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Correspondence |

Airways Disease Presenting as Restrictive ImpairmentAirways Disease Presenting as Restriction: A Variant in Asthma, a Defining Feature in World Trade Center Lung Disorder FREE TO VIEW

Albert Miller, MD; Jack M. Mann, MD, FCCP
Author and Funding Information

From the Albert Einstein College of Medicine (Dr Miller); Pulmonary Function Laboratory (Dr Miller), Beth Israel Medical Center; Weill Cornell College of Medicine (Dr Mann); and New York Hospital Queens (Dr Mann).

Correspondence to: Albert Miller, MD, Beth Israel Medical Center, Dazian 7th Floor, 1st Ave at 16th St, New York, NY 10003; e-mail: almillermd@gmail.com


Financial/nonfinancial disclosures: The authors have 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. See online for more details.


Chest. 2013;144(6):1977-1978. doi:10.1378/chest.13-1763
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Published online
To the Editor:

The recent article by Berger et al1 in CHEST (July 2013) has refocused the interest of readers of CHEST to airway disease presenting as restrictive dysfunction. As cited in the article, this syndrome was noted in individual patients and then by the senior correspondent of this letter in a large series of patients with asthma, in whom it was estimated to characterize at least 8% of patients presenting with asthma. The decrease in expiratory reserve volume was especially notable in the days of precomputerized spirometry, when tracings of tidal breathing were followed by a forced exhalation. “Airway disease presenting as restrictive dysfunction” has come to characterize a large number of patients at the World Trade Center (WTC) on September 11, 2011, with typical airway symptoms of cough, dyspnea, and wheezing.2,3

The findings of Berger et al,1 including normal pulmonary compliance, elastic recoil, and lung parenchyma on CT scan, support the attribution to an airways disorder. Another strong indication, bronchial hyperreactivity, was noted both in known patients with asthma1 and in WTC patients with restrictive dysfunction.3 Early in the experience with WTC lung disorder, Prezant et al4 reported “nearly equal” reductions (from pre-September 11, 2001, values) in FVC and FEV1 of at least 0.5 L in > 50% of exposed firefighters. Response to a bronchodilator was seen in 63%, and bronchial hyperreactivity was noted in 24% of these patients. These rates are notable because selection criteria for firefighters rigidly exclude asthma. Bronchodilatation in airways disease presenting as restriction often results in equivalent increases in FVC and FEV1 with little change in FEV1/FVC ratio, and bronchoprovocation brings about equivalent decreases. It is, therefore, surprising that Berger et al1 noted no change in postbronchodilator spirometry and that impulse oscillometry, presumably a more sensitive, if less specific, measure of airways dysfunction, showed only small changes with bronchodilator, leaving persistent abnormality in the majority.

Pseudorestrictive dysfunction due to airways obstruction was known previously in patients with emphysema and severe asthma associated with massive air trapping, who have functional residual capacity values ≥ 130 and residual volume (RV) values ≥ 200% predicted. Increases in RV parallel decreases in FVC. The air trapping seen in WTC airways disorder as localized changes on high-resolution CT scans is decidedly different. Berger et al1 report reduced FRC and unimpressive RV values (eg, an RV/total lung capacity ratio of 0.35 at a mean age of 47 years) in their resident-exposed subjects.1 Weiden et al5 reported median FRC 96% predicted and RV 123% predicted in their firefighters. The highest RV, 131% predicted, was in the least exposed group.

The authors report a reduced mean diffusing capacity but do not describe the number of patients below the lower limit of normal, nor do they characterize those with truly low values. A low diffusing capacity of the lung may point to a specific abnormality originating in the small airways that results from the complex WTC inhalational exposure, namely constrictive or obliterative bronchiolitis. These correspondents reported a biopsy-proven case with onset shortly after WTC exposure and response to azithromycin; this was also cited by Berger et al,1 who also noted pathologic bronchiolitis reported by Caplan-Shaw et al.6 Additionally, two cases were reported by Mount Sinai pathologists.7 The description by Berger et al1 and the dialogue it elicits contribute to the understanding of the pathophysiology of WTC (and other) airways disorders and of the need to continue surveillance of these patients.

References

Berger KI, Reibman J, Oppenheimer BW, Vlahos I, Harrison D, Goldring RM. Lessons from the World Trade Center disaster: airway disease presenting as restrictive dysfunction. Chest. 2013;144(1):249-257. [CrossRef] [PubMed]
 
Banauch GI, Hall C, Weiden M, et al. Pulmonary function after exposure to the World Trade Center collapse in the New York City Fire Department. Am J Respir Crit Care Med. 2006;174(3):312-319. [CrossRef] [PubMed]
 
Aldrich TK, Gustave J, Hall CB, et al. Lung function in rescue workers at the World Trade Center after 7 years. N Engl J Med. 2010;362(14):1263-1272. [CrossRef] [PubMed]
 
Prezant DJ, Weiden M, Banauch GI, et al. Cough and bronchial responsiveness in firefighters at the World Trade Center site. N Engl J Med. 2002;347(11):806-815. [CrossRef] [PubMed]
 
Weiden MD, Ferrier N, Nolan A, et al. Obstructive airways disease with air trapping among firefighters exposed to World Trade Center dust. Chest. 2010;137(3):566-574. [CrossRef] [PubMed]
 
Caplan-Shaw CE, Yee H, Rogers L, et al. Lung pathologic findings in a local residential and working community exposed to World Trade Center dust, gas, and fumes. J Occup Environ Med. 2011;53(9):981-991. [CrossRef] [PubMed]
 
Wu MX, Gordon RE, Herbert R, et al. Case report: lung disease in World Trade Center responders exposed to dust and smoke: carbon nanotubes found in the lungs of World Trade Center patients and dust samples. Environ Health Perspect. 2010;118(4):499-504. [CrossRef] [PubMed]
 

Figures

Tables

References

Berger KI, Reibman J, Oppenheimer BW, Vlahos I, Harrison D, Goldring RM. Lessons from the World Trade Center disaster: airway disease presenting as restrictive dysfunction. Chest. 2013;144(1):249-257. [CrossRef] [PubMed]
 
Banauch GI, Hall C, Weiden M, et al. Pulmonary function after exposure to the World Trade Center collapse in the New York City Fire Department. Am J Respir Crit Care Med. 2006;174(3):312-319. [CrossRef] [PubMed]
 
Aldrich TK, Gustave J, Hall CB, et al. Lung function in rescue workers at the World Trade Center after 7 years. N Engl J Med. 2010;362(14):1263-1272. [CrossRef] [PubMed]
 
Prezant DJ, Weiden M, Banauch GI, et al. Cough and bronchial responsiveness in firefighters at the World Trade Center site. N Engl J Med. 2002;347(11):806-815. [CrossRef] [PubMed]
 
Weiden MD, Ferrier N, Nolan A, et al. Obstructive airways disease with air trapping among firefighters exposed to World Trade Center dust. Chest. 2010;137(3):566-574. [CrossRef] [PubMed]
 
Caplan-Shaw CE, Yee H, Rogers L, et al. Lung pathologic findings in a local residential and working community exposed to World Trade Center dust, gas, and fumes. J Occup Environ Med. 2011;53(9):981-991. [CrossRef] [PubMed]
 
Wu MX, Gordon RE, Herbert R, et al. Case report: lung disease in World Trade Center responders exposed to dust and smoke: carbon nanotubes found in the lungs of World Trade Center patients and dust samples. Environ Health Perspect. 2010;118(4):499-504. [CrossRef] [PubMed]
 
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