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Kaminsky DA, He J, Henderson R, Dixon AE, Irvin CG, Mastronarde J, Smith LJ, Sugar EA, Wise RA, Holbrook JT. Bronchodilator response does not associate with asthma control or symptom burden among patients with poorly controlled asthma. Respir Med 2023; 218:107375. [PMID: 37536444 DOI: 10.1016/j.rmed.2023.107375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 07/26/2023] [Accepted: 07/27/2023] [Indexed: 08/05/2023]
Abstract
PURPOSE The purpose of this study was to determine how four different definitions of bronchodilator response (BDR) relate to asthma control and asthma symptom burden in a large population of participants with poorly controlled asthma. PROCEDURES We examined the baseline change in FEV1 and FVC in response to albuterol among 931 participants with poorly controlled asthma pooled from three clinical trials conducted by the American Lung Association - Airways Clinical Research Centers. We defined BDR based on four definitions and analyzed the association of each with asthma control as measured by the Asthma Control Test or Asthma Control Questionnaire, and asthma symptom burden as measured by the Asthma Symptom Utility Index. MAIN FINDINGS A BDR was seen in 31-42% of all participants, depending on the definition used. There was good agreement among responses (kappa coefficient 0.73 to 0.87), but only 56% of participants met all four definitions for BDR. A BDR was more common in men than women, in Blacks compared to Whites, in non-smokers compared to smokers, and in non-obese compared to obese participants. Among those with poorly controlled asthma, 35% had a BDR compared to 25% of those with well controlled asthma, and among those with a high symptom burden, 34% had a BDR compared to 28% of those with a low symptom burden. After adjusting for age, sex, height, race, obesity and baseline lung function, none of the four definitions was associated with asthma control or symptom burden. CONCLUSION A BDR is not associated with asthma control or symptoms in people with poorly controlled asthma, regardless of the definition of BDR used. These findings question the clinical utility of a BDR in assessing asthma control and symptoms.
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Affiliation(s)
- David A Kaminsky
- Pulmonary and Critical Care, University of Vermont Larner College of Medicine, Burlington, VT, USA.
| | - Jiaxian He
- Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Robert Henderson
- Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Anne E Dixon
- Pulmonary and Critical Care, University of Vermont Larner College of Medicine, Burlington, VT, USA
| | - Charles G Irvin
- Pulmonary and Critical Care, University of Vermont Larner College of Medicine, Burlington, VT, USA
| | | | - Lewis J Smith
- Northwestern University School of Medicine, Chicago, IL, USA
| | - Elizabeth A Sugar
- Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Robert A Wise
- Pulmonary and Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Janet T Holbrook
- Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
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Ioachimescu OC, Ramos JA, Hoffman M, McCarthy K, Stoller JK. Assessing bronchodilator response by changes in per cent predicted forced expiratory volume in one second. J Investig Med 2021; 69:1027-1034. [PMID: 33574095 PMCID: PMC8223640 DOI: 10.1136/jim-2020-001663] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/26/2021] [Indexed: 11/09/2022]
Abstract
In pulmonary function testing by spirometry, bronchodilator responsiveness (BDR) evaluates the degree of volume and airflow improvement in response to an inhaled short-acting bronchodilator (BD). The traditional, binary categorization (present vs absent BDR) has multiple pitfalls and limitations. To overcome these limitations, a novel classification that defines five categories (negative, minimal, mild, moderate and marked BDR), and based on % and absolute changes in forced expiratory volume in 1 s (FEV1), has been recently developed and validated in patients with chronic obstructive pulmonary disease, and against multiple objective and subjective measurements. In this study, working on several large spirometry cohorts from two different institutions (n=31 598 tests), we redefined the novel BDR categories based on delta post-BD–pre-BD FEV1 % predicted values. Our newly proposed BDR partition is based on several distinct intervals for delta post-BD–pre-BD % predicted FEV1 using Global Lung Initiative predictive equations. In testing, training and validation cohorts, the model performed well in all BDR categories. In a validation set that included only normal baseline spirometries, the partition model had a higher rate of misclassification, possibly due to unrestricted BD use prior to baseline testing. A partition that uses delta % predicted FEV1 with the following intervals ≤0%, 0%–2%, 2%–4%, 4%–8% and >8% may be a valid and easy-to-use tool for assessing BDR in spirometry. We confirmed in our cohorts that these thresholds are characterized by low variance and that they are generally gender-independent and race-independent. Future validation in other cohorts and in other populations is needed.
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Affiliation(s)
- Octavian C Ioachimescu
- Medicine, Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Emory University School of Medicine, Atlanta, Georgia, USA .,Sleep Medicine, Atlanta VA Medical Center, Decatur, Georgia, USA
| | - Jose A Ramos
- Respiratory Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Michael Hoffman
- Respiratory Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Kevin McCarthy
- Respiratory Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - James K Stoller
- Respiratory Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
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Area Under the Expiratory Flow-Volume Curve (AEX): Assessing Bronchodilator Responsiveness. Lung 2020; 198:471-480. [PMID: 32211978 PMCID: PMC7242267 DOI: 10.1007/s00408-020-00345-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 03/11/2020] [Indexed: 11/30/2022]
Abstract
Background Area under expiratory flow–volume curve (AEX) is a useful spirometric tool in stratifying respiratory impairment. The AEX approximations based on isovolumic flows can be used with reasonable accuracy when AEX is unavailable. We assessed here pre- to post-bronchodilator (BD) variability of AEX4 as a functional assessment tool for lung disorders. Methods The BD response was assessed in 4330 subjects by changes in FEV1, FVC, and AEX4, which were derived from FVC, peak expiratory flow, and forced expiratory flow at 25%, 50%, and 75% FVC. Newly proposed BD response categories (negative, minimal, mild, moderate and marked) have been investigated in addition to standard criteria. Results Using standard BD criteria, 24% of subjects had a positive response. Using the new BD response categories, only 23% of subjects had a negative response; 45% minimal, 18% mild, 9% moderate, and 5% had a marked BD response. Mean percent change of the square root AEX4 was 0.3% and 14.3% in the standard BD-negative and BD-positive response groups, respectively. In the new BD response categories of negative, minimal, mild, moderate, and marked, mean percent change of square root AEX4 was − 8.2%, 2.9%, 9.2%, 15.0%, and 24.8%, respectively. Conclusions Mean pre- to post-BD variability of AEX4 was < 6% and stratified well between newly proposed categories of BD response (negative, minimal, mild, moderate and marked). We suggest that AEX4 (AEX) could become a useful measurement for stratifying dysfunction in obstructive lung disease and invite further investigation into indications for using bronchodilator agents or disease-modifying, anti-inflammatory therapies.
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Hansen JE, Dilektasli AG, Porszasz J, Stringer WW, Pak Y, Rossiter HB, Casaburi R. A New Bronchodilator Response Grading Strategy Identifies Distinct Patient Populations. Ann Am Thorac Soc 2019; 16:1504-1517. [PMID: 31404502 PMCID: PMC6956832 DOI: 10.1513/annalsats.201901-030oc] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Accepted: 08/08/2019] [Indexed: 01/06/2023] Open
Abstract
Rationale: A positive bronchodilator response (BDR) according to American Thoracic Society/European Respiratory Society (ATS/ERS) guidelines require both 200 ml and 12% increase in forced expiratory volume in 1 second (FEV1) or forced vital capacity (FVC) after bronchodilator inhalation. This dual criterion is insensitive in those with high or low FEV1.Objectives: To establish BDR criteria with volume or percentage FEV1 change.Methods: The largest FEV1 and FVC were identified from three pre- and three post-bronchodilator maneuvers in COPDGene (Genetic Epidemiology of COPD) participants. A total of 7,741 individuals with coefficient of variation less than 15% for both FEV1 and FVC formed bronchodilator categories of FEV1 response: negative (≤0.00% or ≤0.00 L), minimal (>0.00% to ≤9.00% or >0.00 L to ≤0.09 L), mild (>9.00% to ≤16.00% or >0.09 L to ≤0.16 L), moderate (>16.00% to ≤26.00% or >0.16 L to ≤0.26 L), and marked (>26.00% or >0.26 L). These response size categories are based on empirical limits considering average FEV1 increase of approximately 160 ml and the clinically important difference for FEV1. To compare flow and volume response characteristics, BDR-FEV1 category assignments were applied for the BDR-FVC response.Results: Twenty percent met mild and 31% met moderate or marked BDR-FEV1 criteria, whereas 12% met mild and 33% met moderate or marked BDR-FVC criteria. In contrast, only 20.6% met ATS/ERS positive criteria. Compared with the negative BDR-FEV1 category, the minimal, mild, moderate, and marked BDR-FEV1 categories were associated with greater 6-minute-walk distance and lower St. George's Respiratory Questionnaire and modified Medical Research Council dyspnea scale scores. Compared with negative BDR, moderate and marked BDR-FEV1 categories were associated with fewer exacerbations, and minimal BDR was associated with lower computed tomography airway wall thickness. Compared with the negative category, all BDR-FVC categories were associated with increasing emphysema percentage and gas trapping percentage. Moderate and marked BDR-FVC categories were associated with higher St. George's Respiratory Questionnaire scores but fewer exacerbations and lower dyspnea scores.Conclusions: BDR grading by FEV1 volume or percentage response identified subjects otherwise missed by ATS/ERS criteria. BDR grades were associated with functional exercise performance, quality of life, exacerbation frequency, dyspnea, and radiological airway measures. BDR grades in FEV1 and FVC indicate different clinical and radiological characteristics.
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Affiliation(s)
| | - Asli G Dilektasli
- Rehabilitation Clinical Trials Center and
- Department of Pulmonary Medicine, Faculty of Medicine, Uludağ University, Bursa, Turkey; and
| | | | | | - Youngju Pak
- UCLA Clinical and Translational Science Institute, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, California
| | - Harry B Rossiter
- Rehabilitation Clinical Trials Center and
- Faculty of Biological Sciences, University of Leeds, Leeds, United Kingdom
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Affiliation(s)
- James E Hansen
- Department of Medicine, Harbor-UCLA Medical Center, Torrance, CA.
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Hansen JE. Has My Patient Responded? Am J Respir Crit Care Med 2012; 185:895; author reply 895; discussion 896. [DOI: 10.1164/ajrccm.185.8.895] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Pellegrino R, Brusasco V. Correspondence. Am J Respir Crit Care Med 2012. [DOI: 10.1164/ajrccm.185.8.896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Hansen JE, Sun XG, Adame D, Wasserman K. Argument for changing criteria for bronchodilator responsiveness. Respir Med 2008; 102:1777-83. [PMID: 18701269 DOI: 10.1016/j.rmed.2008.06.019] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2007] [Revised: 05/16/2008] [Accepted: 06/30/2008] [Indexed: 11/15/2022]
Abstract
BACKGROUND Extensively used current guidelines of the American Thoracic Society/European Respiratory Society (ATS/ERS) define a positive aerosolized bronchodilator (BD) response as: "...an increase in FEV(1) and/or FVC > or = 12% of control and > or = 200 mL." We hypothesized that BD responsiveness was better assessed using a statistical approach, linked to each individual's spirometric measurements, rather than the variability of others. DESIGN We retrospectively analyzed 1-year's pre- and post-BD spirometric tests from our hospital's clinical laboratory. Using measurements of forced expiratory volume in 1-s (FEV(1)), forced expiratory volume in 3-s (FEV(3)), and forced vital capacity (FVC) from each of three satisfactory forced pre-BD and three satisfactory forced post-BD spirometric maneuvers, we classified each of 313 consecutive patient studies as responders or non-responders in two ways. First, we used ATS/ERS guideline criteria based on population variability. Second, we used unpaired, single-tailed t-tests at P<0.05 for FEV(1), FEV(3), and FVC, considering the variability of and difference between each individual's pre- and post-BD maneuvers. RESULTS 135 studies were both ATS/ERS and t-test non-responders, three were ATS/ERS responders and t-test non-responders, 86 were ATS/ERS and t-test responders, and 89 were ATS/ERS non-responders and t-test responders. The latter 89 included many patients with either low baseline FEV(1) (< 1.50 L) who could not reach the 200 mL increase criterion or high baseline FEV(1) (> 3.00 L) who could not reach the 12% increase criterion. CONCLUSIONS We believe individual t-tests may categorize patient's BD responsiveness better than ATS/ERS guideline criteria which are based on population responses and require both fixed volume and percentage changes. Its usefulness by others remains to be shown.
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Affiliation(s)
- James E Hansen
- Division of Respiratory and Critical Care Physiology and Medicine, Department of Medicine, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA 90502, USA.
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RODRIGUES JR. ROBERTO, PEREIRA CARLOSALBERTODECASTRO. Resposta a broncodilatador na espirometria: que parâmetros e valores são clinicamente relevantes em doenças obstrutivas? ACTA ACUST UNITED AC 2001. [DOI: 10.1590/s0102-35862001000100007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Respostas estatísticas dos parâmetros funcionais são largamente utilizadas após administração de broncodilatador (Bd) nos laboratórios de função pulmonar em doenças com obstrução ao fluxo aéreo. Sua relevância clínica é discutível. Objetivo: Determinar que parâmetros espirométricos refletem a melhora na tolerância ao exercício e na dispnéia em resposta a broncodilatador em doenças pulmonares obstrutivas. Métodos: 50 pacientes com DPOC e/ou asma (VEF1/CVF = 41 ± 11%) realizaram manobras de CV lenta e forçada, VVM e um teste de caminhada em corredor de seis minutos após treinamento, antes e após salbutamol, 400mcg fornecido por spray com espaçador. As respostas a broncodilatador foram expressas em valores absolutos, como incremento em relação ao valor inicial e em relação aos valores previstos. Resposta após Bd foi considerada clinicamente significante quando a distância percorrida se elevou 30m ou mais e/ou a dispnéia foi reduzida dois ou mais pontos com qualquer aumento na caminhada. Resultados: 32 pacientes foram considerados respondedores (R) e 18 não respondedores (NR). Como a distância caminhada em seis minutos se correlacionou com a idade (rs = --0,38; p < 0,01), análise dos dados espirométricos foi realizada incluindo a idade como covariada e expressa como x ± EPE. O incremento do VEF1 não diferiu nos dois grupos: R = 255 ± 57ml, NR = 256 ± 43ml. Idem para a VVM: R = 11 ± 2L/min, NR = 10 ± 2L/min. A melhor separação (p < 0,01) foi dada pela mudança da capacidade inspiratória (CI) seguida da mudança da capacidade vital lenta (CV): CI% da inicial nos R = 23 ± 3% e os NR = 3 ± 4%; CI absoluta: R = 411 ± 58ml, NR = 163 ± 77ml; CI% previsto: R = 19 ± 3% e NR = 3 ± 4%. Para a CV os valores observados foram: CV% do inicial -- R = 18 ± 2% e NR = 9 ± 3%; CV absoluta -- R = 448 ± 52ml e NR = 256 ± 70ml. Incrementos para a CI > 15% do inicial e 0,3L e da CV > 15% da inicial e 0,4L separaram os respondedores com valor preditivo positivo (VPP) em torno de 90%. Conclusão: A melhora do VEF1, CVF e VVM não prediz melhora na capacidade de exercício após Bd. Esta é melhor refletida por aumentos na CI e/ou CV acima de 15% dos valores iniciais.
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Silverman JA, Sommer LZ, Robicsek A, Dickstein J, Greenberg A, Kruger J, Rucker J, Volgyesi G, Fisher JA, Iscoe S. Tracheal constrictor drive above the apneic threshold in anesthetized dogs. J Appl Physiol (1985) 2000; 89:2258-62. [PMID: 11090576 DOI: 10.1152/jappl.2000.89.6.2258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
We have previously shown that raising arterial PCO(2) (Pa(CO(2))) by small increments in dogs ventilated below the apneic threshold (AT) results in almost complete tracheal constriction before the return of phrenic activity (Dickstein JA, Greenberg A, Kruger J, Robicsek A, Silverman J, Sommer L, Sommer D, Volgyesi G, Iscoe S, and Fisher JA. J Appl Physiol 81: 1844-1849, 1996). We hypothesized that, if increasing chemical drive above the AT mediates increasing constrictor drive to tracheal smooth muscle, then pulmonary slowly adapting receptor input should elicit more tracheal dilation below the AT than above. In six methohexital sodium-anesthetized, paralyzed, and ventilated dogs, we measured changes in tracheal diameter in response to step increases in tidal volume (VT) or respiratory frequency (f) below and above the AT at constant Pa(CO(2)) ( approximately 40 and 67 Torr, respectively). Increases in VT (400-1,200 ml) caused significantly more (P = 0.005) tracheal dilation below than above AT (7.0 +/- 2.2 vs. 2.8 +/- 1.0 mm, respectively). In contrast, increases in f (14-22 breaths/min) caused similar (P = 0.93) tracheal dilations below and above (1.0 +/- 1.3 and 1.0 +/- 0.8 mm, respectively) AT. The greater effectiveness of dilator stimuli below compared with above the AT is consistent with the hypothesis that drive to tracheal smooth muscle increases even after attainment of maximal constriction. Our results emphasize the importance of controlling PCO(2) with respect to the AT when tracheal smooth muscle tone is experimentally altered.
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Affiliation(s)
- J A Silverman
- Department of Anaesthesia, Mount Sinai Hospital, University of Toronto, Toronto, Canada VM5G 1X5
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