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A Better Way to Assess BronchoreversibilityA Better Way to Assess Bronchoreversibility FREE TO VIEW

James E. Hansen, MD, FCCP
Author and Funding Information

From the Department of Medicine, Harbor-UCLA Medical Center.

Correspondence to: James E. Hansen, MD, FCCP, Department of Medicine, Harbor-UCLA Medical Center, 1000 W Carson St, Torrance, CA 90509; e-mail: jimandbev@cox.net


Financial/nonfinancial disclosures: The author has reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

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


© 2012 American College of Chest Physicians


Chest. 2012;141(4):1118. doi:10.1378/chest.11-2705
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To the Editor:

The well-written article by Hanania et al1 in CHEST (October 2011) stresses the importance and usefulness of measuring the short- and long-term effects of drugs that affect bronchoreversibility in patients with obstructive lung disease. The authors carefully compare several criteria for a positive response1 after aerosol drug administration in the laboratory. All of these criteria1 are based on population-based “clinical” limits rather than the variability of the individual being tested. All criteria compare only the “best of three” predrug and postdrug FEV1 and/or FVC spirometry values that meet American Thoracic Society standards2 and ignore data from other forced exhalations.

It is surprising that these authors (as well as many others) did not use more of the data available from bronchodilator testing by considering all six spirometric maneuvers so that each patient’s response could be analyzed statistically. As reported previously, a Student t test or rank-order test allows determination of when changes in FEV1, FEV3, FEV6, and/or FVC are statistically significant and markedly changes the detection of responsiveness.3,4 As pointed out recently by Dolmage et al5 in evaluating the 6-min walk test, it is the consistency of change that determines whether a response to an intervention is statistically significant. For example, as the result of an intervention, a vehicle mileage change from 13, 12, and 11 miles per gallon to 16, 15, and 14 miles per gallon (25% average increase) would be statistically significant and usually important.

Among the current American Thoracic Society guidelines,6 the guideline requiring a >200 mL response in those with a low FEV1 to identify bronchoreversibility is the most troublesome. An intervention changing FEV1 from 560, 600, and 640 mL to 750, 700, and 800 mL (25% average increase) may well improve dyspnea and the quality of life in a patient with COPD. Despite any added disclaimer, to report such a patient as nonresponsive is misleading. Whenever possible, should not we, who see the raw spirometric data, report the consistency, statistical significance, and percentage of the patient’s change when we are asked to measure bronchoreversibility?

Hanania NA, Celli BR, Donohue JF, Martin UJ. Bronchodilator reversibility in COPD. Chest. 2011;1404:1055-1063 [CrossRef] [PubMed]
 
Standardization of spirometry, 1994 update. American Thoracic Society. Am J Respir Crit Care Med. 1995;1523:1107-1136 [PubMed]
 
Hansen JE, Casaburi R, Goldberg AS. A statistical approach for assessment of bronchodilator responsiveness in pulmonary function testing. Chest. 1993;1044:1119-1126 [CrossRef] [PubMed]
 
Hansen JE, Sun XG, Adame D, Wasserman K. Argument for changing criteria for bronchodilator responsiveness. Respir Med. 2008;10212:1777-1783 [CrossRef] [PubMed]
 
Dolmage TE, Hill K, Evans RA, Goldstein RS. Has my patient responded? Interpreting clinical measurements such as the six minute walk test. Am J Respir Crit Care Med. 2011;1846:643-646 [CrossRef]
 
Pellegrino R, Viegi G, Brusasco V, et al. Interpretative strategies for lung function tests. Eur Respir J. 2005;265:948-968 [CrossRef] [PubMed]
 

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References

Hanania NA, Celli BR, Donohue JF, Martin UJ. Bronchodilator reversibility in COPD. Chest. 2011;1404:1055-1063 [CrossRef] [PubMed]
 
Standardization of spirometry, 1994 update. American Thoracic Society. Am J Respir Crit Care Med. 1995;1523:1107-1136 [PubMed]
 
Hansen JE, Casaburi R, Goldberg AS. A statistical approach for assessment of bronchodilator responsiveness in pulmonary function testing. Chest. 1993;1044:1119-1126 [CrossRef] [PubMed]
 
Hansen JE, Sun XG, Adame D, Wasserman K. Argument for changing criteria for bronchodilator responsiveness. Respir Med. 2008;10212:1777-1783 [CrossRef] [PubMed]
 
Dolmage TE, Hill K, Evans RA, Goldstein RS. Has my patient responded? Interpreting clinical measurements such as the six minute walk test. Am J Respir Crit Care Med. 2011;1846:643-646 [CrossRef]
 
Pellegrino R, Viegi G, Brusasco V, et al. Interpretative strategies for lung function tests. Eur Respir J. 2005;265:948-968 [CrossRef] [PubMed]
 
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