Affiliations: Dr. Parsons is affiliated with The Ohio State University Medical Center.
Correspondence to: Jonathan P. Parsons, MD, MSc, FCCP, 201 Davis Heart/Lung Research Institute, 473 W 12th Ave, Columbus, OH 43210; e-mail: firstname.lastname@example.org
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
I read with interest the article by Pohlig1 in a recent issue of CHEST (January 2009) outlining coding and billing for exercise-induced bronchospasm (EIB). I was concerned about a statement that the author made concerning diagnostic evaluation for EIB. The author states that exercise testing and/or eucapnic voluntary hyperventilation (EVH) testing have significant logistical drawbacks and therefore, methacholine challenge is the “preferred” method for diagnosis of EIB. In the article,1 the author writes: “Therefore, methacholine or histamine challenges are more sensitive and preferred for the average individual.”
I strongly disagree with the author's statement. A 2007 workgroup report on EIB from the American Academy of Allergy, Asthma & Immunology2 stated that methacholine challenge is a “suboptimal” test for the documentation of EIB. In addition, one of the studies by Rundell et al3 that the author uses to support her statement in fact states that direct challenges such as methacholine are less sensitive than physical challenges such as exercise or EVH testing. That same article by Rundell et al3 was comparing EVH testing to field-exercise testing in elite cold weather athletes and did not support the author's statement about methacholine challenge testing. It also does not apply to “average individuals” as the author writes, because the study by Rundell et al3 was a study of elite athletes. Many authors have stated4,5 that methacholine challenge is not sensitive and specific to the bronchoconstriction associated with exercise, and that in reality it is a less preferred test for the documentation of EIB than EVH testing or exercise.
The author also states that EVH testing may “overdiagnose” EIB; however, no evidence is provided to support that statement. It is true that many of the prevalence studies related to EIB have included populations of athletes and that EVH testing might be best suited for that population. However, I am not aware of any data to support the author's statement about overdiagnosis, as one would need a “gold standard” diagnostic test to which one could compare EVH, and that test is not available at this time.
Financial/nonfinancial disclosures: Dr. Parsons has received honoraria from GlaxoSmithKline, Inc; Merck, Inc; AstraZeneca, Inc; and Schering-Plough, Inc.
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