohio
| | - Arindam Chakrabarti
- Department of Critical Care, Cleveland Clinic, Cleveland, Ohio.,Department of Pathobiology, Cleveland Clinic, Cleveland, Ohio
| | - Michael V Novotny
- Department of Critical Care, Cleveland Clinic, Cleveland, Ohio.,Department of Pathobiology, Cleveland Clinic, Cleveland, Ohio
| | - Michael C Seeds
- Section on Molecular Medicine, Wake Forest University, Winston-Salem, North Carolina
| | - William A Altemeier
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington.,Center for Lung Biology, University of Washington, Seattle, Washington
| | - Michael H Gelb
- Department of Chemistry, University of Washington, Seattle, Washington.,Department of Biochemistry, University of Washington, Seattle, Washington
| | - Robert Duncan Hite
- Division of Pulmonary Disease & Critical Care Medicine, Department of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Teal S Hallstrand
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington.,Center for Lung Biology, University of Washington, Seattle, Washington
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Schindel CS, Schiwe D, Heinzmann-Filho JP, Gheller MF, Campos NE, Pitrez PM, Donadio MVF. Determinants of exercise capacity in children and adolescents with severe therapy-resistant asthma. J Asthma 2020; 59:115-125. [PMID: 33026845 DOI: 10.1080/02770903.2020.1833915] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
OBJECTIVE To evaluate the exercise capacity of children and adolescents with severe therapy resistant asthma (STRA) aiming to identify its main determinants. METHODS Cross-sectional study including individuals aged 6-18 years with a diagnosis of STRA. Clinical (age and gender), anthropometric (weight, height and body mass index) and disease control data were collected. Lung function (spirometry), cardiopulmonary exercise testing (CPET) and exercise-induced bronchoconstriction (EIB) test were performed. RESULTS Twenty-four patients aged 11.5 ± 2.6 years were included. The mean forced expiratory volume in one second (FEV1) was 91.3 ± 9.2%. EIB occurred in 54.2% of patients. In CPET, the peak oxygen uptake (VO2peak) was 34.1 ± 7.8 mL kg-1 min-1. A significant correlation between ventilatory reserve and FEV1 (r = 0.57; p = 0.003) was found. Similarly, there was a significant correlation between CPET and percent of FEV1 fall in the EIB test for both VE/VO2 (r = 0.47; p = 0.02) and VE/VCO2 (r = 0.46; p = 0.02). Patients with FEV1<80% had lower ventilatory reserve (p = 0.009). In addition, resting heart rate correlated with VO2peak (r=-0.40; p = 0.04), VE/VO2 (r = 0.46; p = 0.02) and VE/VCO2 (r = 0.48; p = 0.01). CONCLUSIONS Exercise capacity is impaired in approximately 30% of children and adolescents with STRA. The results indicate that different aspects of aerobic fitness are influenced by distinct determinants, including lung function and EIB.
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Affiliation(s)
- Cláudia Silva Schindel
- Laboratório de Atividade Física em Pediatria, Centro Infant, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, Brazil
| | - Daniele Schiwe
- Laboratório de Atividade Física em Pediatria, Centro Infant, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, Brazil
| | - João Paulo Heinzmann-Filho
- Laboratório de Atividade Física em Pediatria, Centro Infant, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, Brazil
| | - Mailise Fátima Gheller
- Laboratório de Atividade Física em Pediatria, Centro Infant, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, Brazil
| | - Natália Evangelista Campos
- Laboratório de Atividade Física em Pediatria, Centro Infant, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, Brazil
| | - Paulo Márcio Pitrez
- Centro Infant, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS) and Hospital Moinhos de Vento, Porto Alegre, Brazil
| | - Márcio Vinícius Fagundes Donadio
- Laboratório de Atividade Física em Pediatria, Centro Infant, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, Brazil
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6
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Souza de Almeida AH, Rodrigues Filho EDA, Lubambo Costa E, de Albuquerque CG, Sarinho ESC, Medeiros Peixoto D, Dela Bianca ACC, Correia Júnior MAV, Rizzo JÂ. Obesity is a risk factor for exercise-induced bronchospasm in asthmatic adolescents. Pediatr Pulmonol 2020; 55:1916-1923. [PMID: 32462822 DOI: 10.1002/ppul.24875] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 05/26/2020] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Exercise-induced bronchospasm (EIB) is common in young asthmatics and obesity is becoming an epidemic in this population. Both conditions can give rise to or worsen respiratory symptoms upon exercise and may interfere with recreational and sports activities. OBJECTIVE To investigate the association between obesity and the risk and severity of EIB in asthmatic children and adolescents. METHODS This study included data from asthmatic patients aged between 7 and 19 years undergoing treadmill running tests to evaluate EIB, defined as a reduction greater than or equal to 10% in forced expiratory volume in the first second (FEV1 ) compared to baseline. Eutrophic, obese, and overweight individuals were categorized according to body mass index z-score (eutrophic, -0.5 < z ≤ 1; overweight, 1 < z < 2; and obese, z ≥ 2). RESULTS Of the 156 individuals studied (42% female), 58% were eutrophic, 22% overweight, and 19% obese. Seventy-three individuals (47%) presented with EIB, with higher risk among obese (OR, 2.86; 95% CI, 1.00-8.14; P = .05). Asthma severity was another independent risk factor for EIB (OR, 2.95; 95% CI, 1.36-6.42; P = .006). The number of patients in whom FEV1 returned to baseline values (difference less than 10% from baseline) at the 13th minute after challenge was lower in obese individuals compared to eutrophic and overweight ones (P = .04). Baseline FEV1 , gender, or age were not found to be risk factors for EIB in any of the groups. CONCLUSION Obese youngsters with asthma present a greater risk for EIB with slower recovery than their nonobese peers. Clinicians should be aware of this association, especially in those with more severe disease, for adequate recognition and treatment.
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Affiliation(s)
- Anderson H Souza de Almeida
- Health Sciences Post-graduation Program, Universidade Federal de Pernambuco, Recife, Pernambuco, Brazil.,Center for Allergy and Clinical Immunology Research at Hospital das Clínicas, Universidade Federal de Pernambuco, Recife, Pernambuco, Brazil
| | - Edil de Albuquerque Rodrigues Filho
- Center for Allergy and Clinical Immunology Research at Hospital das Clínicas, Universidade Federal de Pernambuco, Recife, Pernambuco, Brazil.,Infant and Adolescent Health Post-graduation Program, Universidade Federal de Pernambuco, Recife, Pernambuco, Brazil
| | - Eduarda Lubambo Costa
- Health Sciences Post-graduation Program, Universidade Federal de Pernambuco, Recife, Pernambuco, Brazil.,Center for Allergy and Clinical Immunology Research at Hospital das Clínicas, Universidade Federal de Pernambuco, Recife, Pernambuco, Brazil
| | - Cláudio G de Albuquerque
- Center for Allergy and Clinical Immunology Research at Hospital das Clínicas, Universidade Federal de Pernambuco, Recife, Pernambuco, Brazil.,Infant and Adolescent Health Post-graduation Program, Universidade Federal de Pernambuco, Recife, Pernambuco, Brazil
| | - Emanuel S C Sarinho
- Health Sciences Post-graduation Program, Universidade Federal de Pernambuco, Recife, Pernambuco, Brazil.,Center for Allergy and Clinical Immunology Research at Hospital das Clínicas, Universidade Federal de Pernambuco, Recife, Pernambuco, Brazil.,Infant and Adolescent Health Post-graduation Program, Universidade Federal de Pernambuco, Recife, Pernambuco, Brazil
| | - Décio Medeiros Peixoto
- Health Sciences Post-graduation Program, Universidade Federal de Pernambuco, Recife, Pernambuco, Brazil.,Center for Allergy and Clinical Immunology Research at Hospital das Clínicas, Universidade Federal de Pernambuco, Recife, Pernambuco, Brazil.,Infant and Adolescent Health Post-graduation Program, Universidade Federal de Pernambuco, Recife, Pernambuco, Brazil
| | - Ana C C Dela Bianca
- Center for Allergy and Clinical Immunology Research at Hospital das Clínicas, Universidade Federal de Pernambuco, Recife, Pernambuco, Brazil.,Infant and Adolescent Health Post-graduation Program, Universidade Federal de Pernambuco, Recife, Pernambuco, Brazil
| | - Marco A V Correia Júnior
- Center for Allergy and Clinical Immunology Research at Hospital das Clínicas, Universidade Federal de Pernambuco, Recife, Pernambuco, Brazil.,Hebiatrics and Physical Education Post-graduation Program, Universidade de Pernambuco, Recife, Pernambuco, Brazil
| | - José Â Rizzo
- Health Sciences Post-graduation Program, Universidade Federal de Pernambuco, Recife, Pernambuco, Brazil.,Center for Allergy and Clinical Immunology Research at Hospital das Clínicas, Universidade Federal de Pernambuco, Recife, Pernambuco, Brazil.,Infant and Adolescent Health Post-graduation Program, Universidade Federal de Pernambuco, Recife, Pernambuco, Brazil
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7
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Greiwe J, Cooke A, Nanda A, Epstein SZ, Wasan AN, Shepard KV, Capão-Filipe M, Nish A, Rubin M, Gregory KL, Dass K, Blessing-Moore J, Randolph C. Work Group Report: Perspectives in Diagnosis and Management of Exercise-Induced Bronchoconstriction in Athletes. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:2542-2555. [PMID: 32636147 DOI: 10.1016/j.jaip.2020.05.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 05/18/2020] [Indexed: 11/26/2022]
Abstract
Exercise-induced bronchoconstriction, otherwise known as exercise-induced bronchoconstriction with asthma or without asthma, is an acute airway narrowing that occurs as a result of exercise and can occur in patients with asthma. A panel of members from the American Academy of Allergy, Asthma & Immunology Sports, Exercise, & Fitness Committee reviewed the diagnosis and management of exercise-induced bronchoconstriction in athletes of all skill levels including recreational athletes, high school and college athletes, and professional athletes. A special emphasis was placed on the recommendations and regulations set forth by professional athletic organizations after a detailed review of their collective bargaining agreements, substance abuse policies, antidoping program manuals, and the World Anti-Doping Agency antidoping code. The recommendations in this review are based on currently available evidence in addition to providing guidance for athletes of all skill levels as well as their treating physicians to better understand which pharmaceutical and nonpharmaceutical management options are appropriate as well as which medications are permitted or prohibited, and the proper documentation required to remain compliant.
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Affiliation(s)
- Justin Greiwe
- Bernstein Allergy Group Inc, Cincinnati, Ohio; Division of Immunology/Allergy Section, Department of Internal Medicine, The University of Cincinnati College of Medicine, Cincinnati, Ohio.
| | - Andrew Cooke
- Lake Allergy, Asthma & Immunology PA, Tavares, Fla
| | - Anil Nanda
- Asthma and Allergy Center, Lewisville and Flower Mound, Texas; Division of Allergy and Immunology, University of Texas Southwestern Medical Center, Dallas, Texas
| | | | | | - Kirk V Shepard
- Division of Allergy and Immunology, Department of Internal Medicine, University of South Florida Morsani College of Medicine and James A. Haley Veterans' Hospital, Tampa, Fla
| | | | - Andy Nish
- Northeast Georgia Physician's Group Allergy and Asthma, Gainesville, Ga
| | - Mark Rubin
- Asthma and COPD Emmi Solutions, Chicago, Ill; CME Education Program Steering Committee, The France Foundation, Old Lyme, Conn
| | - Karen L Gregory
- Oklahoma Allergy and Asthma Clinic, Oklahoma City, Okla; School of Nursing and Health Studies, Georgetown University, Washington, DC
| | - Kathleen Dass
- Michigan Allergy, Asthma & Immunology Center PLLC, Oak Park, Mich; Division of Immunology/Allergy Section, Department of Internal Medicine, Oakland University William Beaumont Hospital, Rochester, Mich
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8
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Keijzer PB, van der Kamp MR, Thio BJ, de Jongh FH, Driessen JM. Assessing paediatric exercise-induced bronchoconstriction using electromyography. ERJ Open Res 2020; 6:00298-2019. [PMID: 32613016 PMCID: PMC7322899 DOI: 10.1183/23120541.00298-2019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 04/22/2020] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Asthma is one of the most common chronic diseases in childhood, occurring in up to 10% of all children. Exercise-induced bronchoconstriction (EIB) is indicative of uncontrolled asthma and can be assessed using an exercise challenge test (ECT). However, this test requires children to undergo demanding repetitive forced breathing manoeuvres. We aimed to study the electrical activity of the diaphragm using surface electromyography (EMG) as an alternative measure to assess EIB. METHODS Forty-two children suspected of EIB performed an ECT wearing a portable EMG amplifier. EIB was defined as a fall in FEV 1 of more than 13%. Children performed spirometry before exercise, and at 1, 3 and 6 min after exercise until the nadir FEV1 was attained and after the use of a bronchodilator. EMG measurements were obtained between spirometry measurements. RESULTS Twenty out of 42 children were diagnosed with EIB. EMG peak amplitudes measured at the diaphragm increased significantly more in children with EIB; 4.85 μV (1.82-7.84), compared to children without EIB; 0.20 μV (-0.10-0.54), (p<0.001) at the lowest FEV 1 post-exercise. Furthermore, the increase in EMG peak amplitude could accurately distinguish between EIB and non-EIB using a cut-off of 1.15 μV (sensitivity 95%, specificity 91%). CONCLUSION EMG measurements of the diaphragm are strongly related to the FEV1 and can accurately identify EIB. EMG measurements are a less invasive, effort-independent measure to assess EIB and could be an alternative when spirometry is not feasible.
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Affiliation(s)
- Pascal B. Keijzer
- Medisch Spectrum Twente, Enschede, the Netherlands
- University of Twente, Enschede, the Netherlands
| | - Mattiènne R. van der Kamp
- Medisch Spectrum Twente, Enschede, the Netherlands
- Roessingh Research and Development, Enschede, the Netherlands
| | | | - Frans H.C. de Jongh
- Medisch Spectrum Twente, Enschede, the Netherlands
- University of Twente, Enschede, the Netherlands
| | - Jean M.M. Driessen
- OCON Sport, Hengelo, the Netherlands
- Tjongerschans Ziekenhuis, Heerenveen, the Netherlands
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9
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Altman MC, Lai Y, Nolin JD, Long S, Chen CC, Piliponsky AM, Altemeier WA, Larmore M, Frevert CW, Mulligan MS, Ziegler SF, Debley JS, Peters MC, Hallstrand TS. Airway epithelium-shifted mast cell infiltration regulates asthmatic inflammation via IL-33 signaling. J Clin Invest 2019; 129:4979-4991. [PMID: 31437129 PMCID: PMC6819127 DOI: 10.1172/jci126402] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Accepted: 08/07/2019] [Indexed: 12/21/2022] Open
Abstract
Asthma is a heterogeneous syndrome that has been subdivided into physiologic phenotypes and molecular endotypes. The most specific phenotypic manifestation of asthma is indirect airway hyperresponsiveness (AHR), and a prominent molecular endotype is the presence of type 2 inflammation. The underlying basis for type 2 inflammation and its relationship to AHR are incompletely understood. We assessed the expression of type 2 cytokines in the airways of subjects with and without asthma who were extensively characterized for AHR. Using quantitative morphometry of the airway wall, we identified a shift in mast cells from the submucosa to the airway epithelium specifically associated with both type 2 inflammation and indirect AHR. Using ex vivo modeling of primary airway epithelial cells in organotypic coculture with mast cells, we show that epithelial-derived IL-33 uniquely induced type 2 cytokines in mast cells, which regulated the expression of epithelial IL33 in a feed-forward loop. This feed-forward loop was accentuated in epithelial cells derived from subjects with asthma. These results demonstrate that type 2 inflammation and indirect AHR in asthma are related to a shift in mast cell infiltration to the airway epithelium, and that mast cells cooperate with epithelial cells through IL-33 signaling to regulate type 2 inflammation.
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Affiliation(s)
| | - Ying Lai
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - James D. Nolin
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Sydney Long
- Division of Allergy and Infectious Diseases and
| | - Chien-Chang Chen
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Adrian M. Piliponsky
- Center for Immunity and Immunotherapies, Seattle Children’s Research Institute, Seattle, Washington, USA
| | - William A. Altemeier
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Megan Larmore
- Department of Comparative Medicine, University of Washington, Seattle, Washington, USA
| | - Charles W. Frevert
- Department of Comparative Medicine, University of Washington, Seattle, Washington, USA
| | - Michael S. Mulligan
- Division of Cardiothoracic Surgery, Department of Surgery, University of Washington, Seattle, Washington, USA
| | - Steven F. Ziegler
- Immunology Program, Benaroya Research Institute, Seattle, Washington, USA
| | - Jason S. Debley
- Center for Immunity and Immunotherapies, Seattle Children’s Research Institute, Seattle, Washington, USA
- Division of Pulmonary and Sleep Medicine, Department of Pediatrics, University of Washington, Seattle, Washington, USA
| | - Michael C. Peters
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, UCSF, San Francisco, California, USA
| | - Teal S. Hallstrand
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington, USA
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10
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Barreto M, Capi M, Lionetto L, Caiazzo I, Salerno G, Cardelli P, Simmaco M, Villa MP. Urinary and exhaled biomarkers of exercise-induced bronchoconstriction in atopic asthmatic children. Pediatr Pulmonol 2019; 54:1447-1456. [PMID: 31218848 DOI: 10.1002/ppul.24419] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Revised: 05/07/2019] [Accepted: 05/28/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND Exercise-induced bronchoconstriction (EIB) reflects poor asthma control. Assessing noninvasive biomarkers associated with EIB could help to monitor patients in the pediatric age. AIMS To test exhaled and urinary biomarkers for assessing EIB in atopic asthmatic children. METHODS In 45 atopic patients (11.1 ± 1.8 years, 25 males) we measured the fractional exhaled nitric oxide (FENO ), its alveolar (CaNO), and bronchial (J'awNO) components corrected for the trumpet shape of the airways and axial NO diffusion (TMAD), concentrations of urinary adenosine and 8-hydroxy-2'-deoxyguanosine (8-OxodG), blood eosinophils count, total immunoglobulin E , skin prick tests, and baseline spirometry before a treadmill exercise challenge. Forty healthy control subjects participated solely to baseline measurements. RESULTS Patients yielded higher FENO and urinary adenosine concentrations than healthy controls. After the challenge, 18 patients (40%) had EIB; these patients had higher levels of CaNO, CaNO TMAD, and urinary adenosine than patients without EIB. Baseline spirometry, FE NO , JawNO, JawNO TMAD, urinary 8-OxodG, allergy, and blood eosinophil counts were found similar in both groups. In multiple linear regression, the fall in FEV 1 was explained by CaNO TMAD, urinary adenosine and blood eosinophil count, whereas the fall in FEF 25-75 was explained by CaNO TMAD and blood eosinophil count. Both CaNO TMAD ≥10.5 ppb and urinary adenosine ≥406 nmol/mmol Cr predicted a fall in FEV 1 ≥10%, while only CaNO TMAD ≥10.5 ppb predicted a fall in FEF 25-75 ≥26%. CONCLUSION Concentrations of peripheral airway NO are complementary with urinary adenosine for assessing EIB and promising tools of asthma control in pediatric patients with the atopic phenotype.
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Affiliation(s)
- Mario Barreto
- Pediatric Unit Sant'Andrea Hospital, NESMOS Department, Faculty of Medicine and Psychology, Sapienza University, Rome, Italy
| | - Matilde Capi
- Analytical Laboratory - Clinical Biochemistry Unit, Sant'Andrea University Hospital, Rome, Sapienza, Italy
| | - Luana Lionetto
- Analytical Laboratory - Clinical Biochemistry Unit, Sant'Andrea University Hospital, Rome, Sapienza, Italy
| | - Ilaria Caiazzo
- Pediatric Unit Sant'Andrea Hospital, NESMOS Department, Faculty of Medicine and Psychology, Sapienza University, Rome, Italy
| | - Gerardo Salerno
- Analytical Laboratory - Clinical Biochemistry Unit, Sant'Andrea University Hospital, Rome, Sapienza, Italy
| | - Patrizia Cardelli
- Analytical Laboratory - Clinical Biochemistry Unit, Sant'Andrea University Hospital, Rome, Sapienza, Italy
| | - Maurizio Simmaco
- Analytical Laboratory - Clinical Biochemistry Unit, Sant'Andrea University Hospital, Rome, Sapienza, Italy
| | - Maria Pia Villa
- Pediatric Unit Sant'Andrea Hospital, NESMOS Department, Faculty of Medicine and Psychology, Sapienza University, Rome, Italy
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11
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Kippelen P, Anderson SD, Hallstrand TS. Mechanisms and Biomarkers of Exercise-Induced Bronchoconstriction. Immunol Allergy Clin North Am 2019; 38:165-182. [PMID: 29631728 DOI: 10.1016/j.iac.2018.01.008] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Exercise is a common trigger of bronchoconstriction. In recent years, there has been increased understanding of the pathophysiology of exercise-induced bronchoconstriction. Although evaporative water loss and thermal changes have been recognized stimuli for exercise-induced bronchoconstriction, accumulating evidence points toward a pivotal role for the airway epithelium in orchestrating the inflammatory response linked to exercise-induced bronchoconstriction. Overproduction of inflammatory mediators, underproduction of protective lipid mediators, and infiltration of the airways with eosinophils and mast cells are all established contributors to exercise-induced bronchoconstriction. Sensory nerve activation and release of neuropeptides maybe important in exercise-induced bronchoconstriction, but further research is warranted.
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Affiliation(s)
- Pascale Kippelen
- Department of Life Sciences, Division of Sport, Health and Exercise Sciences, Centre for Human Performance, Exercise and Rehabilitation, Brunel University London, Kingston Lane, Uxbridge UB8 3PH, UK
| | - Sandra D Anderson
- Central Clinical School, Sydney Medical School, University of Sydney, Parramatta Road, Sydney New South Wales 2006, Australia.
| | - Teal S Hallstrand
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, Center for Lung Biology, University of Washington, Box 358052, 850 Republican Street, Seattle, WA 98109-4714, USA
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12
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Lammers N, van Hoesel MHT, Kamphuis M, Brusse-Keizer M, van der Palen J, Visser R, Thio BJ, Driessen JMM. Assessing Exercise-Induced Bronchoconstriction in Children; The Need for Testing. Front Pediatr 2019; 7:157. [PMID: 31106184 PMCID: PMC6498950 DOI: 10.3389/fped.2019.00157] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Accepted: 04/03/2019] [Indexed: 11/13/2022] Open
Abstract
Objective: Exercise-induced bronchoconstriction (EIB) is a specific morbidity of childhood asthma and a sign of insufficient disease control. EIB is diagnosed and monitored based on lung function changes after a standardized exercise challenge test (ECT). In daily practice however, EIB is often evaluated with self-reported respiratory symptoms and spirometry. We aimed to study the capacity of pediatricians to predict EIB based on information routinely available during an outpatient clinic visit. Methods: A clinical assessment was performed in 20 asthmatic children (mean age 11.6 years) from the outpatient clinic of the MST hospital from May 2015 to July 2015. During this assessment, video images were made. EIB was measured with a standardized ECT performed in cold, dry air. Twenty pediatricians (mean years of experience 14.4 years) each evaluated five children, providing 100 evaluations, and predicted EIB severity based on their medical history, physical examination, and video images. EIB severity was predicted again after additionally providing baseline spirometry results. Results: Nine children showed no EIB, four showed mild EIB, two showed moderate, and five showed severe EIB. Based on clinical information and spirometry results, pediatricians detected EIB with a sensitivity of 84% (95% CI 72-91%) and a specificity of 24% (95% CI 14-39%).The agreement between predicted EIB severity classifications and the validated classifications after the ECT was slight [Kappa = 0.05 (95% CI 0.00-0.17)]. This agreement still remained slight when baseline spirometry results were provided [Kappa = 0.19 (95% CI 0.06-0.32)]. Conclusion: Pediatricians' prediction of EIB occurrence was sensitive, but poorly specific. The prediction of EIB severity was poor. Pediatricians should be aware of this in order to prevent misjudgement of EIB severity and disease control.
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Affiliation(s)
- Natasja Lammers
- Department of Pediatrics, Medisch Spectrum Twente, Enschede, Netherlands
| | | | - Marije Kamphuis
- Faculty of Science and Technology, University of Twente, Enschede, Netherlands
| | | | - Job van der Palen
- Medical School Twente, Medisch Spectrum Twente, Enschede, Netherlands.,Department of Research Methodology, Measurement and Data Analysis, University of Twente, Enschede, Netherlands
| | - Reina Visser
- Department of Pediatrics, Medisch Spectrum Twente, Enschede, Netherlands
| | - Boony J Thio
- Department of Pediatrics, Medisch Spectrum Twente, Enschede, Netherlands
| | - Jean M M Driessen
- OCON Sport, Ziekenhuisgroep Twente, Hengelo, Netherlands.,Department of Sportsmedicine, Tjongerschans Hospital, Heerenveen, Netherlands
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13
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Hallstrand TS, Leuppi JD, Joos G, Hall GL, Carlsen KH, Kaminsky DA, Coates AL, Cockcroft DW, Culver BH, Diamant Z, Gauvreau GM, Horvath I, de Jongh FHC, Laube BL, Sterk PJ, Wanger J. ERS technical standard on bronchial challenge testing: pathophysiology and methodology of indirect airway challenge testing. Eur Respir J 2018; 52:13993003.01033-2018. [PMID: 30361249 DOI: 10.1183/13993003.01033-2018] [Citation(s) in RCA: 78] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Accepted: 07/20/2018] [Indexed: 12/20/2022]
Abstract
Recently, this international task force reported the general considerations for bronchial challenge testing and the performance of the methacholine challenge test, a "direct" airway challenge test. Here, the task force provides an updated description of the pathophysiology and the methods to conduct indirect challenge tests. Because indirect challenge tests trigger airway narrowing through the activation of endogenous pathways that are involved in asthma, indirect challenge tests tend to be specific for asthma and reveal much about the biology of asthma, but may be less sensitive than direct tests for the detection of airway hyperresponsiveness. We provide recommendations for the conduct and interpretation of hyperpnoea challenge tests such as dry air exercise challenge and eucapnic voluntary hyperpnoea that provide a single strong stimulus for airway narrowing. This technical standard expands the recommendations to additional indirect tests such as hypertonic saline, mannitol and adenosine challenge that are incremental tests, but still retain characteristics of other indirect challenges. Assessment of airway hyperresponsiveness, with direct and indirect tests, are valuable tools to understand and to monitor airway function and to characterise the underlying asthma phenotype to guide therapy. The tests should be interpreted within the context of the clinical features of asthma.
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Affiliation(s)
- Teal S Hallstrand
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, WA, USA
| | - Joerg D Leuppi
- University Clinic of Medicine, Cantonal Hospital Baselland, Liestal, and Medical Faculty University of Basel, Basel, Switzerland
| | - Guy Joos
- Dept of Respiratory Medicine, University of Ghent, Ghent, Belgium
| | - Graham L Hall
- Children's Lung Health, Telethon Kids Institute, School of Physiotherapy and Exercise Science, Curtin University, and Centre for Child Health Research University of Western Australia, Perth, Australia
| | - Kai-Håkon Carlsen
- University of Oslo, Institute of Clinical Medicine, and Oslo University Hospital, Division of Child and Adolescent Medicine, Oslo, Norway
| | - David A Kaminsky
- Pulmonary and Critical Care, University of Vermont College of Medicine, Burlington, VT, USA
| | - Allan L Coates
- Division of Respiratory Medicine, Translational Medicine, Research Institute-Hospital for Sick Children, University of Toronto, ON, Canada
| | - Donald W Cockcroft
- Division of Respirology, Critical Care and Sleep Medicine, Royal University Hospital, Saskatoon, SK, Canada
| | - Bruce H Culver
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, WA, USA
| | - Zuzana Diamant
- Dept of Clinical Pharmacy and Pharmacology and QPS-Netherlands, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands.,Dept of Respiratory Medicine and Allergology, Lund University, Lund, Sweden
| | - Gail M Gauvreau
- Division of Respirology, Dept of Medicine, McMaster University, Hamilton, ON, Canada
| | - Ildiko Horvath
- Dept of Pulmonology, National Korányi Institute of Pulmonology, Budapest, Hungary
| | - Frans H C de Jongh
- Dept of Pulmonary Medicine, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Beth L Laube
- Division of Pediatric Pulmonology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Peter J Sterk
- Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Jack Wanger
- Pulmonary Function Testing and Clinical Trials Consultant, Rochester, MN, USA
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14
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Albuquerque Rodrigues Filho ED, Rizzo JÂ, Gonçalves AV, Correia Junior MADV, Sarinho ESC, Medeiros D. Exercise-induced bronchospasm in children and adolescents with allergic rhinitis by treadmill and hyperventilation challenges. Respir Med 2018; 138:102-106. [PMID: 29724380 DOI: 10.1016/j.rmed.2018.04.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Revised: 03/18/2018] [Accepted: 04/01/2018] [Indexed: 01/19/2023]
Abstract
BACKGROUND Respiratory complaints after exercise are common in patients with rhinitis. Exercise-induced bronchospasm (EIB) may be one of the causes. OBJECTIVES To evaluate EIB prevalence in a group of children and adolescents with allergic rhinitis, to compare the treadmill running (TR) and eucapnic voluntary hyperventilation (EVH) challenge methods as diagnostic tools and to assess the association between respiratory complaints on exercise and EIB. METHODS Patients aged between 10 and 20 years were studied at the Pulmonology Department of the Hospital das Clínicas -UFPE- Recife, Brazil. The severity of symptoms of rhinitis and exercise-related respiratory complaints in the past year were evaluated. Challenges were performed in random sequence, no more than 72 h apart and followed international guidelines. Forced expiratory volume in the first second (FEV1) was determined before and 3, 5, 7, 10, 15 and 30 min after each challenge. A >10% reduction in FEV1 from baseline at two points after the challenge was considered sufficient to diagnose EIB. RESULTS Of the thirty-five subjects evaluated, thirteen (37%) showed EIB, six by both methods, three only after TR and four only after EVH (Coens' Kappa = 0.489). There was no association between respiratory complaints after exercise and EIB (p = 0.74). CONCLUSION A high prevalence of EIB was found in this population but only moderate agreement between the challenges used to diagnose EIB. Caution should be adopted when comparing these methods or interpreting their results interchangeably. There was no association between reported respiratory symptoms after exercise and EIB.
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Affiliation(s)
- Edil de Albuquerque Rodrigues Filho
- Health Sciences Postgraduate Course, Universidade Federal de Pernambuco, Recife, Pernambuco, Brazil; Child and Adolescent Health Postgraduate Course, Universidade Federal de Pernambuco, Recife, Pernambuco, Brazil
| | - José Ângelo Rizzo
- Health Sciences Postgraduate Course, Universidade Federal de Pernambuco, Recife, Pernambuco, Brazil; Pneumology Department, Clinical Hospital, Federal University of Pernambuco, Recife, Brazil; Center for Research in Allergy and Clinical Immunology, Clinical Hospital, Federal University of Pernambuco, Recife, Brazil; Child and Adolescent Health Postgraduate Course, Universidade Federal de Pernambuco, Recife, Pernambuco, Brazil.
| | - Adriana Velozo Gonçalves
- Health Sciences Postgraduate Course, Universidade Federal de Pernambuco, Recife, Pernambuco, Brazil
| | - Marco Aurélio de Valois Correia Junior
- Health Sciences Postgraduate Course, Universidade Federal de Pernambuco, Recife, Pernambuco, Brazil; Center for Research in Allergy and Clinical Immunology, Clinical Hospital, Federal University of Pernambuco, Recife, Brazil; Child and Adolescent Health Postgraduate Course, Universidade Federal de Pernambuco, Recife, Pernambuco, Brazil; Postgraduate Course in Hebiatrics and Physical Education at the University of Pernambuco, Recife, Pernambuco, Brazil
| | - Emanuel Sávio Cavalcanti Sarinho
- Health Sciences Postgraduate Course, Universidade Federal de Pernambuco, Recife, Pernambuco, Brazil; Center for Research in Allergy and Clinical Immunology, Clinical Hospital, Federal University of Pernambuco, Recife, Brazil; Child and Adolescent Health Postgraduate Course, Universidade Federal de Pernambuco, Recife, Pernambuco, Brazil
| | - Décio Medeiros
- Health Sciences Postgraduate Course, Universidade Federal de Pernambuco, Recife, Pernambuco, Brazil; Center for Research in Allergy and Clinical Immunology, Clinical Hospital, Federal University of Pernambuco, Recife, Brazil; Child and Adolescent Health Postgraduate Course, Universidade Federal de Pernambuco, Recife, Pernambuco, Brazil
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15
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de Aguiar KB, Anzolin M, Zhang L. Global prevalence of exercise-induced bronchoconstriction in childhood: A meta-analysis. Pediatr Pulmonol 2018; 53:412-425. [PMID: 29364581 DOI: 10.1002/ppul.23951] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 01/03/2018] [Indexed: 11/10/2022]
Abstract
AIM This systematic review and meta-analysis aimed to estimate the global prevalence of exercise-induced bronchoconstriction (EIB) in children and adolescents. METHOD We searched PubMed, Google Scholar, and the Virtual Health Library-BIREME from inception to December 23, 2017. We selected observational studies that reported the prevalence of EIB (diagnosed by exercise challenge test) in children and adolescents aged 5-18 years. We conducted random-effects meta-analyses to estimate the pooled prevalence of EIB and 95% CI. RESULTS We included 66 studies (55 696 participants, 5670 cases of EIB) in the review, of which 33 in general population of children and adolescents, 10 in child and adolescent athletes and 23 in children and adolescents with asthma. The global mean prevalence of EIB in the general population of children and adolescents was 9% (IC95%: 8-10%), with a higher rate (12%) in Asia-Pacific and America. The mean prevalence of EIB was 15% (95% CI: 9-21%) in child and adolescent athletes, and 46% (95% CI: 39-53%) in children and adolescents with asthma. We estimated that, globally, around 16.5 million (95% CI: 15-18 million) children and adolescents up to 18 years of age may have EIB. CONCLUSION EIB in childhood should be considered as a global public health problem that needs more attention. The substantial heterogeneity between studies highlights the need for evidence-based guidelines for diagnosis of EIB in this age group.
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Affiliation(s)
- Karine B de Aguiar
- Postgraduate Program in Health Sciences, Faculty of Medicine, Federal University of Rio Grande, Rio Grande, Brazil
| | - Marina Anzolin
- Faculty of Medicine, Federal University of Rio Grande, Rio Grande, Brazil
| | - Linjie Zhang
- Postgraduate Program in Health Sciences and Postgraduate Program in Public Health, Faculty of Medicine, Federal University of Rio Grande, Rio Grande-RS, Brazil
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16
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van Veen WJ, Driessen JMM, Kersten ETG, van Leeuwen JC, Brusse-Keizer MGJ, van Aalderen WMC, Thio BJ. BMI predicts exercise induced bronchoconstriction in asthmatic boys. Pediatr Pulmonol 2017; 52:1130-1134. [PMID: 28696535 DOI: 10.1002/ppul.23758] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Accepted: 06/13/2017] [Indexed: 01/28/2023]
Abstract
BACKGROUND Exercise induced bronchoconstriction (EIB) is a frustrating morbidity of asthma in children. Obesity has been associated with asthma and with more severe EIB in asthmatic children. OBJECTIVES To quantify the effect of BMI on the risk of the occurrence of EIB in children with asthma. METHODS Data were collected from six studies in which exercise challenge tests were performed according to international guidelines. We included 212 Children aged 7-18 years, with a pediatrician-diagnosed mild-to-moderate asthma. RESULTS A total of 103 of 212 children (49%) had a positive exercise challenge (fall of FEV1 ≥ 13%). The severity of EIB, as measured by the maximum fall in FEV1 , was significantly greater in overweight and obese children compared to normal weight children (respectively 23.9% vs 17.9%; P = 0.045). Asthmatic children with a BMI z-score around +1 had a 2.9-fold higher risk of the prevalence of EIB compared to children with a BMI z-score around the mean (OR 2.9; 95%CI: 1.3-6.1; P < 0.01). An increase in BMI z-score of 0.1 in boys led to a 1.4-fold increased risk of EIB (OR 1.4; 95%CI: 1.0-1.9; P = 0.03). A reduction in pre-exercise FEV1 was associated with a higher risk of EIB (last quartile six times higher risk compared to highest quartile (OR 6.1 [95%CI 2.5-14.5]). CONCLUSIONS The severity of EIB is significantly greater in children with overweight and obesity compared to non-overweight asthmatic children. Furthermore, this study shows that the BMI-z-score, even with a normal weight, is strongly associated with the incidence of EIB in asthmatic boys.
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Affiliation(s)
- Wilma J van Veen
- Department of Pediatrics, Medisch Spectrum Twente, Enschede, The Netherlands.,University of Groningen, University Medical Center Groningen, Beatrix Children's Hospital, Groningen, The Netherlands
| | - Jean M M Driessen
- Department of Sportsmedicine, Tjongerschans Hospital, Heerenveen, The Netherlands.,Department of Sportsmedicine, OCON-Sport, Hengelo, The Netherlands
| | - Elin T G Kersten
- Department of Pediatrics, Medisch Spectrum Twente, Enschede, The Netherlands.,University of Groningen, University Medical Center Groningen, Beatrix Children's Hospital, Groningen, The Netherlands
| | - Janneke C van Leeuwen
- Department of Pediatrics, Medisch Spectrum Twente, Enschede, The Netherlands.,University of Groningen, University Medical Center Groningen, Beatrix Children's Hospital, Groningen, The Netherlands
| | | | - Wim M C van Aalderen
- Department of Pediatrics Respiratory Medicine and Allergy, Emma Children's Hospital-Academic Medical Center, Amsterdam, The Netherlands
| | - Bernard J Thio
- Department of Pediatrics, Medisch Spectrum Twente, Enschede, The Netherlands.,Medical School Twente, Medisch Spectrum Twente, Enschede, The Netherlands
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17
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Demoulin-Alexikova S, Marchal F, Bonabel C, Demoulin B, Foucaud L, Coutier-Marie L, Schweitzer CE, Ioan I. Down-Regulation of Cough during Exercise Is Less Frequent in Healthy Children than Adults. Role of the Development and/or Atopy? Front Physiol 2017; 8:304. [PMID: 28567019 PMCID: PMC5434114 DOI: 10.3389/fphys.2017.00304] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Accepted: 04/27/2017] [Indexed: 11/18/2022] Open
Abstract
Cough is typically associated with physical activity in children with asthma, but the characteristics of the relationship between cough and exercise has not been established under physiological conditions. The aim of the study was to describe the effect of exercise on the reflex cough response elicited by a single breath of capsaicin in non-asthmatic children. A group of non-asthmatic adults was studied as reference. Thirty children and 29 adults were recruited. The cough reflex sensitivity to capsaicin was first determined to establish the dose that provokes 5 cough efforts (C5). The number of coughs elicited by C5 (NC5) was then compared at baseline and during a standardized submaximal treadmill exercise. Data are expressed as median (interquartile range). Children and adults showed a significant decrease in NC5 (respectively from 5.0 (4.0–6.0) to 2.5 (2.0–4.0), p < 0.0005 and from 6.0 (5.0–7.0) to 2.0 (0.0–3.0, p < 0.0005). During exercise, NC5 was observed to decrease in all adult subjects, but in only 24/30 children (80%, p = 0.02). A trend for a higher incidence of personal and familial atopy was observed in children that lacked cough down-regulation during exercise compared with other children. It is concluded that the cough reflex response to capsaicin is down regulated by exercise in both children and adults. The effect however is less consistently observed in the former. The difference may reflect maturation of descending inhibitory pathways of the cough reflex, but may also be associated to atopy. The data stress the importance of assessing the time relationship of cough and exercise in questionnaire studies of asthma.
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Affiliation(s)
- Silvia Demoulin-Alexikova
- EA 3450 DevAH - Laboratoire de Physiologie, Faculty of Medicine, University of LorraineVandœuvre-lès-Nancy, France.,Service d'Explorations Fonctionnelles Pédiatriques, Hôpital d'enfants de Brabois - CHRU de NancyVandoeuvre-lès-Nancy, France
| | - François Marchal
- EA 3450 DevAH - Laboratoire de Physiologie, Faculty of Medicine, University of LorraineVandœuvre-lès-Nancy, France.,Service d'Explorations Fonctionnelles Pédiatriques, Hôpital d'enfants de Brabois - CHRU de NancyVandoeuvre-lès-Nancy, France
| | - Claude Bonabel
- Service d'Explorations Fonctionnelles Pédiatriques, Hôpital d'enfants de Brabois - CHRU de NancyVandoeuvre-lès-Nancy, France
| | - Bruno Demoulin
- EA 3450 DevAH - Laboratoire de Physiologie, Faculty of Medicine, University of LorraineVandœuvre-lès-Nancy, France
| | - Laurent Foucaud
- EA 3450 DevAH - Laboratoire de Physiologie, Faculty of Medicine, University of LorraineVandœuvre-lès-Nancy, France
| | - Laurianne Coutier-Marie
- EA 3450 DevAH - Laboratoire de Physiologie, Faculty of Medicine, University of LorraineVandœuvre-lès-Nancy, France.,Service d'Explorations Fonctionnelles Pédiatriques, Hôpital d'enfants de Brabois - CHRU de NancyVandoeuvre-lès-Nancy, France
| | - Cyril E Schweitzer
- EA 3450 DevAH - Laboratoire de Physiologie, Faculty of Medicine, University of LorraineVandœuvre-lès-Nancy, France.,Service d'Explorations Fonctionnelles Pédiatriques, Hôpital d'enfants de Brabois - CHRU de NancyVandoeuvre-lès-Nancy, France
| | - Iulia Ioan
- EA 3450 DevAH - Laboratoire de Physiologie, Faculty of Medicine, University of LorraineVandœuvre-lès-Nancy, France.,Service d'Explorations Fonctionnelles Pédiatriques, Hôpital d'enfants de Brabois - CHRU de NancyVandoeuvre-lès-Nancy, France
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18
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Weiler JM, Brannan JD, Randolph CC, Hallstrand TS, Parsons J, Silvers W, Storms W, Zeiger J, Bernstein DI, Blessing-Moore J, Greenhawt M, Khan D, Lang D, Nicklas RA, Oppenheimer J, Portnoy JM, Schuller DE, Tilles SA, Wallace D. Exercise-induced bronchoconstriction update-2016. J Allergy Clin Immunol 2016; 138:1292-1295.e36. [PMID: 27665489 DOI: 10.1016/j.jaci.2016.05.029] [Citation(s) in RCA: 101] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Revised: 05/13/2016] [Accepted: 05/25/2016] [Indexed: 12/26/2022]
Abstract
The first practice parameter on exercise-induced bronchoconstriction (EIB) was published in 2010. This updated practice parameter was prepared 5 years later. In the ensuing years, there has been increased understanding of the pathogenesis of EIB and improved diagnosis of this disorder by using objective testing. At the time of this publication, observations included the following: dry powder mannitol for inhalation as a bronchial provocation test is FDA approved however not currently available in the United States; if baseline pulmonary function test results are normal to near normal (before and after bronchodilator) in a person with suspected EIB, then further testing should be performed by using standardized exercise challenge or eucapnic voluntary hyperpnea (EVH); and the efficacy of nonpharmaceutical interventions (omega-3 fatty acids) has been challenged. The workgroup preparing this practice parameter updated contemporary practice guidelines based on a current systematic literature review. The group obtained supplementary literature and consensus expert opinions when the published literature was insufficient. A search of the medical literature on PubMed was conducted, and search terms included pathogenesis, diagnosis, differential diagnosis, and therapy (both pharmaceutical and nonpharmaceutical) of exercise-induced bronchoconstriction or exercise-induced asthma (which is no longer a preferred term); asthma; and exercise and asthma. References assessed as relevant to the topic were evaluated to search for additional relevant references. Published clinical studies were appraised by category of evidence and used to document the strength of the recommendation. The parameter was then evaluated by Joint Task Force reviewers and then by reviewers assigned by the parent organizations, as well as the general membership. Based on this process, the parameter can be characterized as an evidence- and consensus-based document.
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Riiser A. Bronchial hyperresponsiveness in childhood: A narrative review. World J Respirol 2016; 6:63-68. [DOI: 10.5320/wjr.v6.i2.63] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2015] [Revised: 02/02/2016] [Accepted: 03/23/2016] [Indexed: 02/06/2023] Open
Abstract
Bronchial hyperresponsiveness (BHR) is an important but not asthma-specific characteristic and can be assessed by direct and indirect methods, based on the stimulus causing airway obstruction. BHR has been proposed as a prognostic marker of asthma severity and persistence, and may also be used to control pharmacological management of asthma. The most recent data on the prevalence and development of BHR in childhood and its predictive value for subsequent asthma development in late adolescence and adulthood is discussed in this review. According to the BHR-related scientific articles written in the English language and indexed in the publicly searchable PubMed database, the prevalence of BHR varies based upon the methods used to assess it and the population examined. In general, however, BHR prevalence is reduced as children grow older, in both healthy and asthmatic populations. While asthma can be predicted by BHR, the predictive value is limited. Reduced lung function, allergic sensitization, female sex, and early respiratory illness have been identified as risk factors for BHR. The collective studies further indicate that BHR is a dynamic feature related to asthma, but asymptomatic BHR is also common. Ultimately, the prevalence of BHR varies depending on the population, the environment, and the evaluation methods used. While both the methacholine challenge and the exercise test may predict asthma in adolescence or early adulthood, the predictive value is higher for the methacholine challenge compared to the exercise test. The collective data presented in the present study demonstrate how BHR develops through childhood and its relation to bronchial asthma.
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Johansson H, Norlander K, Janson C, Malinovschi A, Nordang L, Emtner M. The relationship between exercise induced bronchial obstruction and health related quality of life in female and male adolescents from a general population. BMC Pulm Med 2016; 16:63. [PMID: 27117559 PMCID: PMC4847200 DOI: 10.1186/s12890-016-0226-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Accepted: 04/14/2016] [Indexed: 11/14/2022] Open
Abstract
Background Previous studies have observed that exercise-induced bronchoconstriction (EIB) is more common and more strongly related to exercise related breathing problems in female adolescents than male adolescents. However, few studies have investigated the association between EIB and health related quality of life (HRQoL) from a gender perspective. The aim of this study was to examine the association between EIB and HRQoL and physical activity level in female and male adolescents with and without EIB. Methods From a population based study on exercise-induced breathing problems among adolescents (13–15 years, n = 3838) a cross sectional study with prospective data collection was carried out in a random subsample of 140 adolescents. The subjects in the sample were tested for EIB with a standardised exercise test, of which 49 adolescents were tested positive. HRQoL was assessed with the Pediatric Quality of Life Inventory (PedsQL) and the adolescents’ physical activity levels were measured objectively with accelerometer. Results The female subjects with EIB reported a lower HRQoL, both in total score (p = 0.03) and physical functioning score (p = 0.009) and had a lower baseline FEV1 compared to females without EIB (88 vs. 94 % predicted, p = 0.001). No differences were found in HRQoL or baseline lung function between males with or without EIB. There were no differences in minutes of moderate to vigorous physical activity per day between females or males with and without EIB. Conclusion In a general population, the female adolescents with EIB had lower HRQoL and poorer baseline lung function compared to counterparts without EIB. These differences were not observed in males. EIB does not appear to affect the level of daily physical activity neither in females nor males.
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Affiliation(s)
- Henrik Johansson
- Neuroscience/Physiotherapy, Uppsala University, Uppsala, Sweden.
| | - Katarina Norlander
- Surgical Sciences: Otolaryngology and Head & Neck Surgery, Uppsala University, Uppsala, Sweden
| | - Christer Janson
- Medical Sciences, Lung- allergy- and sleep research, Uppsala University, Uppsala, Sweden
| | - Andrei Malinovschi
- Medical Sciences, Clinical Physiology, Uppsala University, Uppsala, Sweden
| | - Leif Nordang
- Surgical Sciences: Otolaryngology and Head & Neck Surgery, Uppsala University, Uppsala, Sweden
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21
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Tripodi S, Barreto M, Di Rienzo-Businco A, Grossi O, Sfika I, Ragusa G, Campisano M, Miceli-Sopo S. Asthma Control Test and Bronchial Challenge with Exercise in Pediatric Asthma. Front Pediatr 2016; 4:16. [PMID: 27014666 PMCID: PMC4782564 DOI: 10.3389/fped.2016.00016] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Accepted: 02/22/2016] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Poor asthma control can lead to exercise-induced bronchoconstriction (EIB), but the relationship between subjective disease control and EIB is unclear. No studies have compared asthma control test (ACT) scores of children with those of their parents regarding EIB. We assessed whether ACT scores predict the occurrence of EIB in two age groups. We also evaluated ACT scores and objective measures as explanatory variables for airway response to exercise. METHODS Patients (71, aged <12 years; 93, aged ≥12 years) and their parents completed an ACT questionnaire separately. Current therapy, skin prick testing, and spirometry at baseline and after exercise were assessed. EIB was defined as a fall in forced expiratory volume in 1 s (FEV1) of at least 12% from baseline. Sensitivity and specificity for cut-off values of ACT scores predictive of EIB were plotted, and the area under curve (AUC) was described. RESULTS Atopy and current therapy were similarly frequent. EIB was observed in 23.9% of children aged <12 years and in 33.3% of children aged ≥12 years. EIB occurrence in subjects previously scored as having full control (25), partial control (20-24), and no control (<20) varied according to the age group and responders. Percentages of EIB cases increased as ACT scores decreased in children aged ≥12 years alone (child ACT scores, 25: 21.9%, 20-24: 31.1%, <20: 62.5%, p = 0.017). Plots for ACT scores as predictors of EIB yielded low non-significant AUC values in children aged <12 years; in contrast, moderate AUC values emerged in children aged ≥12 years (child: 0.67, p = 0.007; parent: 0.69, p = 0.002). Sensitivity of ACT scores below 20 as a predictor of EIB was low in older children (child: 32.3%, parent: 22.6%), whereas specificity was high (child: 90.3%, parent: 93.5%). Multiple regression analysis with percent fall in FEV1 as dependent variable included FEV1/FVC%, ACT child score, and gender in the prediction model (r = 0.42, p = 0.000). CONCLUSION ACT scores are a more effective means of excluding than confirming EIB in asthmatic patients aged ≥12 years; their predictive value decreases in younger patients. ACT scores together with lung function may help to predict airway response to exercise. New tools for pediatric asthma assessment may optimize this association.
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Affiliation(s)
- Salvatore Tripodi
- Allergy Pediatric Unit, Pediatrics Department, Sandro Pertini Hospital , Rome , Italy
| | - Mario Barreto
- NESMOS Department, Faculty of Medicine and Psychology, Pediatric Unit Sant'Andrea Hospital, "Sapienza" University , Rome , Italy
| | | | - Oriano Grossi
- Allergy Pediatric Unit, Pediatrics Department, Sandro Pertini Hospital , Rome , Italy
| | - Ifigenia Sfika
- Allergy Pediatric Unit, Pediatrics Department, Sandro Pertini Hospital , Rome , Italy
| | - Giovanni Ragusa
- Allergy Pediatric Unit, Pediatrics Department, Sandro Pertini Hospital , Rome , Italy
| | - Martina Campisano
- NESMOS Department, Faculty of Medicine and Psychology, Pediatric Unit Sant'Andrea Hospital, "Sapienza" University , Rome , Italy
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Johansson H, Norlander K, Alving K, Hedenström H, Janson C, Malinovschi A, Nordang L, Emtner M. Exercise test using dry air in random adolescents: Temporal profile and predictors of bronchoconstriction. Respirology 2015; 21:289-96. [PMID: 26588807 DOI: 10.1111/resp.12682] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Revised: 07/14/2015] [Accepted: 08/25/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND OBJECTIVE Guidelines recommend exercise tests using dry air to diagnose exercise-induced bronchoconstriction (EIB). Lung function changes subsequent to these tests have not been investigated in a general adolescent population, and it remains unknown whether signs of airway inflammation, measured using exhaled nitric oxide (FeNO), can predict a positive response. The aim of this study was to investigate the temporal aspect of decline in forced expiratory volume in 1 s (FEV1 ) after an exercise test using dry air, and to investigate predictors of EIB. METHODS From a cross-sectional study on adolescents aged 13-15 years (n = 3838), a random subsample of 146 adolescents (99 with and 47 without self-reported exercise-induced dyspnoea) underwent standardized treadmill exercise tests for EIB while breathing dry air. RESULTS Of the adolescents, 34% had a positive EIB test (decline of ≥10% in FEV1 from baseline) within 30 min. Of the subjects with EIB, 53% showed the greatest decline in FEV1 at 5 to 10 min (mean decline 18.5%), and the remaining 47% of the subjects showed the greatest decline at 15 to 30 min (mean decline 18.9%) after exercise. Increased FeNO (>20 ppb), female gender and self-reported exercise-induced dyspnoea were independently associated with a positive EIB test. CONCLUSION When assessing general adolescents for EIB with exercise test using dry air, there is a temporal variation in the greatest FEV1 decline after exercise. Therefore, lung function should be measured for at least 30 min after the exercise. Increased FeNO, female gender and self-reported exercise-induced dyspnoea can be predictors of a positive EIB test.
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Affiliation(s)
- Henrik Johansson
- Neuroscience/Physiotherapy and Medical Sciences, Respiratory Medicine and Allergology, Uppsala University, Uppsala, Sweden
| | - Katarina Norlander
- Surgical Sciences: Otolaryngology and Head and Neck Surgery, Uppsala University, Uppsala, Sweden
| | - Kjell Alving
- Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Hans Hedenström
- Medical Sciences, Clinical Physiology, Uppsala University, Uppsala, Sweden
| | - Christer Janson
- Medical Sciences, Respiratory Medicine and Allergology, Uppsala University, Uppsala, Sweden
| | - Andrei Malinovschi
- Medical Sciences, Clinical Physiology, Uppsala University, Uppsala, Sweden
| | - Leif Nordang
- Surgical Sciences: Otolaryngology and Head and Neck Surgery, Uppsala University, Uppsala, Sweden
| | - Margareta Emtner
- Neuroscience/Physiotherapy and Medical Sciences, Respiratory Medicine and Allergology, Uppsala University, Uppsala, Sweden
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23
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Chateaubriand do Nascimento Silva Filho MJ, Gonçalves AV, Tavares Viana M, Peixoto DM, Cavalcanti Sarinho ES, Rizzo JÂ. Exercise-induced bronchoconstriction diagnosis in asthmatic children: comparison of treadmill running and eucapnic voluntary hyperventilation challenges. Ann Allergy Asthma Immunol 2015; 115:277-81. [PMID: 26238422 DOI: 10.1016/j.anai.2015.07.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Revised: 07/02/2015] [Accepted: 07/12/2015] [Indexed: 11/29/2022]
Abstract
BACKGROUND Exercise-induced bronchoconstriction (EIB) occurs in up to 90% of young people with asthma and can be diagnosed using serial measurements of forced expiratory volume in 1 second (FEV1) after standardized exercise, usually treadmill running (TR). Eucapnic voluntary hyperventilation (EVH) is a guideline-recommended alternative challenge for EIB diagnosis. The 2 methods have not been compared for EIB diagnosis in this population. OBJECTIVE To compare 2 methods of EIB diagnosis in children and adolescents with asthma. METHODS Thirty-four children 8 to 18 years of age attending the allergy clinic of the Hospital das Clínicas (Recife, Brazil) from September through December 2013 were examined. All underwent a basal FEV1 determination followed by TR for 8 minutes or EVH for 6 minutes on consecutive days. The first challenge was chosen at random. Serial FEV1 determinations were obtained at 3, 5, 7, 10, 15, and 30 minutes after the challenge and the test result was considered positive if at least 2 consecutive FEV1 measurements decreased at least 10% below the basal value. RESULTS Thirteen patients responded to the 2 challenges, 6 only after TR and 4 exclusively after EVH (agreement 71%, κ = 0.41). The 95% limits of agreement of FEV1 decreasing after the challenges were widely spread (mean 0.1%, limits 19.8% to -19.6%). CONCLUSION The 2 tests cannot be used interchangeably and the reproducibility of the FEV1 response to the EVH challenge has to be properly evaluated to better understand its role in EIB diagnosis.
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Affiliation(s)
| | - Adriana Velozo Gonçalves
- Health Sciences Postgraduate Course, Universidade Federal de Pernambuco, Recife, Pernambuco, Brazil
| | - Marcelo Tavares Viana
- Health Sciences Postgraduate Course, Universidade Federal de Pernambuco, Recife, Pernambuco, Brazil
| | - Décio Medeiros Peixoto
- Departments of Pediatrics and Allergy, Hospital das Clínicas, Universidade Federal de Pernambuco, Recife, Pernambuco, Brazil
| | | | - José Ângelo Rizzo
- Departments of Pneumology and Allergy, Hospital das Clínicas, Universidade Federal de Pernambuco, Recife, Pernambuco, Brazil.
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Akar HH, Tahan F, Gungor HE. The association of forced expiratory volume in one second and forced expiratory flow at 50% of the vital capacity, peak expiratory flow parameters, and blood eosinophil counts in exercise-induced bronchospasm in children with mild asthma. Asia Pac Allergy 2015; 5:98-102. [PMID: 25938074 PMCID: PMC4415185 DOI: 10.5415/apallergy.2015.5.2.98] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2014] [Accepted: 03/03/2015] [Indexed: 12/03/2022] Open
Abstract
Background Exercise-induced bronchoconstriction (EIB), which describes acute airway narrowing that occurs as a result of exercise, is associated with eosinophilic airway inflammation, bronchial hyperresponsiveness. The forced expiratory volume in one second (FEV1) is the most commonly used spirometric test in the diagnosis of EIB in exercise challenge in asthma. Other parameters such as forced expiratory flow at 50% of the vital capacity (FEF50%) and peak expiratory flow (PEF) are used less often in the diagnosis of EIB. Objective The purpose of this study is to evaluate the association of FEV1 and FEF50%, PEF parameters, blood eosinophil counts in EIB in children with mild asthma. Methods Sixty-seven children (male: 39, female: 28) with mild asthma were included in this study. Pulmonary functions were assessed before and at 1, 5, 10, 15, and 20 minutes after exercise. The values of spirometric FEV1, FEF50%, PEF, and blood eosinophil counts were evaluated in EIB in children with mild asthma. Results There was a positive correlation between FEV1 with FEF50% and PEF values (p<0.05; FEF50%, r=0.68; PEF, r=0.65). Also, a positive correlation was found between blood eosinophil counts and the values of spirometric FEV1, FEF50%, and PEF (p<0.05; FEV1, r=0.54; FEF50%, r=0.42; PEF, r=0.26). In addition to these correlations, in the exercise negative group for FEV1, the FEF50% and PEF values decreased more than the cutoff values in 3, and 2 patients, respectively. Conclusion According to the presented study, eosinophil may play a major role in the severity of EIB in mild asthma. FEF50% and PEF values can decrease in response to exercise without changes in FEV1 in mild asthmatic patients.
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Affiliation(s)
- H Haluk Akar
- Department of Pediatric Allergy, Erciyes University School of Medicine, 38039 Kayseri, Turkey
| | - Fulya Tahan
- Department of Pediatric Allergy, Erciyes University School of Medicine, 38039 Kayseri, Turkey
| | - Hatice Eke Gungor
- Department of Pediatric Allergy, Erciyes University School of Medicine, 38039 Kayseri, Turkey
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Caillaud D, Horo K, Baiz N, Banerjee S, Charpin D, Lavaud F, de Blay F, Raherison C, Annesi-Maesano I. Exercise-induced bronchospasm related to different phenotypes of rhinitis without asthma in primary schoolchildren: the French Six Cities Study. Clin Exp Allergy 2015; 44:858-66. [PMID: 24666547 DOI: 10.1111/cea.12310] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2013] [Revised: 02/06/2014] [Accepted: 02/26/2014] [Indexed: 11/27/2022]
Abstract
BACKGROUND Exercise-induced bronchospasm (EIB) is frequent among asthmatic children. However, opinions differ on the relation between EIB and rhinitis in the absence of asthma. OBJECTIVES We assessed the relationship between EIB and various phenotypes of rhinitis according to asthmatic status at the general population level in the Six Cities Study. METHODS Of 7781 schoolchildren with a mean age of 10 years underwent an EIB test and skin prick test to assess allergic sensitization. Their parents completed a standardized questionnaire recording asthma-like symptoms and past-year rhinoconjunctivitis, ever hay fever (EHF), and a score for allergic rhinitis (SFAR) ≥7 as a marker of 'past-year allergic rhinitis'. Exercise-induced bronchospasm was defined as a fall in peak expiratory flow rate ≥15% after exercise. RESULTS Of the 6813 schoolchildren retained for analysis, 227 (3.33%) experienced EIB after exercise. Odds ratios [95% confidence intervals] between EIB and allergic rhinitis phenotypes in the absence of asthma were 1.56 [0.92-2.63] for EHF, 1.97 [1.16-3.35] for past-year rhinoconjunctivitis, and 1.84 [1.16-2.91] for a SFAR ≥7. Results were unchanged after adjustment for confounders. Multiple correspondence analysis showed that EIB, although related to asthma, constitutes a separate entity. Exercise-induced bronchospasm was not significantly related to familial history of asthma. CONCLUSION In our large population-based sample of children, different phenotypes of atopic rhinitis were associated with EIB, independently of asthma. Exercise-induced bronchospasm, although related to asthma, seems to constitute a separate entity. CLINICAL RELEVANCE In this large (6813) sample of 10-year children drawn from the general population, EIB is associated with rhinitis phenotypes in the absence of asthma. Furthermore, it constitutes an entity independent from asthma and is not related to a familial history of asthma. Thus, investigating these symptoms could be important in this disease, as a specific nasal treatment might improve EIB in these children.
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Affiliation(s)
- D Caillaud
- Service de Pneumologie, CHU Gabriel Montpied, Université d'Auvergne, Clermont-Ferrand, France
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Barreto M, Zambardi R, Villa MP. Exhaled nitric oxide and other exhaled biomarkers in bronchial challenge with exercise in asthmatic children: current knowledge. Paediatr Respir Rev 2015; 16:68-74. [PMID: 24368252 DOI: 10.1016/j.prrv.2013.11.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2012] [Revised: 04/23/2013] [Accepted: 11/15/2013] [Indexed: 12/31/2022]
Abstract
The fractional concentration of exhaled nitric oxide (FENO), a known marker of atopic-eosinophilic inflammation, may be used as a surrogate to assess exercise-induced bronchoconstriction (EIB) in asthmatic children. The predictive value of baseline FENO for EIB appears to be influenced by several factors, including age, atopy, current therapy with corticosteroids and measurement technique. Nonetheless, FENO cut-off values appear to be able to rule out EIB. FENO levels decrease during EIB, apparently through neural mechanisms rather than by decreased airway-epithelial surface. Partition of FENO into proximal and peripheral contributions of the respiratory tract may improve our understanding on NO exchange during exercise and help to screen subjects prone to EIB. Other biomarkers of inflammation and oxidative stress contained in exhaled gases and exhaled breath condensate (EBC) may shed light on the pathophysiology of EIB. Exhaled breath temperature is a promising real-time measurement whose routine use for assessing EIB warrants further investigation.
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Affiliation(s)
- Mario Barreto
- Pediatric Unit, Sant'Andrea Hospital, NESMOS Department, Faculty of Medicine and Psychology, Sapienza University of Rome, Rome, Italy.
| | - Rosanna Zambardi
- Pediatric Unit, Sant'Andrea Hospital, NESMOS Department, Faculty of Medicine and Psychology, Sapienza University of Rome, Rome, Italy
| | - Maria Pia Villa
- Pediatric Unit, Sant'Andrea Hospital, NESMOS Department, Faculty of Medicine and Psychology, Sapienza University of Rome, Rome, Italy
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27
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Weiler JM, Hallstrand TS, Parsons JP, Randolph C, Silvers WS, Storms WW, Bronstone A. Improving screening and diagnosis of exercise-induced bronchoconstriction: a call to action. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2014; 2:275-80.e7. [PMID: 24811017 DOI: 10.1016/j.jaip.2013.11.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 09/26/2013] [Revised: 11/12/2013] [Accepted: 11/14/2013] [Indexed: 12/26/2022]
Abstract
This article summarizes the findings of an expert panel of nationally recognized allergists and pulmonologists who met to discuss how to improve detection and diagnosis of exercise-induced bronchoconstriction (EIB), a transient airway narrowing that occurs during and most often after exercise in people with and without underlying asthma. EIB is both commonly underdiagnosed and overdiagnosed. EIB underdiagnosis may result in habitual avoidance of sports and physical activity, chronic deconditioning, weight gain, poor asthma control, low self-esteem, and reduced quality of life. Routine use of a reliable and valid self-administered EIB screening questionnaire by professionals best positioned to screen large numbers of people could substantially improve the detection of EIB. The authors conducted a systematic review of the literature that evaluated the accuracy of EIB screening questionnaires that might be adopted for widespread EIB screening in the general population. Results of this review indicated that no existing EIB screening questionnaire had adequate sensitivity and specificity for this purpose. The authors present a call to action to develop a new EIB screening questionnaire, and discuss the rigorous qualitative and quantitative research necessary to develop and validate such an instrument, including key methodological pitfalls that must be avoided.
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Affiliation(s)
- John M Weiler
- Department of Internal Medicine, University of Iowa, Iowa City, Iowa.
| | - Teal S Hallstrand
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington, Seattle, Wash
| | - Jonathan P Parsons
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, The Ohio State University Medical Center, Columbus, Ohio
| | - Christopher Randolph
- Department of Pediatrics, Division of Allergy and Clinical Immunology, Yale University, New Haven, Conn
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28
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Parsons JP. Exercise-induced bronchospasm: symptoms are not enough. Expert Rev Clin Immunol 2014; 5:357-9. [DOI: 10.1586/eci.09.15] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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29
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Kippelen P, Tufvesson E, Ali L, Bjermer L, Anderson SD. Urinary CC16 after challenge with dry air hyperpnoea and mannitol in recreational summer athletes. Respir Med 2013; 107:1837-44. [PMID: 24120076 DOI: 10.1016/j.rmed.2013.09.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2013] [Revised: 09/20/2013] [Accepted: 09/21/2013] [Indexed: 10/26/2022]
Abstract
Airway epithelial injury is regarded as a key contributing factor to the pathogenesis of exercise-induced bronchoconstriction (EIB) in athletes. The concentration of the pneumoprotein club cell (Clara cell) CC16 in urine has been found to be a non-invasive marker for hyperpnoea-induced airway epithelial perturbation. Exercise-hyperpnoea induces mechanical, thermal and osmotic stress to the airways. We investigated whether osmotic stress alone causes airway epithelial perturbation in athletes with suspected EIB. Twenty-four recreational summer sports athletes who reported respiratory symptoms on exertion performed a standard eucapnic voluntary hyperpnoea test with dry air and a mannitol test (osmotic challenge) on separate days. Median urinary CC16 increased from 120 to 310 ρg μmol creatinine(-1) after dry air hyperpnoea (P = 0.002) and from 90 to 191 ρg μmol creatinine(-1) after mannitol (P = 0.021). There was no difference in urinary CC16 concentration between athletes who did or did not bronchoconstrict after dry air hyperpnoea or mannitol. We conclude that, in recreational summer sports athletes with respiratory symptoms, osmotic stress per se to the airway epithelium induces a rise in urinary excretion of CC16. This suggests that hyperosmolarity of the airway surface lining perturbs the airway epithelium in symptomatic athletes.
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Affiliation(s)
- Pascale Kippelen
- Centre for Sports Medicine and Human Performance, Brunel University, UB8 3PH Uxbridge, Middlesex, UK.
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30
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Laslovich SM, Laslovich JM. Exercise and Asthma. Strength Cond J 2013. [DOI: 10.1519/ssc.0b013e31829d232f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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31
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Hallstrand TS, Lai Y, Altemeier WA, Appel CL, Johnson B, Frevert CW, Hudkins KL, Bollinger JG, Woodruff PG, Hyde DM, Henderson WR, Gelb MH. Regulation and function of epithelial secreted phospholipase A2 group X in asthma. Am J Respir Crit Care Med 2013; 188:42-50. [PMID: 23614662 PMCID: PMC3735246 DOI: 10.1164/rccm.201301-0084oc] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2013] [Accepted: 04/08/2013] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Indirect airway hyperresponsiveness (AHR) is a fundamental feature of asthma that is manifest as exercise-induced bronchoconstriction (EIB). Secreted phospholipase A2 group X (sPLA2-X) plays a key role in regulating eicosanoid formation and the development of inflammation and AHR in murine models. OBJECTIVES We sought to examine sPLA2-X in the airway epithelium and airway wall of patients with asthma, the relationship to AHR in humans, and the regulation and function of sPLA2-X within the epithelium. METHODS We precisely phenotyped 34 patients with asthma (19 with and 15 without EIB) and 10 normal control subjects to examine in vivo differences in epithelial gene expression, quantitative morphometry of endobronchial biopsies, and levels of secreted protein. The regulation of sPLA2-X gene (PLA2G10) expression was examined in primary airway epithelial cell cultures. The function of epithelial sPLA2-X in eicosanoid formation was examined using PLA2 inhibitors and murine tracheal epithelial cells with Pla2g10 deletion. MEASUREMENTS AND MAIN RESULTS We found that sPLA2-X protein is increased in the airways of patients with asthma and that epithelial-derived sPLA2-X may be increased in association with indirect AHR. The expression of sPLA2-X increases during in vitro epithelial differentiation; is regulated by inflammatory signals including tumor necrosis factor, IL-13, and IL-17; and is both secreted from the epithelium and directly participates in the release of arachidonic acid by epithelial cells. CONCLUSIONS These data reveal a relationship between epithelial-derived sPLA2-X and indirect AHR in asthma and that sPLA2-X serves as an epithelial regulator of inflammatory eicosanoid formation. Therapies targeting epithelial sPLA2-X may be useful in asthma.
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Hallstrand TS, Lai Y, Henderson WR, Altemeier WA, Gelb MH. Epithelial regulation of eicosanoid production in asthma. Pulm Pharmacol Ther 2013; 25:432-7. [PMID: 23323271 DOI: 10.1016/j.pupt.2012.02.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Alterations in the airway epithelium have been associated with the development of asthma in elite athletes and in subjects that are susceptible to exercise-induced bronchoconstriction (EIB). The syndrome of EIB refers to acute airflow obstruction that is triggered by a period of physical exertion. Asthmatics who are susceptible to EIB have increased levels of cysteinyl leukotrienes (CysLTs, i.e., LTs C₄, D₄, and E₄) in induced sputum and exhaled breath condensate, and greater shedding of epithelial cells into the airway lumen. Exercise challenge in individuals susceptible to this disorder initiates a sustained increase in CysLTs in the airways, and secreted mucin release and smooth muscle constriction, which may be mediated in part through activation of sensory nerves. We have identified a secreted phospholipase A₂ (sPLA₂) with increased levels in the airways of patients with EIB called sPLA₂ group X(sPLA₂-X).We have found that sPLA₂-X is strongly expressed in the airway epithelium in asthma. Further,we discovered that transglutaminase 2 (TGM2) is expressed at increased levels in asthma and serves asa regulator of sPLA₂-X. Finally, we demonstrated that sPLA₂-X acts on target cells such as eosinophils to initiate cellular eicosanoid synthesis. Collectively, these studies identify a novel mechanism linking the airway epithelium to the production of inflammatory eicosanoids by leukocytes.
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Affiliation(s)
- Teal S Hallstrand
- Division of Pulmonary and Critical Care, University of Washington, Box 356522, 1959 NE Pacific Street, Seattle, WA 98195, USA.
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Kippelen P, Anderson SD. Pathogenesis of exercise-induced bronchoconstriction. Immunol Allergy Clin North Am 2013; 33:299-312, vii. [PMID: 23830126 DOI: 10.1016/j.iac.2013.02.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
This article presents the various potential mechanisms responsible for the development of exercise-induced bronchoconstriction (EIB). Although the etiology of EIB is multifactorial, and the physiologic processes involved may vary between individuals (especially between those with and without asthma), drying of the small airways with an associated inflammatory response seems prerequisite for EIB. Dysregulated repair processes following exercise-induced airway epithelial injury may also serve as basis for EIB development/progression.
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Affiliation(s)
- Pascale Kippelen
- Centre for Sports Medicine & Human Performance, Brunel University, Uxbridge, Middlesex UB8 3PH, UK.
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Role of cells and mediators in exercise-induced bronchoconstriction. Immunol Allergy Clin North Am 2013; 33:313-28, vii. [PMID: 23830127 DOI: 10.1016/j.iac.2013.02.003] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
A susceptible group of subjects with asthma develops airflow obstruction in response to the transfer of water out of the airways during exercise. The transfer of water or the challenge with a hypertonic solution serves as a strong stimulus to the airway epithelium. Susceptible subjects have epithelial shedding into the airway lumen, and airway inflammation that leads to the overproduction of leukotrienes and other eicosanoids following exercise challenge. The sensory nerves of the airways may serve as a critical link that mediates the effect of eicosanoids, leading to bronchoconstriction and mucus production in response to exercise challenge.
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Refractoriness to exercise challenge: a review of the mechanisms old and new. Immunol Allergy Clin North Am 2013; 33:329-45, viii. [PMID: 23830128 DOI: 10.1016/j.iac.2013.02.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
This article discusses the available literature on refractoriness in exercise-induced bronchoconstriction, namely, a decrease in airway responsiveness with repeated exercise challenges. The mechanisms of this naturally occurring protective feature is unknown. Reviewing previous studies together with findings in more recent studies, the authors propose desensitization of the G protein-coupled cysteinyl leukotriene receptor1 as the mechanism of refractoriness and that this desensitization occurs as a result of interplay between leukotrienes and prostaglandins.
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Baek HS, Cho J, Kim JH, Oh JW, Lee HB. Ratio of leukotriene e(4) to exhaled nitric oxide and the therapeutic response in children with exercise-induced bronchoconstriction. ALLERGY, ASTHMA & IMMUNOLOGY RESEARCH 2012; 5:26-33. [PMID: 23277875 PMCID: PMC3529225 DOI: 10.4168/aair.2013.5.1.26] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/21/2011] [Revised: 04/16/2012] [Accepted: 05/16/2012] [Indexed: 11/20/2022]
Abstract
Purpose This study assessed the association between the ratio of leukotriene E4 (LTE4) to fractional exhaled nitric oxide (FENO) in the response of children with exercise-induced bronchoconstriction (EIB) enrolled in a therapeutic trial with montelukast or inhaled corticosteroid (fluticasone propionate [FP]). Methods Children aged 6 to 18 years with EIB were randomized in a 4-week, placebo-controlled, double-blinded trial with montelukast or FP. Before and after treatment, treadmill exercise challenges were performed. The LTE4 levels in the induced sputum and urine and the FENO levels were measured in subjects before and 30 minutes after the exercise challenges. The same tests were conducted after treatment. Results A total of 24 patients completed the study: 12 in the montelukast group and 12 in FP group. Both study groups displayed a similar postexercise maximum decrease in forced expiratory volume in one second (FEV1) before treatment as well as after treatment. However, there were significant differences in the magnitude of change between the two (Δ; -18.38±14.53% vs. -4.67±8.12% for the montelukast and FP groups, respectively; P=0.021). The Δ logarithmic sputum baseline and postexercise LTE4/FENO ratio were significantly lower in the montelukast group than in the FP group (baseline; -0.09±0.21 vs. -0.024±0.03, P=0.045; postexercise, -0.61±0.33 vs. -0.11±0.28, P=0.023). Conclusions These data indicate that the efficacy of montelukast for preventing a maximum decrease in FEV1 after exercise is significantly higher than that of FP, and the high LTE4/FENO ratio is associated with a greater response to montelukast than to FP for EIB therapy. These results suggest that LTE4 may play an important role in EIB.
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Affiliation(s)
- Hey-Sung Baek
- Department of Pediatrics, Kangdong Sacred Heart Hospital, Hallym University School of Medicine, Seoul, Korea
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37
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New insights into pathogenesis of exercise-induced bronchoconstriction. Curr Opin Allergy Clin Immunol 2012; 12:42-8. [PMID: 22157157 DOI: 10.1097/aci.0b013e32834ecc67] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Exercise-induced bronchoconstriction (EIB) refers to acute airflow obstruction that is triggered by a period of physical exertion. Here we review recent findings about the epidemiology of EIB, immunopathology leading to EIB, and the latest understanding of the pathogenesis of EIB. RECENT FINDINGS Longitudinal studies demonstrated that airway hyper-responsiveness to exercise or cold air at an early age are among the strongest predictors of persistent asthma. Patients that are susceptible to EIB have epithelial disruption and increased levels of inflammatory eicosanoids such as cysteinyl leukotrienes (CysLT)s. The leukocytes implicated in production of eicosanoids in the airways include both a unique mast cell population as well as eosinophils. A secreted phospholipase A(2) (sPLA(2)) enzyme that serves as a regulator of CysLT formation is present in increased quantities in asthma. Transglutaminase 2 (TGM2) is expressed at increased levels in asthma and serves as a regulator of secreted phospholipase A(2) group X (sPLA(2)-X). Further, sPLA(2)-X acts on target cells such as eosinophils to initiate cellular eicosanoid synthesis. SUMMARY Recent studies have advanced our understanding of EIB as a syndrome that is caused by the increased production of inflammatory eicosanoids. The airway epithelium may be an important regulator of the production of inflammatory eicosanoids by leukocytes.
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Peroni DG, Chinellato I, Piazza M, Zardini F, Bodini A, Olivieri F, Boner AL, Piacentini GL. Exhaled breath temperature and exercise-induced bronchoconstriction in asthmatic children. Pediatr Pulmonol 2012; 47:240-4. [PMID: 21905269 DOI: 10.1002/ppul.21545] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2011] [Accepted: 08/04/2011] [Indexed: 12/14/2022]
Abstract
It has been hypothesized that exhaled breath temperature (EBT) is related to the degree of airway inflammation/remodeling in asthma. The purpose of this study was to evaluate the relationship between the level of airway response to exercise and EBT in a group of controlled or partly controlled asthmatic children. Fifty asthmatic children underwent measurements of EBT before and after a standardized exercise test. EBT was 32.92 ± 1.13 and 33.35 ± 0.95°C before and after exercise, respectively (P < 0.001). The % decrease in FEV(1) was significantly correlated with the increase in EBT (r = 0.44, P = 0.0013), being r = 0.49 (P < 0.005) in the children who were not receiving regular inhaled corticosteroids (ICS) and 0.37 (n.s.) in those who were. This study further supports the hypothesis that EBT can be considered a potential composite tool for monitoring asthma.
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Affiliation(s)
- Diego G Peroni
- Department of Paediatrics, University of Verona, Verona, Italy
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Bolger C, Tufvesson E, Sue-Chu M, Devereux G, Ayres JG, Bjermer L, Kippelen P. Hyperpnea-induced bronchoconstriction and urinary CC16 levels in athletes. Med Sci Sports Exerc 2011; 43:1207-13. [PMID: 21131866 DOI: 10.1249/mss.0b013e31820750d8] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
PURPOSE Exercise-induced bronchoconstriction (EIB) is a common condition in both individuals with asthma and otherwise healthy elite athletes. Although excessive water loss by peripheral airways during hyperpnea is regarded as the initial trigger for EIB, the cascade of events that follows remains unclear. Our goal was to establish whether transient disruption of the airway epithelial barrier occurs after a short period of hyperpnea of dry air in athletes with EIB. METHODS Urinary concentration of the pneumoprotein Clara cell (CC16) was used as an assumed biomarker of lung epithelial cell damage or dysfunction. Samples were collected at baseline and for 90 min after an 8-min eucapnic voluntary hyperpnea (EVH) test in 50 female individuals (28 athletes and 22 untrained). RESULTS Nineteen subjects (10 athletes) demonstrated a sustained bronchoconstriction after EVH (mean±SE forced expiratory volume in the first second (FEV1) fall from baseline=23.4%±2.6%). The remaining subjects had a negative challenge result with an FEV1 fall of 5.9%±0.6%. An increase (P<0.001) in urinary CC16 concentration was noticed after EVH in all but one subject, with no group difference (median CC16 increase before to after challenge: athletes EVH 0.083 ng·μmol, athletes EVH 0.223 ng·μmol, untrained EVH 0.074 ng·μmol, untrained EVH 0.571 ng·μmol; P>0.05). CONCLUSIONS Urinary levels of CC16 are increased after EVH in all individuals (trained and untrained, with and without EIB) suggestive of dehydration-induced perturbation of the distal respiratory epithelium during episodes of hyperventilation.
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Affiliation(s)
- Claire Bolger
- School of Medical Sciences, Department of Occupational Medicine, University of Aberdeen, Aberdeen, United Kingdom
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Bolger C, Tufvesson E, Anderson SD, Devereux G, Ayres JG, Bjermer L, Sue-Chu M, Kippelen P. Effect of inspired air conditions on exercise-induced bronchoconstriction and urinary CC16 levels in athletes. J Appl Physiol (1985) 2011; 111:1059-65. [DOI: 10.1152/japplphysiol.00113.2011] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Injury to the airway epithelium has been proposed as a key susceptibility factor for exercise-induced bronchoconstriction (EIB). Our goals were to establish whether airway epithelial cell injury occurs during EIB in athletes and whether inhalation of warm humid air inhibits this injury. Twenty-one young male athletes (10 with a history of EIB) performed two 8-min exercise tests near maximal aerobic capacity in cold dry (4°C, 37% relative humidity) and warm humid (25°C, 94% relative humidity) air on separate days. Postexercise changes in urinary CC16 were used as a biomarker of airway epithelial cell perturbation and injury. Bronchoconstriction occurred in eight athletes in the cold dry environment and was completely blocked by inhalation of warm humid air [maximal fall in forced expiratory volume in 1 s = 18.1 ± 2.1% (SD) in cold dry air and 1.7 ± 0.8% in warm humid air, P < 0.01]. Exercise caused an increase in urinary excretion of CC16 in all subjects ( P < 0.001), but this rise in CC16 was blunted following inhalation of warm humid air [median CC16 increase pre- to postchallenge = 1.91 and 0.35 ng/μmol in cold dry and warm humid air, respectively, in athletes with EIB ( P = 0.017) and 1.68 and 0.48 ng/μmol in cold dry and warm humid air, respectively, in athletes without EIB ( P = 0.002)]. The results indicate that exercise hyperpnea transiently disrupts the airway epithelium of all athletes (not only in those with EIB) and that inhalation of warm moist air limits airway epithelial cell perturbation and injury.
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Affiliation(s)
| | - E. Tufvesson
- Department of Respiratory Medicine and Allergology, Lund University Hospital, Lund, Sweden
| | - S. D. Anderson
- Royal Prince Alfred Hospital, Department of Respiratory and Sleep Medicine, Sydney Medical School, University of Sydney, Camperdown, New South Wales, Australia; and
| | - G. Devereux
- Department of Occupational Medicine, University of Aberdeen, Aberdeen
| | - J. G. Ayres
- Institute of Occupational and Environmental Medicine, University of Birmingham, Birmingham
| | - L. Bjermer
- Department of Respiratory Medicine and Allergology, Lund University Hospital, Lund, Sweden
| | - M. Sue-Chu
- Department of Lung Medicine, St. Olavs Hospital, University Hospital of Trondheim, and Department of Circulation and Imaging, Norwegian University of Science and Technology, Trondheim, Norway
| | - P. Kippelen
- Centre for Sports Medicine and Human Performance, Brunel University, Uxbridge, Middlesex, United Kingdom
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Fuentes C, Contreras S, Padilla O, Castro-Rodriguez JA, Moya A, Caussade S. Exercise challenge test: is a 15% fall in FEV(1) sufficient for diagnosis? J Asthma 2011; 48:729-35. [PMID: 21749286 DOI: 10.3109/02770903.2011.594139] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
INTRODUCTION In the exercise challenge test (ECT), a drop in forced expiratory volume in the first second (FEV(1)) of between 10 and 15% is the determinant variable for a diagnosis of exercise-induced bronchospasm. HYPOTHESIS The use of FEV(1) plus mean forced expiratory flow between 25% and 75% of the forced vital capacity (FEF(25-75%)) may increase the sensitivity of the ECT in asthmatic children. SPECIFIC OBJECTIVE To compare FEV(1) and FEF(25-75%) changes in a group of asthmatic and healthy children. METHODOLOGY This was a cross-sectional study. Asthmatics were categorized by their severity (GINA) and after 1 month without controller therapy, an ECT was done under standard protocol. As well, a questionnaire about rhinitis and asthma was conducted with the entire population. ROC curves were used for analysis. RESULTS A total of 147 children (34 healthy and 113 asthmatics, 18 and 58 males, respectively) were evaluated. Divided into healthy children and intermittent, mild and moderate persistent asthmatics, they had similar average ages (9.4, 9.48, 8.97, and 11.2 years, respectively). Using a 15% fall in FEV(1), we obtained 29% sensitivity and 100% specificity. However, when we used a 10% fall in FEV(1), sensitivity was 47% and specificity was 97%. Adding a 28% fall in FEF(25-75%), sensitivity was 52% and specificity was 94%. CONCLUSION This study suggests that test sensitivity can increase by using a lower FEV(1) cut-off (10%) and adding a 28% fall in FEF(25-75%).
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Affiliation(s)
- Claudia Fuentes
- Pediatric Division, Respiratory Section, Pontificia Universidad Católica de Chile, Santiago, Chile
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Weiss P, Rundell KW. Exercise-Induced Lung Disease: Too Much of a Good Thing? PEDIATRIC ALLERGY, IMMUNOLOGY, AND PULMONOLOGY 2011; 24:149-157. [PMID: 35927868 DOI: 10.1089/ped.2011.0066] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Exercise in children has important health benefits. However, in elite endurance athletes, there is an increased prevalence of exercise-induced bronchoconstriction and airway inflammation. Particularly at risk are those who practice in cold weather, ice rinks, swimming pools, and air pollution. The inflammation is caused by repetitive episodes of hyperventilation of cold, dry air, allergens, or toxins such as chlorine or air pollution. Children may be particularly at risk for lung injury under these conditions because of the immaturity and ongoing development of their lung. However, studies in pediatric athletes and exercising young children are sparse. Epithelial injury associated with hyperventilation of cold, dry air has not been described in children. However, exercise in the presence of air pollution and chlorine is associated with airway injury and the development of asthma in children; the effect appears to be modulated by both atopy and genetic polymorphisms. While management of exercise-induced bronchoconstriction and asthma is well established, there is little data to guide treatment or prevention of remodeling in athletes or inhalational lung injury in children. Studies underscore the need to maintain high levels of air quality. More investigations should be undertaken to better define the natural history, pathophysiology, and treatment of exercise-induced pulmonary inflammation in both elite athletes and exercising children.
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Affiliation(s)
- Pnina Weiss
- Department of Pediatric Respiratory Medicine, Yale University, New Haven, Connecticut
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Weiler JM, Anderson SD, Randolph C, Bonini S, Craig TJ, Pearlman DS, Rundell KW, Silvers WS, Storms WW, Bernstein DI, Blessing-Moore J, Cox L, Khan DA, Lang DM, Nicklas RA, Oppenheimer J, Portnoy JM, Schuller DE, Spector SL, Tilles SA, Wallace D, Henderson W, Schwartz L, Kaufman D, Nsouli T, Shieken L, Rosario N. Pathogenesis, prevalence, diagnosis, and management of exercise-induced bronchoconstriction: a practice parameter. Ann Allergy Asthma Immunol 2011; 105:S1-47. [PMID: 21167465 DOI: 10.1016/j.anai.2010.09.021] [Citation(s) in RCA: 142] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2010] [Accepted: 09/26/2010] [Indexed: 02/06/2023]
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Baek HS, Kim YD, Shin JH, Kim JH, Oh JW, Lee HB. Serum leptin and adiponectin levels correlate with exercise-induced bronchoconstriction in children with asthma. Ann Allergy Asthma Immunol 2011; 107:14-21. [PMID: 21704880 DOI: 10.1016/j.anai.2011.03.013] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2010] [Revised: 03/15/2011] [Accepted: 03/28/2011] [Indexed: 10/18/2022]
Abstract
BACKGROUND Exercise-induced bronchoconstriction (EIB), a form of bronchial hyperresponsiveness (BHR), is common in children with asthma or obesity. Epidemiological studies have shown that asthma and obesity are increasing in parallel, but obesity- and adipokine-related effects on inflammation and BHR have not yet been demonstrated in the human airway. OBJECTIVE To address the relationship between leptin and adiponectin and EIB in children with asthma. METHODS Eighty-five prepubertal children between the ages of 6 and 10 years were included in our study. They comprised obese with asthma (n = 19), normal weight with asthma (n = 23), obese without asthma (n = 23), and healthy (n = 20). We measured serum leptin and adiponectin levels. We also performed pulmonary function tests: baseline, postbronchodilator inhalation, methacholine inhalation, and exercise. The area under the forced expiratory volume in 1 second (FEV(1))-time curve quantified the severity of EIB over a 20-minute period after exercise (AUC(20)). RESULTS The obese children had significantly elevated levels of leptin and reduced levels of adiponectin. The maximum decreases in %FEV(1) and AUC(20) after exercise were positively correlated with leptin levels and negatively with serum adiponectin levels in children with asthma. The odds for having EIB were incrementally and significantly higher for children with higher levels of serum leptin. CONCLUSIONS Levels of the adipocyte-derived hormones leptin and adiponectin are significantly correlated with BHR induced by exercise challenge in children with asthma. Further studies are needed to elucidate whether the changes in leptin and adiponectin levels bear a causal relationship to the EIB/BHR.
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Affiliation(s)
- Hey-Sung Baek
- Department of Pediatrics, Hanyang University School of Medicine, 17 Haengdang-Dong, Seoul, Korea
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Clearie KL, Williamson PA, Meldrum K, Gillen M, Carlsson LG, Carlholm M, Ekelund J, Lipworth BJ. Pharmacokinetic and pharmacodynamic comparison of hydrofluoroalkane and chlorofluorocarbon formulations of budesonide. Br J Clin Pharmacol 2011; 71:504-13. [PMID: 21395643 PMCID: PMC3080637 DOI: 10.1111/j.1365-2125.2010.03857.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2010] [Accepted: 10/23/2010] [Indexed: 11/30/2022] Open
Abstract
AIMS A hydrofluoroalkane formulation of budesonide pressurized metered-dose inhaler has been developed to replace the existing chlorofluorocarbon one. The aim of this study was to evaluate the pharmacokinetic and pharmacodynamic characteristics of both formulations. METHODS Systemic bioavailability and bioactivity of both hydrofluoroalkane and chlorofluorocarbon pressurized metered-dose inhaler formulations at 800 µg twice daily was determined during a randomized crossover systemic pharmacokinetic/pharmacodynamic study at steady state in healthy volunteers. Measurements included the following: plasma cortisol AUC(24h) [area under the concentration-time curve (0-24 h)], budesonide AUC(0-12h) and C(max) . Clinical efficacy was determined during a randomized crossover pharmacodynamic study in asthmatic patients receiving 200 µg followed by 800 µg budesonide via chlorofluorocarbon or hydrofluoroalkane pressurized metered-dose inhaler each for 4 weeks. Methacholine PC(20) (primary outcome), exhaled nitric oxide, spirometry, peak expiratory flow and symptoms were evaluated. RESULTS In the pharmacokinetic study, there were no differences in cortisol, AUC(0-12h) [area under the concentration-time curve (0-12 h)], T(max) (time to maximum concentration) or C(max) (peak serum concentration) between the hydrofluoroalkane and chlorofluorocarbon pressurized metered-dose inhaler. The ratio of budesonide hydrofluoroalkane vs. chlorofluorocarbon pressurized metered-dose inhaler for cortisol AUC(24h) was 1.02 (95% confidence interval 0.93-1.11) and budesonide AUC(0-12h) was 1.03 (90% confidence interval 0.9-1.18). In the asthma pharmacodynamic study, there was a significant dose response (P < 0.0001) for methacholine PC(20) (provocative concentration of methacholine needed to produce a 20% fall in FEV(1) ) with a relative potency ratio of 1.10 (95% confidence interval 0.49-2.66), and no difference at either dose. No significant differences between formulations were seen with the secondary outcome variables. CONCLUSIONS Hydrofluoroalkane and chlorofluorocarbon formulations of budesonide were therapeutically equivalent in terms of relative lung bioavailability, airway efficacy and systemic effects.
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Affiliation(s)
- Karine L Clearie
- Asthma and Allergy Research Group, University of Dundee, Dundee, Scotland, UK
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Larsson J, Perry CP, Anderson SD, Brannan JD, Dahlén SE, Dahlén B. The occurrence of refractoriness and mast cell mediator release following mannitol-induced bronchoconstriction. J Appl Physiol (1985) 2011; 110:1029-35. [PMID: 21252215 DOI: 10.1152/japplphysiol.00978.2010] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
For several hours after exercise-induced bronchoconstriction, there is diminished responsiveness to repeated challenge. The mechanism causing this refractoriness is unclear. Inhalation of dry powder mannitol is a new bronchial provocation test that has been suggested as a surrogate for an exercise challenge. Refractoriness to repeated mannitol challenge has however not been established. Our objective was to investigate if repeated challenge with mannitol is associated with refractoriness and diminished release of mast cell mediators of bronchoconstriction. Sixteen subjects with asthma underwent repeated inhalation of mannitol 90 min apart. Lung function was assessed by forced expiratory volume in 1 s (FEV₁). The urinary excretion (ng/mmol creatinine) of the mediators 9α,11β-prostaglandin (PG) F₂ and leukotriene (LT) E₄ were measured. The group mean fall in FEV₁ after the second challenge was 48.5 ± 5.8% of the first (P < 0.001). The protection afforded by the initial challenge, however, varied considerably between subjects (range 88-0%). Furthermore, the urinary excretion of the two mediators was increased after both challenges. The average excretion of mediators after the challenges was significantly higher for the six most refractory subjects. This was observed both for LTE₄ (95.6 ± 5.2 vs. 58.0 ± 2.4 for the 6 least refractory) (P < 0.001) and for 9α,11β-PGF₂ (137.6 ± 6.7 vs. 50.1 ± 1.1 for the 6 least refractory) (P = 0.002). As occurs with exercise-induced bronchoconstriction, repeated inhalation of mannitol induced refractoriness. We propose that refractoriness is due to tachyphylaxis at the level of the airway smooth muscle responsiveness to mediators of bronchoconstriction rather than due to fatigue of their release from mast cells.
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Affiliation(s)
- Johan Larsson
- The Unit for Experimental Asthma and Allergy Research, Division of Physiology, The National Institute of EnvironmentalMedicine, Sweden.
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47
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Bikov A, Gajdócsi R, Huszár É, Szili B, Lázár Z, Antus B, Losonczy G, Horváth I. Exercise increases exhaled breath condensate cysteinyl leukotriene concentration in asthmatic patients. J Asthma 2010; 47:1057-62. [PMID: 20868319 DOI: 10.1080/02770903.2010.512690] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Although the importance of cysteinyl leukotrienes (Cys-LTs) in exercise-induced bronchoconstriction (EIB) is supported by various sources of evidence, how the concentration of these mediators change during the development of EIB has not been investigated. OBJECTIVES Our goal was to determine the effect of exercise on the concentration of airway Cys-LT in asthmatic patients by measuring Cys-LT in exhaled breath condensate (EBC). METHODS Seventeen atopic asthmatic patients with a previous history of EIB and six healthy volunteers were studied. Before and two times within 10 minutes after exercise challenge, FEV₁ was measured and EBC was collected for Cys-LT measurement. Exhaled nitric oxide level, a marker of airway inflammation, was also determined at baseline. RESULTS Baseline Cys-LT level was higher in the asthmatic group versus healthy subjects (168 pg/mL /112-223/ vs. 77 pg/mL /36-119/, p = .03). EBC Cys-LT concentration increased in all asthmatic patients post-exercise (n = 17, p = .03), with the increase significantly greater in patients developing exercise-induced bronchospasm (n = 7, p = .03), whereas no change was observed in healthy controls (p = .59). The exercise-induced fall in FEV(1) in asthmatics was related to the increase in EBC Cys-LT concentration (r = -0.40, p = .03). CONCLUSIONS Our study shows that Cys-LT concentration of EBC is elevated minutes after physical exercise in asthmatic patients and strongly supports the concept that the release of this mediator is involved in the development of EIB.
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Affiliation(s)
- András Bikov
- Department of Pulmonology, Semmelweis University, Budapest, Hungary
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48
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Abstract
Exercise-induced bronchospasm (EIB) is a common occurrence in individuals with asthma, though it can also affect individuals without asthma. It occurs frequently in athletes. Common symptoms include coughing, dyspnea, chest tightness, and wheezing; however, there can be a variety of more subtle symptoms. The differential diagnosis of EIB is broad and includes several pulmonary and cardiac disorders. During the initial evaluation, a complete history, physical examination, and spirometry should be performed. In most patients with EIB, the baseline spirometry is normal; therefore, bronchoprovocation testing is strongly recommended. Both pharmacologic and nonpharmacologic approaches are important in the treatment of EIB. Management of EIB on the sideline of athletic events requires preparation and immediate access to rescue inhalers.
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Affiliation(s)
- Jonathan P Parsons
- The Ohio State University Medical Center, Ohio State University Asthma Center, Columbus, OH, USA.
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49
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Anderson SD, Pearlman DS, Rundell KW, Perry CP, Boushey H, Sorkness CA, Nichols S, Weiler JM. Reproducibility of the airway response to an exercise protocol standardized for intensity, duration, and inspired air conditions, in subjects with symptoms suggestive of asthma. Respir Res 2010; 11:120. [PMID: 20807446 PMCID: PMC2939602 DOI: 10.1186/1465-9921-11-120] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2010] [Accepted: 09/01/2010] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Exercise testing to aid diagnosis of exercise-induced bronchoconstriction (EIB) is commonly performed. Reproducibility of the airway response to a standardized exercise protocol has not been reported in subjects being evaluated with mild symptoms suggestive of asthma but without a definite diagnosis. This study examined reproducibility of % fall in FEV1 and area under the FEV1 time curve for 30 minutes in response to two exercise tests performed with the same intensity and duration of exercise, and inspired air conditions. METHODS Subjects with mild symptoms of asthma exercised twice within approximately 4 days by running for 8 minutes on a motorized treadmill breathing dry air at an intensity to induce a heart rate between 80-90% predicted maximum; reproducibility of the airway response was expressed as the 95% probability interval. RESULTS Of 373 subjects challenged twice 161 were positive (≥ 10% fall FEV1 on at least one challenge). The EIB was mild and 77% of subjects had <15% fall on both challenges. Agreement between results was 76.1% with 56.8% (212) negative (< 10% fall FEV1) and 19.3% (72) positive on both challenges. The remaining 23.9% of subjects had only one positive test. The 95% probability interval for reproducibility of the % fall in FEV1 and AUC0-30 min was ± 9.7% and ± 251% for all 278 adults and ± 13.4% and ± 279% for all 95 children. The 95% probability interval for reproducibility of % fall in FEV1 and AUC0-30 min for the 72 subjects with two tests ≥ 10% fall FEV1 was ± 14.6% and ± 373% and for the 34 subjects with two tests ≥ 15% fall FEV1 it was ± 12.2% and ± 411%. Heart rate and estimated ventilation achieved were not significantly different either on the two test days or when one test result was positive and one was negative. CONCLUSIONS Under standardized, well controlled conditions for exercise challenge, the majority of subjects with mild symptoms of asthma demonstrated agreement in test results. Performing two tests may need to be considered when using exercise to exclude or diagnose EIB, when prescribing prophylactic treatment to prevent EIB and when designing protocols for clinical trials.
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Affiliation(s)
- Sandra D Anderson
- Department of Respiratory & Sleep Medicine, 11 West, Royal Prince Alfred Hospital, Missenden Road, Camperdown NSW 2050, Australia
- Sydney Medical School, University of Sydney, NSW 2006, Australia
| | - David S Pearlman
- Colorado Allergy and Asthma Centers, Suite 150/125 Rampart Way, Denver CO 80230- 6405, USA
| | - Kenneth W Rundell
- Professor of The Basic Sciences, The Commonwealth Medical College, 150 North Washington Avenue, Scranton PA, PA 18503-1843, USA
| | - Claire P Perry
- Department of Respiratory & Sleep Medicine, 11 West, Royal Prince Alfred Hospital, Missenden Road, Camperdown NSW 2050, Australia
| | - Homer Boushey
- Asthma Clinical Research Center, University of California, San Francisco CA 90089, USA
| | - Christine A Sorkness
- Department of Medicine, Allergy and Asthma Clinical Research, University of Wisconsin, Madison, WI 53705, USA
| | - Sara Nichols
- CompleWare Corporation, PO Box 3090, North Liberty, IA 52317, USA
| | - John M Weiler
- CompleWare Corporation, PO Box 3090, North Liberty, IA 52317, USA
- Department of Internal Medicine, University of Iowa, Iowa City, IA52242, USA
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50
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Abstract
PURPOSE OF REVIEW Leukotrienes are lipid mediators involved in the pathogenesis of asthma. There is significant new information about the actions of leukotrienes in asthma and the evolving role of antileukotriene therapies. We review recent findings on regulation of leukotriene synthesis, biological function of leukotrienes in disease models, and use of leukotriene modifiers in clinical practice. RECENT FINDINGS Our understanding of the regulation of leukotriene synthesis at a molecular level has greatly advanced. Recent evidence indicates that genetic variation in the leukotriene synthetic pathway affects the clinical response to leukotriene modifiers. The participation of leukotriene B4 in the allergic sensitization process in animal models suggests a larger role for leukotriene B4 in asthma. Preclinical and in-vitro models suggest that the cysteinyl leukotrienes are important in airway remodeling. Leukotrienes are key mediators of exercise-induced bronchoconstriction with recent studies demonstrating that leukotriene modifiers reduce the severity of exercise-induced bronchoconstriction during short-term and long-term use. SUMMARY Leukotrienes are clearly involved in airway inflammation and certain clinical features of asthma. Evolving evidence indicates that leukotriene B4 has an important role in the development of asthma and that cysteinyl leukotrienes are key mediators of the airway remodeling process.
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