Pulmonary Function Testing in Work-Related Asthma: An Overview from Spirometry to Specific Inhalation Challenge

Work-related asthma (WRA) is a very frequent condition in the occupational setting, and refers either to asthma induced (occupational asthma, OA) or worsened (work-exacerbated asthma, WEA) by exposure to allergens (or other sensitizing agents) or to irritant agents at work. Diagnosis of WRA is frequently missed and should take into account clinical features and objective evaluation of lung function. The aim of this overview on pulmonary function testing in the field of WRA is to summarize the different available tests that should be considered in order to accurately diagnose WRA. When WRA is suspected, initial assessment should be carried out with spirometry and bronchodilator responsiveness testing coupled with first-step bronchial provocation testing to assess non-specific bronchial hyper-responsiveness (NSBHR). Further investigations should then refer to specialists with specific functional respiratory tests aiming to consolidate WRA diagnosis and helping to differentiate OA from WEA. Serial peak expiratory flow (PEF) with calculation of the occupation asthma system (OASYS) score as well as serial NSBHR challenge during the working period compared to the off work period are highly informative in the management of WRA. Finally, specific inhalation challenge (SIC) is considered as the reference standard and represents the best way to confirm the specific cause of WRA. Overall, clinicians should be aware that all pulmonary function tests should be standardized in accordance with current guidelines.

Effect of CPAP on airway reactivity and airway inflammation in children with moderate-severe asthma

BACKGROUND AND OBJECTIVE

Asthma is characterized by airway hyperreactivity and airway inflammation. We previously demonstrated that adults with mild well-controlled asthma exhibited a marked decrease in airway reactivity (PC20 increased >2-fold) after using nocturnal continuous positive airway pressure (CPAP) for 1 week. If CPAP produces a similar suppression of airway reactivity in children with moderate-severe asthma, who require chronic use of corticosteroids, then this non-pharmacological therapy might provide a beneficial alternative or supplemental therapy in these subjects.

METHODS

Children aged 8-17 years with moderate-severe asthma were treated with 4 weeks of nocturnal CPAP (8-10 cm H2 O) or sham CPAP (<2 cm H2 O). Adherence was monitored with a modem installed in the equipment or by memory cards. Airway reactivity, assessed by methacholine bronchial challenge, was measured prior to and following treatment.

RESULTS

The percentage of subjects adherent to treatment was similar in both groups (19/27 CPAP vs 19/28 sham, ~70%). There was a tendency for PC20 to increase with treatment in both groups (3.0-5.3 mg/mL CPAP vs 3.2 to 4.3 mg/mL sham, P = 0.083); however, the change did not differ significantly between groups (P = 0.569).

CONCLUSION

We found that the 4-week treatment with nocturnal CPAP did not produce a twofold suppression of airway reactivity in children with moderate-severe asthma.

Objective confirmation of asthma diagnosis improves medication adherence

OBJECTIVE

The impact of diagnostic work-up in asthma management on medication redemption and probably also drug adherence is largely unknown, but we hypothesized that a confirmed diagnosis of asthma in a hospital-based out-patient clinic increases the willingness to subsequent medication redemption in a real life setting.

METHODS

In a retrospective register-based study, 300 medical records of patients referred with possible asthma during one year were examined, of whom 171 had asthma (57%). One-year data on dispensed medicine was collected using the Danish Registry of Medicinal Product Statistics. Patients who had a positive asthma (e.g. bronchial challenge) were classified as verified asthma, whereas unverified asthma refers to doctor's diagnosis of asthma with negative or no diagnostic tests performed.

RESULTS

111 (65%) had a verified diagnosis and patients with verified asthma were more frequently prescribed new therapy compared to those with unverified asthma (88.9% vs. 65.0%, respectively, p < 0.001). No difference was found in first time redemption of prescriptions (72% vs. 64%, respectively, p = 0.3), whereas the second (52% vs. 27%, p = 0.001) and third or more asthma redeemed prescriptions (37% vs. 17%, p = 0.006) showed increased redemption of prescription and probably adherence in the verified compared with the unverified patients with asthma. Furthermore, the use of inhaled corticosteroid (ICS) was calculated as Percent Days Covered (PDC), which was higher in the verified group compared with the non-verified asthma group (88% vs. 30%, p = 0.004).

CONCLUSION

Objective verification of a diagnosis of asthma using asthma tests was associated with an improved redemption of prescription.

Aerosol Use in the Pulmonary Function Lab

Aerosolized medications are frequently used in the pulmonary function laboratory. The 2 most common implementations are bronchodilators and bronchial challenge agents. Bronchodilator administration is not well standardized, largely because of the various methods of delivery available for clinical practice. Metered-dose inhalers used with spacer devices are the most common route for bronchodilator administration, but many laboratories use small-volume nebulizers. Interpretation of pre- and post-bronchodilator studies is confounded by the definitions of airway obstruction and bronchodilator responsiveness. Protocols for administering bronchial challenge aerosols (methacholine, mannitol, hypertonic saline) are well defined but are susceptible to some of the same problems that limit comparison of bronchodilator techniques. Bronchial challenges with inhaled aerosols are influenced not only by the delivery device but by the patient's breathing pattern, particularly in protocols that include deep inspiratory efforts.

Assessment of airway hyperreactivity: comparison of forced spirometry and body plethysmography for methacholine challenge tests

INTRODUCTION

Bronchial challenge tests by inhalation of aerosolized methacholine (MCH) are commonly used in the clinical diagnosis of airway hyperresponsiveness (AHR). While the detection of airway narrowing relies on the patient's cooperation performing forced spirometry, body plethysmographic measurements of airway resistance are less depending on the patient's cooperation and do not alter the respiratory tract by maximal maneuvers. Hence we compared both methods concerning their clinical value and correlation during MCH challenges in patients with asthma.

MATERIAL AND METHODS

Cumulative MCH challenges test, consisting of up to 5 steps, evaluated with body plethysmography on each step were performed in 155 patients with bronchial asthma. Airway responses were recorded at each step of MCH application (MasterScreen Body, Cardinal Health, Höchberg). At the baseline test and after crossing the provocation dose (PD) threshold in body plethysmography (PD+100 sReff), forced expirations were performed and FEV(1), FVC, and FEV(1) %FVC were measured. Using regression analysis of the airway parameters and taking the MCH dose as the covariate, we could extrapolate to missing spirometric values and interpolate the estimated MCH dose when crossing the PD threshold (PD-20 FEV(1)) between two consecutive measurements. The administered PD+100 MCH doses for specific airway resistance, sRtot, and sReff were compared with resistance parameters Rtot and Reff, and to PD-20 of FEV(1) and FEV(1) %FVC.

RESULTS

Regarding sReff we found a mild, moderate, or severe AHR in 114 patients (75%), but only 50 (32%) according to FEV1. A statistical analysis showed strongly linear correlated parameters of airway resistance, but no significant correlation between the results of body plethysmography and forced spirometry.

CONCLUSIONS

Using MCH challenges, we found specific airway resistance to be the most sensitive parameter to detect AHR. Raw is largely independent of height and gender facilitating the interpretation of measurements carried out longitudinally.

Pharmacodynamics and pharmacokinetics of BAY x 7195 aerosol, a new and selective receptor antagonist of cysteinyl-leukotrienes, in normal volunteers

1. The safety, tolerability and pharmacokinetics of BAY x 7195 aerosol, a new selective receptor antagonist of cysteinyl-leukotrienes, were investigated in healthy male volunteers in two observational studies (1 and 2 mg; n = 5 each) and two double blind, placebo-controlled two way crossover studies (4 and 8 mg; n = 6 each) using the commercially available Inhaler Ingelheim M. 2. The pharmacodynamic effect was assessed by testing the ability of BAY x 7195 aerosol to inhibit leukotriene-D4 (LTD4) induced bronchoconstriction in healthy volunteers. Using a double-blind, placebo-controlled three way crossover design, volunteers received 2 and 4 mg of BAY x 7195 by means of a newly developed metered dose dry powder inhaler. Bronchoprovocation with nebulized LTD4 was performed 20 min and 8 h (n = 6 each) after drug administration. Specific airways of conductance (SGaw) served to assess the airway's response. 3. BAY x 7195 aerosol was safe and well tolerated. Inhalation of the aerosol had no effect on baseline lung function. Only one volunteer reported cough following the inhalation of the 8 mg dose. 4. The pharmacokinetics of unchanged drug following the administration of BAY x 7195 aerosol were linear in the investigated range of doses and in general very similar to a previously investigated tablet formulation. Plasma-concentration vs time courses followed a two-compartment body model. Compared with oral administration of the tablet formulation absorption tended to be more rapid with the aerosol formulation. 5. Compared with placebo, 2 and 4 mg BAY x 7195 increased the concentration of LTD4 needed to produce a 35% decrease in SGaw 20 min after drug administration by a mean (geometric) of 14.2 and 29.7 fold, respectively. For both doses only three volunteers showed a protective effect against LTD4 induced bronchoconstriction 8 h after drug administration. Individual shifts in the concentration-response curve ranged between 0.4 and 7.2 fold. 6. In conclusion, the present results suggest that BAY x 7195 aerosol is a safe and potent but short acting receptor antagonist of cysteinyl leukotrienes in man.