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Gwen S. Skloot, MD; Paul L. Enright, MD, FCCP
Author and Funding Information

Affiliations: Dr. Skloot is affiliated with the Mt. Sinai School of Medicine. Dr. Enright is affiliated with the University of Arizona.

Correspondence to: Gwen S. Skloot, MD, Mount Sinai School of Medicine, One Gustave Levy Pl, PO Box 1232, New York, NY 10029; e-mail: gwen.skloot@mssm.edu


Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/site/misc/reprints.xhtml).


© 2009 American College of Chest Physicians


Chest. 2009;136(4):1183. doi:10.1378/chest.09-1404
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We appreciate the interest that Drs. Miller and Mann have taken in our article.1 They have made several insightful observations that warrant consideration. The relationship between bronchodilator responsiveness and change in lung function between examinations has already been clarified.2 Significant predictors of greater average decline in lung function between examinations were a lack of bronchodilator responsiveness at examination 1 and weight gain. We agree that the distribution of average changes in lung function between examinations shown in Figure 1 of our article1 is not skewed toward excessive loss. Indeed, the majority of those patients studied had a normal decline in lung function. It is noteworthy, however, that a subset of responders in our population (n = 131) were “rapid fallers” since they lost > 300 mL/yr in FVC. We are currently clinically characterizing these individuals to better understand their accelerated lung function decline.

We reported results from all World Trade Center responders who presented for examination, understanding that those with respiratory symptoms may have been more likely to participate. It is true that if we were able to evaluate all individuals who worked at Ground Zero regardless of symptoms, then the spirometry abnormality rates we reported might have been lower.

The issues related to bronchodilator responsiveness are indeed intriguing. Although some participants had a significant response only at the second examination, this does not mean that this was the “onset” of their responsiveness. There is great variability in bronchodilator response even in those with significant disease. It does not seem justifiable to conclude that those with a robust response only at examination 2 did not have pulmonary dysfunction that was related to exposure at the World Trade Center disaster.

We agree that one limitation of a retrospective review of spirometric quality is that the total lung capacity, expiratory reserve volume, and residual volume are unknown. The reduction in FVC could be due to a “less than full inspiratory capacity” due to patient errors in technique or alternatively to true restrictive lung disease, loss of the expiratory reserve volume due to body habitus or due to airtrapping (increased residual volume). Our technicians were trained to focus on inspiratory maneuvers as well as expiratory maneuvers. This training should have reduced the rate of artificially low FVC. Our results are indeed consistent with the development of reactive airway dysfunction syndrome among some responders with clinical recovery in the majority.

Financial/nonfinancial disclosures: Dr. Skloot has reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article. During the past 3 years, Dr. Enright has received about $20,000 for conducting pulmonary function quality assurance programs for clinical trials of patients with COPD (Pfizer), pulmonary fibrosis (InterMune), and diabetes (MannKind).

Skloot GS, Schechter CB, Herbert R, et al. Longitudinal assessment of spirometry in the World Trade Center Medical Monitoring program. Chest. 2009;135:492-498. [PubMed] [CrossRef]
 
Erratum Chest. 2009;135:1114
 

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Skloot GS, Schechter CB, Herbert R, et al. Longitudinal assessment of spirometry in the World Trade Center Medical Monitoring program. Chest. 2009;135:492-498. [PubMed] [CrossRef]
 
Erratum Chest. 2009;135:1114
 
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