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Kenneth I. Berger, MD, FCCP; Roberta M. Goldring, MD
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From the Department of Medicine, NYU School of Medicine.

Correspondence to: Kenneth I. Berger, MD, FCCP, Department of Medicine, NYU School of Medicine, 240 E 38th St, Mezzanine Level, Room M15, New York, NY 10016; e-mail: kenneth.berger@med.nyu.edu


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):1978-1979. doi:10.1378/chest.13-1961
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To the Editor:

We thank Drs Miller and Mann for their letter regarding our article1 and agree with their perspective. Our findings1 expand on a prior report by Miller and Palecki2 in a population of patients with asthma and isolated case reports by other authors as cited in our article. These studies indicate that a restrictive pattern on plethysmography with normal FEV1/vital capacity may be found in patients with airway disease more often than previously appreciated.

Our study and prior lung biopsy findings3 provide a pathophysiologic mechanism for the restriction related to injury to the distal lung unit. As Drs Miller and Mann indicated, our spirometry and oscillometry findings were minimally responsive to bronchodilator. We believe that this is in accord with the histologic evidence for bronchiolitis, small airway fibrosis, and emphysema noted in subjects exposed to World Trade Center (WTC) dust and fumes.3 In addition, our article provides clues from the standard testing modalities to identify this phenotype: (1) reduction in vital capacity due to reduced expiratory reserve volume with normal inspiratory capacity (ie, restriction from expiratory impairment), (2) relative preservation of diffusing capacity for carbon monoxide suggesting normal alveolar-capillary interface, and (3) reduced alveolar volume to total lung capacity ratio indicating nonuniform airflow distribution. When indicated, confirmation of primary airway disease can be achieved by specific testing of distal lung function and/or by high-resolution CT scanning.

We chose to entitle our manuscript “Lessons From the World Trade Center” to highlight the potential application of our findings to a broader clinical population with intrinsic airway disease and inhalational/environmental injury beyond exposure to WTC dust. Recognition of this pattern when FEV1/VC remains normal is an important first step that is required to avoid misdiagnosis and, thus, allow for optimal treatment.

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]
 
Miller A, Palecki A. Restrictive impairment in patients with asthma. Respir Med. 2007;101(2):272-276. [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]
 

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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]
 
Miller A, Palecki A. Restrictive impairment in patients with asthma. Respir Med. 2007;101(2):272-276. [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]
 
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