Chest
Volume 102, Issue 2, August 1992, Pages 347-355
Journal home page for Chest

Clinical Investigations
Sensitivity and Specificity of Bronchial Provocation Testing: An Evaluation of Four Techniques in Exercise-Induced Bronchospasm

https://doi.org/10.1378/chest.102.2.347Get rights and content

The thresholds used to define a positive result for bronchial provocation challenges (BPC) are arbitrary. Requiring smaller decrements in expired flow to define a positive study would capture more cases of reactive airways (increased sensitivity) but would include some “normal” responses (decreased specificity). To examine the relationship between threshold definition and the ability to correctly classify subjects as either normal or as having airways hyperresponsiveness (AHR), four different BPC tests were administered on different days to 20 patients with a clinical diagnosis of exercise-induced bronchospasm (EIB) and 20 control subjects. The four BPC tests were indoor exercise on a cycle ergometer, methacholine inhalation challenge (MIC), eucapnic voluntary hyperventilation (EVH) with dry gas, and EVH with cold gas. Our results indicate that the thresholds which best separate the two groups are different for each of the four BPC techniques. For methacholine inhalation (MIC), a fall in FEV1 (d%FEV1) of 15 percent or greater at 188 cumulative breath units was 100 percent specific for AHR but had a sensitivity of only 55 percent. Eucapnic voluntary hyperventilation (EVH) with room temperature dry gas was 100 percent specific at a d%FEV1 of 11 percent, but, at that threshold, sensitivity was only 50 percent. EVH with cold air was 100 percent specific at a d% FEV1 of 12 percent but sensitivity was only 35 percent. The bicycle ergometer challenge was far too insensitive to be of value in evaluating AHR. Based on their respective receiver operating characteristic curves, the best separation of the two subject groups occurred at a d%FEV1 of 5 percent and 12 percent for the two EVH techniques and MIC, respectively. An individual’s response to one test was highly correlated with the response to either of the other two (r = 0.66, p<0.001 for dry vs cold gas EVH; r = 0.56, p<0.001 for dry gas EVH vs methacholine; and r = 0.69, p<0.001 for cold gas EVH vs methacholine). Thus, MIC and EVH techniques are equally useful in defining AHR and each has its optimal threshold for a positive test result.

Section snippets

Subjects

Forty subjects were enrolled in a randomized, crossover study of four different BPC tests. Twenty patients were recruited from the Pulmonary Disease Clinic when they presented for evaluation of symptoms of postexertional dyspnea. Symptoms included wheezing, the feeling of tightness in the chest with exercise, dyspnea out of proportion to the level of exertion, or unexplained cough occurring during or soon after exercise. Exclusion criteria included the following: age younger than 20 years or

RESULTS

The EIB subject group was composed of 17 men and three women, aged 22 to 40 years. Fifteen were lifelong nonsmokers, and all former smokers had not smoked within six months. The control group consisted of 16 men and four women, aged 25 to 42 years. Sixteen of the control subjects were lifelong nonsmokers, and none of the remaining four subjects had smoked within four years. None of the EIB subjects or controls had received steroids and none had taken nonsteroidal anti-inflammatory drugs within

DISCUSSION

For practitioners dealing with the spectrum of bronchospastic disorders, a number of BPC techniques are available for use in diagnostic and management decision-making. Selecting a challenge test and interpreting the results can be perplexing. In essence, the goal of a BPC is to differentiate between subjects who have AHR and those who do not. A BPC should provide the physician with an assessment of the patient’s bronchial reactivity thereby confirming or ruling out the presence of inducible

ACKNOWLEDGMENTS

The authors thank SSG James Godville, SSG Thomas McCumber, and SFC William Slivka for their technical assistance and the performance of bronchoprovocation studies.

REFERENCES (35)

  • FilukRB et al.

    Comparison of responses to methacholine and cold air in patients suspected of having asthma

    Chest

    (1989)
  • WeissJW et al.

    Relationship between bronchial responsiveness to hyperventilation with cold and methacholine in asthma

    J Allergy Clin Immunol

    (1983)
  • ForesiA et al.

    Comparison of bronchial responses to ultrasonically nebulized distilled water, exercise, and methacholine in asthma

    Chest

    (1986)
  • SpeelbergB et al.

    Immediate and late asthmatic responses induced by exercise in patients with reversible airflow limitation

    Eur Respir J

    (1989)
  • ZawadskiDK et al.

    Effect of exercise on nonspecific airway reactivity in asthmatics

    J Appl Physiol

    (1988)
  • MaloJ et al.

    Reference values of the provocative concentrations of methacholine that cause 6% and 20% changes in forced expiratory volume in one second in a normal population

    Am Rev Respir Dis

    (1983)
  • Standardization of spirometry—1987 update

    Am Rev Respir Dis

    (1987)
  • Cited by (138)

    • Exercise-induced bronchoconstriction update—2016

      2016, Journal of Allergy and Clinical Immunology
    • Exercise-Induced Asthma: Strategies to Improve Performance

      2016, Pediatric Allergy: Principles and Practice: Third Edition
    • Exercise-induced bronchoconstriction

      2014, Otolaryngologic Clinics of North America
    • Development, Structure, and Physiology in Normal Lung and in Asthma

      2014, Middleton's Allergy: Principles and Practice: Eighth Edition
    • Treatment of Exercise-Induced Bronchoconstriction

      2013, Immunology and Allergy Clinics of North America
      Citation Excerpt :

      The symptoms of EIB range from a slight feeling of chest tightness with a small reduction in lung function to severe bronchospasm and a large reduction in FEV1 after exercise. Documenting EIB with a reduction in FEV1 of at least 10% from the pre-exercise values is considered to be specific for asthma, but exercise itself is not a sensitive means of diagnosing asthma.7,8 Individuals with asthma who develop EIB generally report symptoms such as cough, wheeze, chest tightness, dyspnoea, and fatigue.6

    View all citing articles on Scopus

    Manuscript received July 22; revision accepted November 19

    The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense.

    View full text