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Plichta J, Majos A, Kuna P, Panek M. Nasal allergen and methacholine provocation tests influence co‑expression patterns of TGF‑β/SMAD and MAPK signaling pathway genes in patients with asthma. Exp Ther Med 2024; 28:445. [PMID: 39386939 PMCID: PMC11462400 DOI: 10.3892/etm.2024.12735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 07/16/2024] [Indexed: 10/12/2024] Open
Abstract
Asthma is characterized by chronic bronchial inflammation and is a highly heterogeneous disease strongly influenced by both specific and non-specific exogenous factors. The present study was performed to assess the effect of nasal allergen provocation tests and methacholine provocation tests on the mRNA co-expression patterns of genes (SMAD1/3/6/7, MPK1/3 and TGFB1/3) involved in SMAD and non-SMAD TGF-β signaling pathways in patients with asthma. Reverse transcription-quantitative PCR was performed on blood samples taken pre-provocation and 1 h post-provocation to assess gene expression changes. Of the 59 patients studied, allergen provocations were administered to 27 patients and methacholine provocations to 32 patients. Correlations between expression levels of studied genes were found to be influenced markedly by the challenge administered, challenge test result and time elapsed since challenge. Importantly, increases in expression levels for four gene pairs (MAPK1-SMAD3, MAPK3-SMAD3, SMAD1-SMAD3 and SMAD3-TGFB1) were found to correlate significantly with asthma occurrence in the allergen provocation cohort, but not in the methacholine provocation cohort. The present study allows us to draw the conclusion that both intranasal allergen and bronchial methacholine challenges influence mRNA co-expression patterns of the SMAD1/3/6/7, MPK1/3 and TGFB1/3 genes.
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Affiliation(s)
- Jacek Plichta
- Department of Internal Medicine, Asthma and Allergy, Medical University of Lodz, 90-153 Lodz, Poland
| | - Alicja Majos
- Department of Internal Medicine, Asthma and Allergy, Medical University of Lodz, 90-153 Lodz, Poland
- Department of General and Transplant Surgery, Asthma and Allergy, Medical University of Lodz, 90-153 Lodz, Poland
| | - Piotr Kuna
- Department of Internal Medicine, Asthma and Allergy, Medical University of Lodz, 90-153 Lodz, Poland
| | - Michał Panek
- Department of Internal Medicine, Asthma and Allergy, Medical University of Lodz, 90-153 Lodz, Poland
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Brannan JD, Kippelen P. Bronchial Provocation Testing for the Identification of Exercise-Induced Bronchoconstriction. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 8:2156-2164. [PMID: 32620430 DOI: 10.1016/j.jaip.2020.03.034] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 12/08/2019] [Revised: 03/10/2020] [Accepted: 03/14/2020] [Indexed: 01/26/2023]
Abstract
Exercise-induced bronchoconstriction (EIB) occurs in patients with asthma, children, and otherwise healthy athletes. Poor diagnostic accuracy of respiratory symptoms during exercise requires objective assessment of EIB. The standardized tests currently available are based on the assumption that the provoking stimulus to EIB is dehydration of the airway surface fluid due to conditioning large volumes of inhaled air. "Indirect" bronchial provocation tests that use stimuli to cause endogenous release of bronchoconstricting mediators from airway inflammatory cells include dry air hyperpnea (eg, exercise and eucapnic voluntary hyperpnea) and osmotic aerosols (eg, inhaled mannitol). The airway response to different indirect tests is generally similar in patients with asthma and healthy athletes with EIB. Furthermore, the airway sensitivity to these tests is modified by the same pharmacotherapy used to treat asthma. In contrast, pharmacological agents such as methacholine, given by inhalation, act directly on smooth muscle to cause contraction. These "direct" tests have been used traditionally to identify airway hyperresponsiveness in clinical asthma but are less useful to diagnose EIB. The mechanistic differences between indirect and direct tests have helped to elucidate the events leading to airway narrowing in patients with asthma and elite athletes, while improving the clinical utility of these tests to diagnose and manage EIB.
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Affiliation(s)
- John D Brannan
- Department of Respiratory and Sleep Medicine, John Hunter Hospital, New Lambton, NSW, Australia.
| | - Pascale Kippelen
- Centre for Human Performance, Exercise and Rehabilitation, Brunel University London, Uxbridge, United Kingdom; Division of Sport, Health and Exercise Sciences, College of Health and Life Sciences, Brunel University London, Uxbridge, United Kingdom
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Selvanathan J, Aaron SD, Sykes JR, Vandemheen KL, FitzGerald JM, Ainslie M, Lemière C, Field SK, McIvor RA, Hernandez P, Mayers I, Mulpuru S, Alvarez GG, Pakhale S, Mallick R, Boulet LP, Gupta S. Performance Characteristics of Spirometry With Negative Bronchodilator Response and Methacholine Challenge Testing and Implications for Asthma Diagnosis. Chest 2020; 158:479-490. [PMID: 32298731 DOI: 10.1016/j.chest.2020.03.052] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 02/27/2020] [Accepted: 03/21/2020] [Indexed: 10/24/2022] Open
Abstract
BACKGROUND In patients with a history suggestive of asthma, diagnosis is usually confirmed by spirometry with bronchodilator response (BDR) or confirmatory methacholine challenge testing (MCT). RESEARCH QUESTION We examined the proportion of participants with negative BDR testing who had a positive MCT (and its predictors) result and characteristics of MCT, including effects of controller medication tapering and temporal variability (and predictors of MCT result change), and concordance between MCT and pulmonologist asthma diagnosis. STUDY DESIGN AND METHODS Adults with self-reported physician-diagnosed asthma were recruited by random-digit dialing across Canada. Subjects performed spirometry with BDR testing and returned for MCT if testing was nondiagnostic for asthma. Subjects on controllers underwent medication tapering with serial MCTs over 3 to 6 weeks. Subjects with a negative MCT (the provocative concentration of methacholine that results in a 20% drop in FEV1 [PC20] > 8 mg/mL) off medications were examined by a pulmonologist and had serial MCTs after 6 and 12 months. RESULTS Of 500 subjects (50.5 ± 16.6 years old, 68.0% female) with a negative BDR test for asthma, 215 (43.0%) had a positive MCT. Subjects with prebronchodilator airflow limitation were more likely to have a positive MCT (OR, 1.90; 95% CI, 1.17-3.04). MCT converted from negative to positive, with medication tapering in 18 of 94 (19.1%) participants, and spontaneously over time in 25 of 165 (15.2%) participants. Of 231 subjects with negative MCT, 28 (12.1%) subsequently received an asthma diagnosis from a pulmonologist. INTERPRETATION In subjects with a self-reported physician diagnosis of asthma, absence of bronchodilator reversibility had a negative predictive value of only 57% to exclude asthma. A finding of spirometric airflow limitation significantly increased chances of asthma. MCT results varied with medication taper and over time, and pulmonologists were sometimes prepared to give a clinical diagnosis of asthma despite negative MCT. Correspondingly, in patients for whom a high clinical suspicion of asthma exists, repeat testing appears to be warranted.
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Affiliation(s)
- Janannii Selvanathan
- Keenan Research Center in the Li Ka Shing Knowledge Institute of St. Michael's Hospital, University of Toronto, Toronto, ON, Canada; Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Shawn D Aaron
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON
| | - Jenna R Sykes
- Department of Medicine, Division of Respirology, St. Michael's Hospital, Toronto, ON
| | | | - J Mark FitzGerald
- Centre for Heart and Lung Health, Vancouver Coastal Health Research Institute, Vancouver, BC
| | - Martha Ainslie
- Department of Medicine, University of Manitoba, Winnipeg, MB
| | | | - Stephen K Field
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB
| | - R Andrew McIvor
- Firestone Institute for Respiratory Health, McMaster University, Hamilton, ON
| | - Paul Hernandez
- Department of Medicine, Dalhousie University, QEII Health Sciences Centre, Halifax, NS
| | - Irvin Mayers
- Department of Medicine, University of Alberta, Edmonton, AB
| | - Sunita Mulpuru
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON
| | - Gonzalo G Alvarez
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON
| | - Smita Pakhale
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON
| | - Ranjeeta Mallick
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON
| | | | - Samir Gupta
- Keenan Research Center in the Li Ka Shing Knowledge Institute of St. Michael's Hospital, University of Toronto, Toronto, ON, Canada; Department of Medicine, Division of Respirology, St. Michael's Hospital, Toronto, ON.
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Lehrer PM, Irvin CG, Lu SE, Scardella A, Roehmheld-Hamm B, Aviles-Velez M, Graves J, Vaschillo EG, Vaschillo B, Hoyte F, Nelson H, Wamboldt FS. Heart Rate Variability Biofeedback Does Not Substitute for Asthma Steroid Controller Medication. Appl Psychophysiol Biofeedback 2019; 43:57-73. [PMID: 29124506 DOI: 10.1007/s10484-017-9382-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Despite previous findings of therapeutic effects for heart rate variability biofeedback (HRVB) on asthma, it is not known whether HRVB can substitute either for controller or rescue medication, or whether it affects airway inflammation. Sixty-eight paid volunteer steroid naïve study participants with mild or moderate asthma were given 3 months of HRVB or a comparison condition consisting of EEG alpha biofeedback with relaxing music and relaxed paced breathing (EEG+), in a two-center trial. All participants received a month of intensive asthma education prior to randomization. Both treatment conditions produced similar significant improvements on the methacholine challenge test (MCT), asthma symptoms, and asthma quality of life (AQOL). MCT effects were of similar size to those of enhanced placebo procedures reported elsewhere, and were 65% of those of a course of a high-potency inhaled steroid budesonide given to a sub-group of participants following biofeedback training. Exhaled nitric oxide decreased significantly only in the HRVB group, 81% of the budesonide effect, but with no significant differences between groups. Participants reported becoming more relaxed during practice of both techniques. Administration of albuterol after biofeedback sessions produced a large improvement in pulmonary function test results, indicating that neither treatment normalized pulmonary function as a potent controller medication would have done. Impulse oscillometry showed increased upper airway (vocal cord) resistance during biofeedback periods in both groups. These data suggest that HRVB should not be considered an alternative to asthma controller medications (e.g., inhaled steroids), although both biofeedback conditions produced some beneficial effects, warranting further research, and suggesting potential complementary effects. Various hypotheses are presented to explain why HRVB effects on asthma appeared smaller in this study than in earlier studies. Clinical Trial Registration NCT02766374.
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Affiliation(s)
- Paul M Lehrer
- Department of Psychiatry, Rutgers - Robert Wood Johnson Medical School, 671 Hoes Lane, Piscataway, NJ, 08854, USA.
| | - Charles G Irvin
- University of Vermont, Larner College of Medicine, Burlington, VT, USA
| | - Shou-En Lu
- Rutgers School of Public Health, Piscataway, NJ, USA
| | - Anthony Scardella
- Department of Psychiatry, Rutgers - Robert Wood Johnson Medical School, 671 Hoes Lane, Piscataway, NJ, 08854, USA
| | - Beatrix Roehmheld-Hamm
- Department of Psychiatry, Rutgers - Robert Wood Johnson Medical School, 671 Hoes Lane, Piscataway, NJ, 08854, USA
| | - Milisyaris Aviles-Velez
- Department of Psychiatry, Rutgers - Robert Wood Johnson Medical School, 671 Hoes Lane, Piscataway, NJ, 08854, USA
| | | | | | - Bronya Vaschillo
- Rutgers, The State University of New Jersey, Piscataway, NJ, USA
| | - Flavia Hoyte
- University of Colorado School of Medicine, Aurora, CO, USA.,National Jewish Health, Denver, CO, USA
| | - Harold Nelson
- University of Colorado School of Medicine, Aurora, CO, USA.,National Jewish Health, Denver, CO, USA
| | - Frederick S Wamboldt
- University of Colorado School of Medicine, Aurora, CO, USA.,National Jewish Health, Denver, CO, USA
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Lodge KM, Knolle MD, Jha A. Asthma: From Diagnosis to Endotype to Treatment. Am J Respir Crit Care Med 2019; 197:1065-1067. [PMID: 29494210 DOI: 10.1164/rccm.201710-2139rr] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Affiliation(s)
- Katharine M Lodge
- 1 Respiratory Medicine Division, Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Martin D Knolle
- 2 Department of Respiratory Medicine, Cambridge University Hospitals National Health Service (NHS) Foundation Trust, Cambridge, United Kingdom
| | - Akhilesh Jha
- 3 Royal Papworth Hospital NHS Foundation Trust, Cambridge, United Kingdom; and.,4 Imperial College London, London, United Kingdom
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Sano H, Tomita K, Sano A, Saeki S, Nishikawa Y, Nishiyama O, Iwanaga T, Tohda Y. Accuracy of objective tests for diagnosing adult asthma in symptomatic patients: A systematic literature review and hierarchical Bayesian latent-class meta-analysis. Allergol Int 2019; 68:191-198. [PMID: 30309809 DOI: 10.1016/j.alit.2018.08.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Revised: 08/13/2018] [Accepted: 08/20/2018] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND We obtain summary estimates of the accuracy of additional objective tests for the diagnosis of adult asthma using systematic review and meta-analysis of diagnostic test accuracy studies. METHODS Medline, Embase, and other relevant electronic databases were searched for papers published between January 1989 and December 2016. Studies were included if they evaluated the diagnostic accuracy of objective tests, including airway reversibility (AR), airway hyperresponsiveness (AHR), and fractionated exhaled nitric oxide (FeNO) for the diagnosis of adult asthma in patients with symptoms suggestive of asthma. If papers were assessed appropriate using the adapted QUADAS-2 tool, meta-analysis was conducted using the hierarchical bivariate model. This hierarchical model accounts for both within and between study variability. RESULTS Sixteen studies reported the performance of the evaluated objective tests at presentation. For diagnosis of adult asthma, overall sensitivity and specificity for AR were 0.39 (95% confidence interval [CI] 0.18 to 0.66) and 0.95 (95% CI 0.86 to 1.00); for AHR, 0.86 (95% CI 0.61 to 1.00) and 0.95 (95% CI 0.77 to 1.00); for FeNO, 0.65 (95% CI 0.53 to 0.77) and 0.83 (95% CI 0.75 to 0.90). Comprehensive comparison of three diagnostic tools for adult asthma using the back-calculated likelihood rate (LR) showed that AR and AHR corresponded to a higher LR+, and AHR gave a lower LR-. CONCLUSIONS In the current situation of no gold standard for diagnosis of adult asthma, AR and AHR are appropriate for ruling-in the true diagnosis, and AHR is superior for ruling-out a diagnosis. Since each objective test had a specific characteristic, it should be chosen depending on the situation, such as the capacity of the institution and the conditions of patients.
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Affiliation(s)
- Hiroyuki Sano
- Department of Respiratory Medicine and Allergology, Kindai University Faculty of Medicine, Osaka, Japan
| | - Katsuyuki Tomita
- Department of Respiratory Medicine, Yonago Medical Centre, Tottori, Japan.
| | - Akiko Sano
- Department of Respiratory Medicine and Allergology, Kindai University Faculty of Medicine, Osaka, Japan
| | - Shou Saeki
- Department of Respiratory Medicine and Allergology, Kindai University Faculty of Medicine, Osaka, Japan
| | - Yusaku Nishikawa
- Department of Respiratory Medicine and Allergology, Kindai University Faculty of Medicine, Osaka, Japan
| | - Osamu Nishiyama
- Department of Respiratory Medicine and Allergology, Kindai University Faculty of Medicine, Osaka, Japan
| | - Takashi Iwanaga
- Department of Respiratory Medicine and Allergology, Kindai University Faculty of Medicine, Osaka, Japan
| | - Yuji Tohda
- Department of Respiratory Medicine and Allergology, Kindai University Faculty of Medicine, Osaka, Japan
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Fretzayas A, Moustaki M, Loukou I, Douros K. Differentiating vocal cord dysfunction from asthma. J Asthma Allergy 2017; 10:277-283. [PMID: 29066919 PMCID: PMC5644529 DOI: 10.2147/jaa.s146007] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Vocal cord dysfunction (VCD)-associated symptoms are not rare in pediatric patients. Dyspnea, wheezing, stridor, chest pain or tightness and throat discomfort are the most commonly encountered symptoms. They may occur either at rest or more commonly during exercise in patients with VCD, as well as in asthmatic subjects. The phase of respiration (inspiration rather than expiration), the location of the wheezing origin, the rapid resolution of symptoms, and the timing occurring in relation to exercise, when VCD is exercise induced, raise the suspicion of VCD in patients who may have been characterized as merely asthmatics and, most importantly, had not responded to the appropriate treatment. The gold standard method for the diagnosis of VCD is fiberoptic laryngoscopy, which may also identify concomitant laryngeal abnormalities other than VCD. However, as VCD is an intermittent phenomenon, the procedure should be performed while the patient is symptomatic. For this reason, challenges that induce VCD symptoms should be performed, such as exercise tests. Recently, for the evaluation of patients with exercise-induced VCD, continuous laryngoscopy during exercise (such as treadmill, bicycle ergometer, swimming) was used. A definite diagnosis of VCD is of importance, especially for those patients who have been erroneously characterized as asthmatics, without adequate response to treatment. In these cases, another therapeutic approach is necessary, which will depend on whether they suffer solely from VCD or from both conditions.
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Affiliation(s)
- Andrew Fretzayas
- Third Department of Pediatrics, Athens University Medical School, "Attikon" University Hospital, Haidari, Greece.,Athens Medical Center, Department of Pediatrics, Marousi, Greece
| | - Maria Moustaki
- Department of Cystic Fibrosis, "Aghia Sofia", Children's Hospital, Athens, Greece
| | - Ioanna Loukou
- Department of Cystic Fibrosis, "Aghia Sofia", Children's Hospital, Athens, Greece
| | - Konstantinos Douros
- Respiratory Unit, Third Department of Pediatrics, Athens University Medical School, "Attikon" University Hospital, Haidari, Greece
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8
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Davis BE, Simonson SK, Blais CM, Cockcroft DW. Methacholine Challenge Testing: A Novel Method for Measuring PD 20. Chest 2017; 152:1251-1257. [PMID: 28923758 DOI: 10.1016/j.chest.2017.09.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 07/13/2017] [Accepted: 09/06/2017] [Indexed: 10/18/2022] Open
Abstract
BACKGROUND New guidelines for methacholine challenge testing recommend reporting the test outcome as dose rather than concentration. Jet nebulizers have historically been used for methacholine challenge testing, but much of the weight loss, often (incorrectly) referred to as aerosol output, is actually evaporation. The Wright nebulizer is well characterized and still widely used, but its availability is unclear, and it is nondisposable. We developed a novel method using a vibrating mesh nebulizer (Solo). This method was compared with the standard 2-min tidal breathing method using the Wright nebulizer. Repeatability within and between nebulizers was also tested. METHODS Fifteen patients with mild asthma completed four methacholine challenges (two with the Solo vibrating mesh nebulizer and two with the Wright jet nebulizer). Challenges with the same nebulizer were 24 h apart, and challenges between nebulizers were separated by 1 week. Standard 2-min tidal breathing methods were used with the Wright nebulizer. For the Solo nebulizer, the tidal breathing method was modified by nebulizing to completion 0.5 mL of doubling concentrations of methacholine at 5-min intervals. RESULTS Geometric mean methacholine doses required to cause a 20% fall in FEV1 were similar (96 vs 110 μg; P > .05); methacholine concentrations that caused a 20% fall in FEV1 were significantly lower with the vibrating mesh nebulizer (0.48 vs 4.4 mg/mL; P < .001). Repeatability of methacholine doses required to cause a 20% fall in FEV1 within and between nebulizers was excellent (intraclass correlation coefficient > 0.92). CONCLUSIONS We have developed a novel, simple, repeatable method for conducting methacholine challenges using new nebulizer technology. Importantly, the method meets recommendations set out in the new guidelines. TRIAL REGISTRY ClinicalTrials.gov; No.: 02965482; URL: www.clinicaltrials.gov.
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Affiliation(s)
- Beth E Davis
- Department of Physiology, College of Medicine, University of Saskatchewan, Saskatoon, SK, Canada; Division of Respirology, Critical Care and Sleep Medicine, Department of Medicine, University of Saskatchewan, Saskatoon, SK, Canada.
| | - Samuel K Simonson
- Department of Physiology, College of Medicine, University of Saskatchewan, Saskatoon, SK, Canada
| | - Christianne M Blais
- Department of Physiology, College of Medicine, University of Saskatchewan, Saskatoon, SK, Canada
| | - Donald W Cockcroft
- Department of Physiology, College of Medicine, University of Saskatchewan, Saskatoon, SK, Canada; Division of Respirology, Critical Care and Sleep Medicine, Department of Medicine, University of Saskatchewan, Saskatoon, SK, Canada
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9
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The role of airway hyperresponsiveness measured by methacholine challenge test in defining asthma severity in asthma-obesity syndrome. Curr Opin Allergy Clin Immunol 2017; 16:218-23. [PMID: 27054318 DOI: 10.1097/aci.0000000000000272] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
PURPOSE OF REVIEW Asthma is a complex disease defined by chronic inflammation of the airways. In research and clinical practice measures used for diagnosis, an assessment of control and severity of asthma are varied and there exists no gold standard. To date, several studies have explored the link between obesity and asthma although the exact mechanism is not yet fully understood. A study undertaken by our research group in 2015, on the effects of weight loss on asthma severity in obese asthmatics, demonstrated that an improvement in airway hyperresponsiveness could be achieved after significant weight reduction with a weight loss program. The objective of this article is to review the current literature for the primary and secondary outcomes studied to estimate the effects of weight loss on asthma severity in adults with obesity and asthma. RECENT FINDINGS A review of the most recent research conducted since 2014 demonstrates that effects of weight loss on asthma severity in adults with obesity and asthma has not been the focus of majority of the studies. Apart from our study published in 2015, very few studies used airway hyperresponsiveness as the primary or secondary outcome measure. The literature reveals that significant weight loss does, however, lead to improvement in asthma severity and control in adults with obesity and asthma. SUMMARY The current literature suggests that improvement in lung function requires moderate to significant (5-10%) weight loss in adults with obesity and asthma. However, with a few exceptions, the majority of these studies were small and used variable and questionable asthma severity outcome measures. There is an urgent need for standardization of diagnosis of asthma, study inclusion criteria, and outcome measures to assess asthma severity in research setting. Long-term effects of weight loss interventions on asthma severity and control, in adults with obesity and asthma, also remain unanswered.
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10
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Chapman DG, Irvin CG. Mechanisms of airway hyper-responsiveness in asthma: the past, present and yet to come. Clin Exp Allergy 2015; 45:706-19. [PMID: 25651937 DOI: 10.1111/cea.12506] [Citation(s) in RCA: 92] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Airway hyper-responsiveness (AHR) has long been considered a cardinal feature of asthma. The development of the measurement of AHR 40 years ago initiated many important contributions to our understanding of asthma and other airway diseases. However, our understanding of AHR in asthma remains complicated by the multitude of potential underlying mechanisms which in reality are likely to have different contributions amongst individual patients. Therefore, the present review will discuss the current state of understanding of the major mechanisms proposed to contribute to AHR and highlight the way in which AHR testing is beginning to highlight distinct abnormalities associated with clinically relevant patient populations. In doing so we aim to provide a foundation by which future research can begin to ascribe certain mechanisms to specific patterns of bronchoconstriction and subsequently match phenotypes of bronchoconstriction with clinical phenotypes. We believe that this approach is not only within our grasp but will lead to improved mechanistic understanding of asthma phenotypes and we hoped to better inform the development of phenotype-targeted therapy.
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Affiliation(s)
- D G Chapman
- Woolcock Institute of Medical Research, Sydney Medical School, University of Sydney, Sydney, NSW, Australia; Department of Medicine, University of Vermont College of Medicine, Burlington, VT, USA
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11
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Abstract
BACKGROUND Bronchial hyperresponsiveness (BHR) is often regarded as a 'hallmark' of asthma and bronchoprovocation testing is frequently performed to support a diagnosis of asthma. However, BHR is also found in a spectrum of other lung diseases and can be provoked by a variety of specific stimuli. AIMS To review the pathophysiology of BHR, discuss various methods of testing for BHR and describe the epidemiology of BHR in a variety of previously studied populations. METHODS We performed a systematic review of references identified using Medline and hand searches of identified articles. Because of space limitations, we have included those reports that seem most representative of the overall BHR literature. RESULTS BHR can be induced by a variety of stimuli that trigger a number of different but overlapping physiological mechanisms. Bronchoprovocation testing can be performed using a variety of stimuli, various protocols and differing test criteria, yielding results that may be discordant. Elevated rates of BHR have been reported in studies of smokers, chronic obstructive pulmonary disease patients, atopics, athletes, exposed workers and the general population. CONCLUSIONS Due to the prevalence of BHR in a spectrum of clinical patients and working populations, clinicians should be aware that BHR is not specific for asthma. When performed correctly, the greatest clinical value of BHR testing is to rule out suspected asthma in patients in whom testing is negative. Assessment of BHR also provides insights into the pathological mechanisms of airway disease.
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Affiliation(s)
- J Borak
- Department of Environmental Health Sciences, Yale School of Public Health, Yale University, New Haven, CT 06510, USA, Department of Internal Medicine (Yale Occupational and Environmental Medicine Program), Yale School of Medicine, Yale University, New Haven, CT 06510, USA.
| | - R Y Lefkowitz
- Department of Internal Medicine (Yale Occupational and Environmental Medicine Program), Yale School of Medicine, Yale University, New Haven, CT 06510, USA
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12
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Peiman S, Abtahi H, Akhondzadeh S, Safavi E, Moin M, Rahimi Foroushani A. Fluticasone propionate in clinically suspected asthma patients with negative methacholine challenge test. CLINICAL RESPIRATORY JOURNAL 2015; 11:433-439. [PMID: 26256808 DOI: 10.1111/crj.12353] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 08/24/2014] [Revised: 05/17/2015] [Accepted: 08/03/2015] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Despite reports of response to steroid inhaler in some clinically suspected asthma patients with negative methacholine challenge test (CSA/MCT-), treatment in these patients has not been prospectively studied. OBJECTIVE We studied the role of a 12 week high dose inhaled fluticasone trial in CSA/MCT- patients. METHODS After a 2 week run-in period, CSA/MCT-patients were treated with 12 weeks of Fluticasone propionate 1000 µg/day. The Asthma Control Test (ACT), numeric cough score (NCS) and bronchodilator use were compared with their pretreatment values. RESULTS Thirty-four of 42 CSA/MCT-patients completed the study. Mean pretreatment ACT score (pACT) was significantly increased after treatment (14.7 ± 3.37 to 20.9 ± 3.1, P < 0.001). Posttreatment values of daytime (1.0 ± 1.0) and night-time (0.6 ± 0.9) NCS decreased compared to their pretreatment values (2.8 ± 1.1 and 1.9 ± 1.3, respectively; P < 0.001). ACT score change (ΔACT) were significantly greater in those with pACT < 15 than in those ≥15 (P < 0.001) . Fifteen of 21 patients with ΔACT > 5 did not need to use bronchodilator for their symptom relief. Wheeze disappeared in all six patients with ΔACT > 5 after the trial. Six months after the study, steroid inhaler continued to be used by 72.2% of patients. CONCLUSION A significant portion of CSA/MCT- (especially those with pretreatment ACT score <15) respond to high dose fluticasone inhaler in terms of symptoms relief, disappearance of wheeze and need to bronchodilator use. ΔACT could not be predicted with any individual symptoms or signs before MCT, % FEV1 decline or symptoms during MCT and exhaled nitric oxide.
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Affiliation(s)
- Soheil Peiman
- Department of Pulmonary and Critical Care, Advanced Thoracic Research Center, Imamkhomeini Medical center, Tehran University of Medical Sciences, Tehran, Iran
| | - Hamidreza Abtahi
- Department of Pulmonary and Critical Care, Advanced Thoracic Research Center, Imamkhomeini Medical center, Tehran University of Medical Sciences, Tehran, Iran
| | - Shahin Akhondzadeh
- Department of Psychiatry, Psychiatric Research Center, Roozbeh Psychiatric Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Enayat Safavi
- Department of Pulmonary and Critical Care, Advanced Thoracic Research Center, Imamkhomeini Medical center, Tehran University of Medical Sciences, Tehran, Iran
| | - Mostafa Moin
- Department of Pediatrics, Immunology, Asthma and Allergy Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Abbas Rahimi Foroushani
- Department of Epidemiology and Biostatistics, School of Public Health and Institute of Public Health Research, Tehran University of Medical Sciences, Tehran, Iran
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Mazi A, Lands LC. Effect of lowering methacholine challenge test cutoff in children. Ann Allergy Asthma Immunol 2014; 113:393-7. [PMID: 25091717 DOI: 10.1016/j.anai.2014.06.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2014] [Revised: 06/17/2014] [Accepted: 06/25/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND The diagnosis of asthma is based on clinical judgment, history of personal or familial atopy, and testing, typically with a methacholine challenge test (MCT). Guidelines suggest a provocation concentration that caused a decrease in forced expiratory volume in 1 second of 20% (PC20) cutoff of 4 mg/mL for a positive test result. OBJECTIVE To investigate the effect of lowering the MCT PC20 cutoff from 8 to 4 mg/mL on the number of positive test results and the distribution of test results. METHODS A retrospective study was conducted at the Montreal Children's Hospital from January 1, 2006, through June 31, 2012, on patients referred by nonrespiratory physicians. A 2-minute tidal breathing dosing protocol was used, and the PC20 was calculated by linear interpolation. RESULTS A total of 748 patients were tested using spirometry. A total of 134 (17.9%) had a negative MCT result, and 614 (81.1%) responded at 8 mg/mL or less. A total of 570 patients (92.8% of respondents) responded at a dose of 4 mg/mL or higher (median PC20 of 0.47 mg/mL), with the remainder (7.2% of respondents) responding at a dose between 4 and 8 mg/mL (median PC20 of 6.37 mg/mL). There was no difference in the number of positive test results between the sexes, regardless of cutoff. The sensitivity of MCT was 82.1% at a cutoff of 8 mg/mL and 76.2% at 4 mg/mL. With a pretest likelihood of asthma of 75%, the specificity was 71.2%. CONCLUSION In a standard pediatric referral population, using a PC20 cutoff of 4 mg/mL provided a sensitivity of 76.2%, and only excluded 5.8% of all those referred for suspicion of asthma (7.2% of all test results were ≤8 mg/mL). This finding suggests that a PC20 of 4 mg/mL can reasonably be used as a cutoff for a positive MCT result in children.
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Affiliation(s)
- Ahlam Mazi
- Division of Pediatric Respiratory Medicine, Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Larry C Lands
- Division of Pediatric Respiratory Medicine, Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada.
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The challenge of objective confirmation of asthma diagnosis in primary care. NPJ Prim Care Respir Med 2014; 24:14032. [PMID: 25056516 PMCID: PMC4373401 DOI: 10.1038/npjpcrm.2014.32] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2013] [Revised: 01/13/2014] [Accepted: 01/21/2014] [Indexed: 11/30/2022] Open
Abstract
Asthma represents one of the most common chronic conditions encountered in primary care and diagnosis should be confirmed objectively with the demonstration of variable airflow obstruction. As many asthmatics have normal lung function at the time of clinical presentation, objective confirmation of airflow limitation may be challenging. Fluctuations in airflow obstruction can be documented with simple office spirometry after bronchodilator challenge, home monitoring of peak expiratory flow and bronchoconstriction induced by spasmogens such as methacholine. We present a case highlighting the challenge of objective confirmation of asthma diagnosis in primary care and provide a critical review of the diagnostic approaches highlighted above. Our aim is to provide a pragmatic interpretation of the available literature with a view to assisting clinicians in selecting the diagnostic test best suited for individualised patient encounters.
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Airway hyper-responsiveness in lipopolysaccharide-challenged common marmosets (Callithrix jacchus). Clin Sci (Lond) 2013; 126:155-62. [PMID: 23879175 PMCID: PMC3793853 DOI: 10.1042/cs20130101] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Animal models with a high predictive value for human trials are needed to develop novel
human-specific therapeutics for respiratory diseases. The aim of the present study was to examine
lung-function parameters in marmoset monkeys (Callithrix jacchus) that can be used
to detect pharmacologically or provocation-induced AHR (airway hyper-responsiveness). Therefore a
custom-made lung-function device that allows application of defined aerosol doses during measurement
was developed. It was hypothesized that LPS (lipopolysaccharide)-challenged marmosets show AHR
compared with non-challenged healthy subjects. Invasive plethysmography was performed in 12
anaesthetized orotracheally intubated and spontaneously breathing marmosets. Pulmonary data of
RL (lung resistance), Cdyn (dynamic
compliance), EF50 (mid-expiratory flow), Poes (oesophageal
pressure), MV (minute volume), respiratory frequency (f) and
VT (tidal volume) were collected. Measurements were conducted under
baseline conditions and under MCh (methacholine)-induced bronchoconstriction. The measurement was
repeated with the same group of animals after induction of an acute lung inflammation by
intratracheal application of LPS. PDs (provocative doses) of MCh to achieve a certain increase in
RL were significantly lower after LPS administration. AHR was
demonstrated in the LPS treated compared with the naïve animals. The recorded lung-function
data provide ground for pre-clinical efficacy and safety testing of anti-inflammatory substances in
the common marmoset, a new translational NHP (non-human primate) model for LPS-induced lung
inflammation.
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