A normal spirometry and a negative bronchodilator test does not exclude asthma, and the patient's clinical picture is highly suggestive of asthma, so a methacholine test would confirm the diagnosis, at least of bronchial hyperresponsiveness.

A 38-year-old nonsmoking woman previously diagnosed with atopic rhinitis presents with a two-month history of intermittent cough and wheezing, predominantly at night. Chest X-ray was normal. Spirometry within the normal range with negative bronchodilator test. Which of the following tests would you request next?

[Rhinitis and cough syndrome. Are epidemiologic, clinical and functional characteristics useful in the differential diagnosis with bronchial asthma?].

Patients often visit family practitioners or respiratory specialists complaining of cough. In non-smokers, the most common cause is postnasal drip secondary to rhinitis. The second most common cause is bronchial asthma. a) To know the epidemiological, clinical and functional features of patients who visit our outpatient pneumology clinic complaining of chronic cough as an isolated symptom, in whom bronchial asthma is suspected, but who have received a diagnosis of rhinitis. b) To analyze the differences between such patients and those in whom chronic cough has been attributed to bronchial asthma. One hundred thirty-one patients with chronic cough were enrolled for study under the following protocol: 1) taking of a detailed case history (epidemiological and clinical data), 2) physical examination, 3) blood work-up, 4) paranasal sinus and chest X-rays, 5) spirometry at baseline and after 200 micrograms of salbutamol if obstruction was present, 6) methacholine challenge test, 7) skin tests for common respiratory tract allergens, 8) other techniques, depending on suspected diagnosis (CT chest scan, fiberoptic bronchoscopy, consultation with a gastroenterologist or otorhinolaryngologist). One hundred seventeen (89.3%) patients received a diagnosis of rhinitis. Chronic cough was attributed solely to rhinitis in 61 (46.5%) patients. Forty-four (33.5%) were diagnosed as bronchial asthma; 38 (29%) also had rhinitis. Chronic cough was attributed to a different diagnosis in 26 cases (19.8%). The 61 patients with rhinitis as the sole cause of chronic cough were aged 23.8 +/- 10.8 years (9-63 years); 33 (54% of the 61) were men and 28 (46% of the 61) were women. We found that patients with rhinitis more often suffered nasal symptoms (chi 2 = 22.4; p = 0.01), pharyngeal irritation (chi 2 = 9.63, p = 0.05), dry cough from the upper respiratory tract (chi 2 = 16.4, p = 0.001), atopy (chi 2 = 18.1, p < 0.001) and greater FVC (F = 5.28, p = 0.006) than did patients with asthma or other diagnoses. 1) Rhinitis was the most common cause of chronic cough in the studied patients in whom a diagnosis of bronchial asthma had been suspected. 2) Epidemiological characteristics did not aid differential diagnosis between rhinitis and bronchial asthma (with or without associated rhinitis). 3) A detailed medical history focusing on upper airway symptoms can be useful, although there may be cases of silent postnasal drip syndrome. 4) Paranasal x-rays help to rule out complications of rhinitis. 5) A positive bronchial challenge test does not necessarily indicate a diagnosis of bronchial asthma. 6) Allergy to pollen is the most common finding among atopic patients with rhinitis.

[Clinical study on bronchial hyperresponsiveness and development of bronchial asthma in patients with persistent cough].

The purpose of this study was to ascertain whether in patients with persistent cough the presence of bronchial hyperresponsiveness (BH) and development of asthma could be speculated based on clinical data. Only patients who met strict criteria excluding exogenous factors that influence BH, especially smoking or respiratory infection, were included in this study. The study group included 15 males and 50 females aged 18 to 62 years (mean +/- S.D. of 44 +/- 12 years) whose physical findings, chest X-rays, spirometry results and peripheral leukocyte counts were within normal limits. Duration of cough was at least one month. The patients had no history of wheezing, dyspnea or previous bronchodilator therapy. None of them had ever been smokers. In addition, there was no history of upper respiratory tract infection in the preceding month. BH was assessed by "Astograph" using methacholine. Cmin and Dmir or SGrs/Grs cont. were measured as the indexes of bronchial sensitivity or reactivity respectively. A methacholine Cmin of 3, 125 micrograms/ml or less was taken as a positive indication of BH. The evaluated clinical data were age, pulmonary function (spirogram or flow volume curve), atopic factors (serum total IgE and family or personal history of atopic diseases), peripheral eosinophil count, bronchial sensitivity or reactivity, and clinical features of cough (induction by exercise or cold air and nocturnal worsening). The results were as follows. (1) Twenty-nine (45%) of 65 patients were BH-positive (BH-positive group). (2) There was no significant difference in age, %FVC, IgE, and family or personal history of atopic diseases between the BH-positive and negative group. However, the BH-positive group had significantly lower FEV1.0%, %FEV1.0, PEFR, (p less than 0.05) and V25/H (p less than 0.01) and a higher peripheral eosinophil count (p less than 0.05) than the BH-negative group. (3) Seventeen (85%) of 20 BH-positive patients prescribed bronchodilators (beta 2 agonist/theophylline) responded to therapy within a month. (4) Seven (29%) of 24 BH-positive patients available for 2 years follow-up developed clinical asthma. (5) There was no significant difference in %FVC, FEV1.0%, V25/H and peripheral eosinophil count between the patients who developed asthma (Group A) and those who did not (Group N-A). However, The patients in Group A were older than those in Group N-A.(ABSTRACT TRUNCATED AT 400 WORDS)

[Clinical study on cough variant asthma].

Chronic cough may be the sole presenting manifestation of bronchial asthma (reference 3; Corrao et al, 1979), and "cough variant asthma (CVA)" has been used to categorize such patients. In order to clarify the clinical picture of CVA, we evaluated the clinical history, laboratory data, sputum cytology and pulmonary function in 14 subjects (5 males and 9 females, aged 14 to 65 years) compatible with the following diagnostic criteria: (1) chronic cough persistent for more than 8 weeks, (2) no wheeze nor dyspnea, (3) no rales, (4) no past history of asthma, (5) bronchial hyperreactivity to methacholine proven by Takishima's method (reference 13), (6) effectiveness of bronchodilators against cough, (7) normal chest X-ray film, (8) afebrile and negative CRP, (9) absence of sinusitis and postnasal drip, or if present, they are proved not to be responsible for the cough, and (10) no other causes of cough such as heart disease, prescription of ACE inhibitors, current smoking. The results were as follows. 1) Many of the subjects were atopic, with positive skin tests to one or more common allergens in 10 subjects, elevated serum IgE in 4 subjects, and past history and family history of atopy in 4 and 7 subjects, respectively. 2) Respiratory infection preceded the onset of CVA in 3 subjects. 3) Cough was generally nocturnal, but 2 subjects coughed only in the daytime. 4) FEV1.0% was decreased (less than 70%) in only 2 subjects, whereas V25 was decreased (less than 80% of predicted value) in 11 out of 12 evaluable subjects, which suggested peripheral airway obstruction.(ABSTRACT TRUNCATED AT 250 WORDS)

Bronchial challenge test in patients with a history suggestive of bronchial asthma with normal spirometric studies.

Bronchial hyper-responsiveness (BHR) is the hallmark of bronchial asthma, characterized by clinical features of cough, wheeze, breathlessness and chest tightness which are confirmed by spirometry showing obstructive pattern and reversibility to bronchodilators. In individuals having features of bronchial asthma but normal spirometry, demonstration of BHR with bronchial challenge test (direct or indirect) confirms/ rules out the diagnosis. The aim of this study was to assess BHR in patients (methacholine challenge) with a history suggestive of bronchial asthma but normal spirometry and its role in diagnosis of bronchial asthma. This study was conducted at tertiary care respiratory center. Patients having clinical features of bronchial asthma but spirometry not confirming obstructive disorder and or reversibility were included in the study. After written consent, methacholine challenge test with methacholine chloride and exercise spirometry was done in all patients as per the American Thoracic Society protocol. A total of 50 (n) patients were included in the study. Among them, 42 patients had clinical features suggestive of bronchial asthma but having normal spirometry and eight patients were diagnosed as they had bronchial asthma in the past but asymptomatic and off drugs were included in the study. At PC20 4mg/ml 32 (64%) patients had a positive test, 28(66%) symptomatic patients and four (50%) asymptomatic asthmatics. There were no significant side effects with methacholine test. Airway hyper-responsiveness is an important aspect of bronchial asthma and its demonstration with bronchial challenge (direct and indirect) test is an important diagnostic tool. Methacholine challenge test is a safe procedure to perform under supervision.

Lund-Mackay Computed Tomography Score Is Associated With Obstructive Pulmonary Function Changes in Chronic Cough Patients.

A remarkable relationship between upper airway conditions and lung diseases has been reported. At the same time, sinonasal findings in chronic cough patients have not been fully examined. The purpose of this study is to show paranasal sinus findings and lung function in chronic cough patients without asthma and chest X-ray abnormalities. A total of 1412 patients with persistent cough were enrolled in this study. Of these patients, 376 patients were evaluated for further examination, as the patients with asthma and/or chest X-ray abnormality were excluded from the study. Normal control subjects without any chronic respiratory symptoms were also recruited. Pulmonary function was examined by spirometry. A bronchial obstruction reversibility test was applied. The Lund-Mackay computed tomography (CT) score, peripheral blood eosinophil count, and immunoglobulin E concentration in serum samples were examined. The Sino-Nasal Outcome Test was used to determine the severity of clinical symptoms. The patients with an abnormal soft tissue shadow in the paranasal sinus had significant obstructive lung function. The percent predicted forced expiratory volume in 1 second (FEV<sub1.0</sub) and the FEV<sub1.0</sub/forced vital capacity ratio negatively correlated with Lund-Mackay CT scores both before and after bronchodilator inhalation. There was a statistically significant correlation between pulmonary function and eosinophil count. The patients with chronic cough frequently had paranasal sinus abnormalities. The Lund-Mackay CT score may be useful for assessing the condition of the lower airway in chronic cough patients. Upper airway examinations should play a part in the management of chronic cough.

Chronic cough

Imaging X-rays are used to check for lung cancer, pneumonia and other lung diseases that are contributing to the chronic cough. X-rays of the sinus also can provide evidence of an infection in the area. CT scans are used to check the condition of the patient's lungs and to check sinus cavities for infections. Lung Function Test, a simple test in which the patient inhales and exhales into a spirometer, is normally used to diagnose asthma or chronic obstructive pulmonary disease. With lab tests, a sample of the patient's mucus is tested for bacteria

[Diagnostic standard for differentiation between bronchial asthma and chronic obstructive pulmonary disease].

The aim of this study was to work out the simplified standard for distinguishing COPD from bronchial asthma. An overall sample of 150 individuals was used for statistical analysis. Sixty one were diagnosed as having COPD and 89 as suffering from asthma. For each patient the modified ATS-DLD-75-C questionnaire was filled out, and laboratory tests results were collected. Laboratory findings included: basic spirometry and flow-volume curve parameters, diurnal PEF variation, tests with bronchodilators (salbutamol, ipratropium bromide and corticosteroids), challenges with histamine and exercise, blood gas analysis, skin tests, chest X-ray, ECG, blood cell count, blood and sputum eosinophilia. Continuous variables were transformed into discrete (dichotomous) ones using commonly accepted threshold values. Then, sensitivity, specificity and accuracy indexes were calculated for each variable and for all possible sets of 2, 3 and 4 variables. Finally, 2 sets of 4 signs and symptoms were selected as the most characteristic of the diseases of interest. Asthma was diagnosed if 3 out of 4 following conditions were present: 1) episodes of shortness of breath and wheezing, 2) smoking index (cigarettes number per day x years of smoking) < or = 200, 3) PC20 < or = 8 mg/ml or delta FEV1 after bronchodilator > or = 15% predicted, 4) diurnal PEF variation > or = 20% predicted. COPD was recognised in the same way on the basis of: 1) productive cough, 2) smoking index > 200, 3) signs of emphysema on the chest X-ray, 4) maximal FEV1 < 80% predicted (after treatment). Diagnosis established using this model was correct in 76% and false (what was very important) in only 2.6% of cases. In the remaining 21% of patients it was uncertain (e.g. both of the diseases confirmed).

Negative methacholine challenge tests in subjects who report physician-diagnosed asthma.

The frequency of adults reporting a history of asthma is rising. However, it is unclear whether this increased prevalence accurately demonstrates a rising trend or if it reflects an overall increase in asthma awareness. To determine the frequency of negative methacholine bronchoprovocation tests in adults who report physician-diagnosed asthma and to explore the clinical characteristics of subjects with negative tests. Data from methacholine challenge, spirometry, and physician assessment were analysed from 304 adults who reported physician-diagnosed asthma and responded to community-based advertising for asthma research studies. The clinical characteristics of methacholine-positive and -negative subjects were compared and a predictive model was tested to identify those characteristics associated with a negative test. Of the 304 subjects tested, 83 (27%) had a negative methacholine test. A negative test was positively associated with an adult-onset of symptoms (P<0.001), normal forced expiratory volume in 1 s (P<0.001), and having no history of exacerbation requiring oral steroids (P=0.03). Over half (60%) of those with a negative test reported weekly asthma-like symptoms (cough, dyspnoea, chest tightness, or wheeze), while 39% reported emergency department visits for asthma-like symptoms. A sizeable percentage of subjects who report physician-diagnosed asthma have a negative methacholine challenge test. These subjects are characterized by diagnosis of asthma as an adult and by normal or near normal spirometry. Caution should be exercised in the assessment and diagnosis of adults presenting with asthma-like symptoms, because they may not have asthma. Further diagnostic studies, including bronchoprovocation testing, are warranted in this patient group, especially if their spirometry is normal.

Spirometry

Another major limitation is the fact that many intermittent or mild asthmatics have normal spirometry between acute exacerbation, limiting spirometry's usefulness as a diagnostic. It is more useful as a monitoring tool: a sudden decrease in FEV1 or other spirometric measure in the same patient can signal worsening control, even if the raw value is still normal. Patients are encouraged to record their personal best measures. Related tests Spirometry can also be part of a bronchial challenge test, used to determine bronchial hyperresponsiveness to either rigorous exercise, inhalation of cold/dry air, or with a pharmaceutical agent such as methacholine or histamine. Sometimes, to assess the reversibility of a particular condition, a bronchodilator is administered before performing another round of tests for comparison. This is commonly referred to as a reversibility test, or a post bronchodilator test (Post BD), and is an important part in diagnosing asthma versus COPD.

[Cough variant asthma. Clinical and functional characteristics. Report of 63 cases].

To study the characteristics of our outpatient clinic patients presenting with chronic cough as the sole symptom of bronchial asthma, and to evaluate the bronchial hyperreactivity of such patients in comparison with that of classic asthmatic patients with normal spirometry. For 3 years we studied 193 consecutive patients with chronic cough as the sole symptom, using the study protocol specified in the section on patients and methods. Sixty-three patients were diagnosed of bronchial asthma. Bronchial hyperreactivity was considered to be the cause of coughing based on reversibility testing or a positive methacholine test, along with response to specific antiasthmatic therapy. Forty-six (73%) of the 63 patients had unproductive cough and 28 (44%) coughed mainly at night. In 14 (22%) symptoms began with an upper respiratory tract infection. Wheezing could be heard in only 4 (6%). Diagnosis was based on reversibility in 11 (17%) and methacholine testing in 52 (83%). Mean PC20 was higher in patients diagnosed of variant cough. Unlike classic asthma, persistent and usually unproductive cough caused by asthma has few or no accompanying symptoms. The diagnostic yield of methacholine testing is high in such patients.

Wheezing on maximal forced exhalation in the diagnosis of atypical asthma. Lack of sensitivity and specificity.

To determine whether wheezing on maximal forced exhalation is a predictor of asthma in persons with normal or nearly normal baseline spirometry. Prospective study of patients referred for methacholine challenge testing. Pulmonary function laboratory at a hospital. Forty-four patients referred for methacholine challenge testing because of the clinical suspicion of cough variant or otherwise difficult to diagnose asthma, with normal or nearly normal baseline spirometry and without wheezing on routine lung auscultation during quiet breathing. We listened for wheezing on maximal forced exhalation. Wheezing was defined as a continuous sound with a musical quality. Methacholine challenge testing was done. The concentration of methacholine required to produce a 20% fall in baseline FEV1 (PC20) of less than 8 mg/mL was considered a positive test for asthma. Wheezing was present on maximal forced exhalation in 8 of 14 patients with a positive methacholine challenge test (sensitivity = 57%) and absent in 11 of 30 patients with a negative test (specificity = 37%). Furthermore, wheezing on maximal forced exhalation was present in 13 of 27 patients with a PC20 greater than 16 mg/mL and absent in 2 of 7 with a PC20 less than 4 mg/mL. Wheezing on maximal forced exhalation is neither sensitive nor specific for airway hyperreactivity.

Allergic shiners in a patient with cough-variant asthma: a case report.

Chronic cough, with a duration of coughing of more than 8 weeks in adults, affects 5-10% of the general population. One of the most common causes of chronic cough is cough-variant asthma, which accounts for approximately one-third of cases. This phenotype of asthma is characterized by extreme sensitivity of the neuronal pathways mediating cough to environmental irritants, which results in an urge to cough. This case is an example of cough-variant asthma presenting with allergic shiners due to her severe cough. A 38-year-old Iranian woman, who was well before the start of the coronavirus disease 2019 pandemic, presented with a nonproductive hacking cough that had begun after excessive use of antiseptic solutions. The only positive finding on physical examination was a reddish-purple rash on and around the eyelids mimicking a heliotrope rash, which had probably evolved due to the severity of the cough. The results of the pulmonary function test were within normal limits. Methacholine challenge test and chest x-ray were both normal. Chest high-resolution computed tomography revealed hyperinflation and tree-in-bud opacities. All other laboratory tests were normal. Because of the reversibility in her pulmonary function test, despite normal baseline parameters, asthma treatment was initiated, resulting in disappearance of the cough and the eye discoloration, being indicative of the correct diagnosis and proper treatment. Patients with cough-variant asthma may often have no other classic symptoms of asthma other than cough.

Chronic cough

With lab tests, a sample of the patient's mucus is tested for bacteria Scope tests are used if the above tests are not able to diagnose the chronic cough. A special test may be used that involves a thin, flexible tube which contains a light and camera. This is inserted within the patient through the respiratory tract. A bronchoscope is used for seeing the lungs and air passages, and a biopsy of the linings of the airway may be taken. Additionally, a rhinoscope can be used to examine the upper airway tract. Children are typically diagnosed with chest X-rays or spirometry

Exhaled nitric oxide in evaluation of young adults with chronic cough.

Bronchial asthma (A) is frequently diagnosed in patients with chronic cough. The study was conducted to determine whether an evaluation of fractional exhaled nitric oxide (FeNO) concentration can be used as a screening test for asthma in young adults with chronic cough (CCP). The study was performed on 540 (mean age 26.5; range 18-45 years), nonsmoking young CCP. All patients had resting spirometry within normal limits and no abnormalities on chest radiographs. Skin prick tests with common aeroallergens, bronchial provocation challenge with histamine, and evaluation of FeNO concentration were performed in all patients. One hundred healthy, nonsmoking, nonatopic subjects were used as control subjects (HC). Asthma (A) was diagnosed in 178 CCP (32.96%). Other frequent diagnoses included rhinitis/sinusitis (R) and gastroesophageal reflux (GERD). The median FeNO concentration in A (86 ppb; 95% CI 72 to 94,5 ppb) was significantly greater than in R (37 ppb; 95% CI 35,6 to 42,9 ppb; p < 0.0001), GERD (14,8 ppb; 95%CI 13.3 to 16.2 ppb; p < 0.0001), or in HC (13 ppb; 95%CI 11 to 15 ppb; p < 0.0001). Significant correlation was found between log(FeNO) and bronchial reactivity expressed as log(PC20) (r = -0.529; 95%CI -0.616 to -0.429; p < 0.0001), but even stronger correlation was demonstrated between log(FeNO) and peripheral blood eosinophilia (r = 0.757; 95%CI 0.717 to 0.792). Receiver Operator Characteristic (ROC) curve analysis revealed that CCP can be screened for A by measuring FeNO concentration. Using 40 ppb as a cut-off value for the FeNO concentration, the specificity 82.6% and sensitivity 88.3% can be achieved. In clinical practice, assessment of FeNO concentration can be used as a screening test for asthma in young adults who have chronic cough.

Pulmonology

Procedures Clinical procedures Pulmonary clinical procedures include the following pulmonary tests and procedures: Medical laboratory investigation of blood (blood tests). Sometimes arterial blood gas tests are also required. Spirometry the determination of maximum airflow at a given lung volume as measured by breathing into a dedicated machine; this is the key test to diagnose airflow obstruction. Pulmonary function testing including spirometry, as above, plus response to bronchodilators, lung volumes, and diffusion capacity, the latter being a measure of lung oxygen absorptive area Bronchoscopy with bronchoalveolar lavage (BAL), endobronchial and transbronchial biopsy and epithelial brushing Chest X-rays CT scan Scintigraphy and other methods of nuclear medicine Positron emission tomography (especially in lung cancer) Polysomnography (sleep studies) commonly used for the diagnosis of sleep apnea

Acute bronchitis

A variety of tests may be performed in people presenting with cough and shortness of breath: A chest X-ray is useful to exclude pneumonia which is more common in those with a fever, fast heart rate, fast respiratory rate, or who are old. A sputum sample showing neutrophil granulocytes (inflammatory white blood cells) and culture showing that has pathogenic microorganisms such as Streptococcus species. A blood test would indicate inflammation (as indicated by a raised white blood cell count and elevated C-reactive protein). Decreased breath sounds, crackles, wheezing, and rhonchi that clears with coughs may be heard in the chest. Dullness to percussion and pleural rub suggest disease extension beyond the bronchi such as seen with pneumonia. Paroxysms of cough followed by inspiratory whoop and vomiting suggests pertussis.

Asthma

Spirometry Spirometry is recommended to aid in diagnosis and management. It is the single best test for asthma. If the FEV1 measured by this technique improves more than 12% and increases by at least 200 milliliters following administration of a bronchodilator such as salbutamol, this is supportive of the diagnosis. It however may be normal in those with a history of mild asthma, not currently acting up. As caffeine is a bronchodilator in people with asthma, the use of caffeine before a lung function test may interfere with the results. Single-breath diffusing capacity can help differentiate asthma from COPD. It is reasonable to perform spirometry every one or two years to follow how well a person's asthma is controlled. Others

Bronchiolitis obliterans

Diagnosis Bronchiolitis obliterans is often diagnosed based on the symptoms of obstructive lung disease following lung injury. The definitive diagnosis is through biopsy, but due to the variable distribution of lesions, leading to falsely negative tests, and invasive nature of this procedure it is often not performed. Several tests are often needed to diagnose bronchiolitis obliterans, including spirometry, diffusing capacity of the lung tests (DLCO), lung volume tests, chest X-rays, high-resolution CT (HRCT), and lung biopsy.

Bronchial challenge test

Sometimes, to assess the reversibility of a particular condition, a bronchodilator is administered to counteract the effects of the bronchoconstrictor before repeating the spirometry tests. This is commonly referred to as a reversibility test, or a post bronchodilator test (post BD), and may help in distinguishing asthma from chronic obstructive pulmonary disease. Also, a DLCO test can be used to distinguish asthma (normal to high DLCO) from COPD (reduced DLCO). False positives and negatives are possible in the bronchial challenge test. In addition, asthma may be temporary due to an exposure to noxious stimuli or exercise.

Methacholine Challenge Test -- Clinical Significance

Methacholine challenge testing is a form of non-specific bronchoprovocation and is useful in patients with a questionable diagnosis of asthma. Baseline spirometry should be normal, and an atypical history that may be suggestive of asthma should prompt evaluation for testing. The test has high sensitivity and a strong negative predictive value, helpful in excluding a diagnosis of asthma. Positive test results may suggest asthma. However, other conditions that may produce false-positive test results merit consideration. Positive testing in otherwise asymptomatic patients can be seen in up to 7% of the population and is believed to be normal with hyperreactive airways, which may also be indicative of the future development of clinical asthma and requires follow-up. In patients with a clinical history suggestive of asthma, with negative testing, alternate diagnoses should be considered, such as vocal cord dysfunction, occupational asthma, or central airway obstruction (i.e., tumor, polyp, or foreign body) as these conditions may clinically imitate asthma. Full inspiratory and expiratory phase flow volume loop analysis is important when paradoxical vocal cord motion is suspected. In patients with a history suggestive of asthma with positive testing, response to therapy merits close observation. Baseline spirometry that shows a pattern of airway obstruction (i.e. low FEV1/FVC ratio and low FEV1) may be difficult to interpret as hyperresponsiveness strongly correlates to the baseline level of obstruction, and strong bronchodilator response of more than 12% and 200 mL in either FEV1 or FVC likely establishes the diagnosis without the need for methacholine challenge. [3] [7]

[The application of preoperative pulmonary function and FeNO test in patients with chronic rhinosinusitis].

<bObjective:</b To explore the application of lung function and exhaled nitric oxide in the evaluation of patients with chronic rhinosinusitis(CRS) with or without polyps who denied bronchial asthma history and planned to undergo endoscopic sinus surgery. <bMethod:</b Two hundred and thirty-two patients with CRS during April 2016 to April 2018 in our hospital were recruited in this study. All patients accepted lung function and exhaled nitric oxide test before surgery to evaluate whether accompanied with asthma, improvements after standardized drug therapy in patients with asthma. SpO₂, Ppeak and PETCO₂ were monitored and recorded during surgery. Postoperative symptoms of wheezing, shortness of breath, chest tightness and cough were also observed and recorded. <bResult:</b ① Of the 232 patients, 18 patients were diagnosed as bronchial asthma, with a positive rate of 7.8%. 17 cases had positive results in bronchodilation test, 1 case was negative whose PEF improvement rate was 40.4%; The mean FeNO of the 18 patients was 46 ppb, of which 16 patients whose FeNO was over 25 ppb; The mean FeNO of 40 cases with normal pulmonary function was over 25ppb, of which 4 cases' FeNO were over 50 ppb;② 232 patients' intraopertive anesthesia monitor showed that SpO₂ were greater than 95%, Ppeak were less than 35 cmH₂O, PETCO₂ were greater than 35 mmHg; ③ Mild dyspnea occurred in a patients diagnosed as asthma the next morning after surgery. The auscultation was scattered in the wheezing sound, and the symptoms were relieved in 10 minutes after inhalation of salmeterol. <bConclusion:</b Routine screening for lung function and FeNO and standardized perioperative treatment in patients with CRS before nasal endoscopy is useful.

Bronchitis

Diagnosis Diagnosis is typically based on a person's signs and symptoms. The color of the sputum does not indicate if the infection is viral or bacterial. Determining the underlying organism is usually not required. Other causes of similar symptoms include asthma, pneumonia, bronchiolitis, bronchiectasis, and COPD. A chest X-ray may be useful to detect pneumonia. Another common sign of bronchitis is a cough which lasts ten days to three weeks. If the cough lasts for longer than a month, it may become chronic bronchitis. In addition, a fever may be present. Acute bronchitis is normally caused by a viral infection. Typically, these infections are rhinovirus, parainfluenza, or influenza. No specific testing is normally needed in order to diagnose acute bronchitis.

[Symptoms, physical findings and bronchial hypersensitivity in patients with bronchial asthma and normal spirometry].

The diagnosis of bronchial asthma, a chronic inflammatory disease of the respiratory tract, is made on the basis of anamnesis, pathologic auscultatory findings of the lungs, lung function disturbances, skin tests, as well as the basic indices of immunologic condition in bronchial trunk. The aim of the study was to find out correlation of objective indices of the disease and than relation with the symptoms in the patients with bronchial asthma. The study included 60 young male non smokers with long lasting symptoms of bronchial asthma including shortness of breath, wheezing, hard breathing, nonproductive or productive cough, weakness and night hard breathing. There were no symptoms of respiratory infection over the past two months and lung radiography and spirometry were normal Based on the results of nonspecific bronchoprovocative test two groups of the patients were formed, group I (n=30) with positive histamine test (average value of the inhaled histamine concentration with FEV1 drop by 20% in regard with the initial value (PC20) = 2.99 +/- 0.51 mg/ml of histamine) and group II (n=30) with negative histamine test (PC20(a) = 14.58 +/- 6.34 mg/ml of histamine). The obtained spirometry results revealed a statistically significant difference in values of FEV1 between groups: I group--FEV1 3.2%; II group--EV1 = 101.8%; (p .05, Wilcoxon test), although all the FEV1 values were normal Regarding the presence of the most common symptoms there was not statistically significant difference between the groups (p>0.05, chi-square test). Pathologic auscultatory lung findings were found in 73.4% of the patients in the group I and 27.5% of the patients in the group II. There was statistically significant difference (p<0.05, chi-squared test). A positive correlation between the degree of hypersensitivity and lung physical findings was confirmed (p<0.05 Spearman's rho), but there was no correlation with FEV1 values. There is a correlation with lung pathologic physical findings, lower values of FEV1 (in a range of normal values) and the degree of nonspecific bronchial sensitivity as objective indices of activity of bronchial asthma. There is no correlation of these parameters with patient's symptoms as subjective indices of bronchial asthma.

Eosinophilic bronchitis

The cause of the inflammation can be associated with environmental triggers or common allergens such as dust, chloramine, latex, or welding fumes. Diagnosis Diagnosis of eosinophilic bronchitis is not common as it requires the examination of the patient's sputum for a definitive diagnosis, which can be difficult in those who present with a dry cough. In order to induce the sputum, the patient has to inhale increasing concentrations of hypertonic saline solution. If this is unavailable, a bronchoalveolar lavage can be done, and the bronchial wash fluid can be examined for eosinophils. The diagnosis is usually considered later by ruling out other life-threatening conditions or more common diagnoses such as asthma and GERD, and by seeing an improvement in symptoms with inhaled corticosteroid treatment. Chest X-rays and lung function tests are usually normal. CT scans may show some diffuse airway wall thickening. Management

Wheezing -- Evaluation

When wheezing is heard, some workup is required because it is an abnormal sound. The first imaging test of choice in a patient with wheezing is a chest x-ray to look for a foreign body or a lesion in the central airway. In the non-acute setting, if asthma is suspected, the next step is to obtain baseline pulmonary function tests with bronchodilator administration. Following this, it may be necessary to perform an airway challenge test with a bronchoconstrictive agent such as methacholine. If the wheezing resolves with a bronchodilation agent, a tumor or mass as the cause is a much less likely consideration. If there is no resolution after a breathing treatment, and a tumor or mass is suspected, then a CT scan of the chest and bronchoscopy may be required if possible malignancy is suspected on CT. [7]

Asthma, smoking and chronic cough in rural and urban adult communities in The Gambia.

Asthma is reported to be rare in traditional rural communities, but is thought to be increasing as lifestyles become more urbanized or 'western'. A community-based survey of non-communicable diseases was conducted from October 1996 to June 1997, and included comparison of the prevalence of asthma, smoking and chronic cough in rural and urban Gambia. A cluster sample survey was conducted in a random sample of rural and urban adults (> or = 15 years of age). Subjects were asked about respiratory symptoms using a locally adapted version based on the IULTD questionnaire. Spirometry (basal, methacholine provocation and reversibility with a bronchodilator) and skin prick tests were performed on a randomly selected subsample of all subjects and those who, when interviewed, said they wheezed or had been diagnosed as asthmatic by a doctor. Out of 2166 participants in the urban population, 4.1% reported having had wheezing or whistling in the chest in the previous 12 months, 3.6% reported doctor-diagnosed asthma, and 0.6% chronic cough. In the rural population with 3223 participants these figures were 3.3%, 0.7% and 1.2%, respectively. Wheeze was more common in women, cough for 3 months of the year was more common in the age-groups 45+. Those who reported that they currently smoked accounted for 34% in urban and 42% in rural men. Figures were much lower for women (1.5% and 6.0%). Seven out of 574 randomly selected subjects (1.4%) exhibited bronchial hyper-responsiveness to methacholine challenge. Four of 133 (3.0%) people with self-reported wheeze and 3/69 (4.3%) participants with doctor-diagnosed asthma reacted positively on bronchial provocation with methacholine. There was a remarkably high prevalence of positive skin prick tests to aeroallergens: 38% in participants with a history of wheeze and 27% in those without. The prevalence of wheeze (particularly in association with bronchial hyper-responsiveness) was low in both rural and urban Gambia. This is in contrast to the relatively high prevalence of positive skin prick tests to aeroallergens (in both wheezers and non-wheezers), questioning the mechanisms of interaction between allergy and asthma and the presence of protective factors against asthma in this West African population. The high smoking rates justify international concern about tobacco marketing in developing societies.

Cough as the sole manifestation of airway hyperreactivity.

The authors report 18 patients who presented to the ENT department with isolated cough, which had begun one month to 14 years previously. As the ENT examination was negative, the patients were referred to the Department of General Medicine where a bronchial reactivity test with acetylcholine was found to be positive, leading to a diagnosis of airway hyperreactivity. The group was predominantly female (15/18) and atopy was rare; indeed, only one patient, who had a history of allergic rhinitis, was found to be atopic. Bronchodilators and inhaled steroids cured or helped the cough in 16/18 patients. When a patient presents with chronic cough without other respiratory symptoms it is important to consider a diagnosis of airway hyperreactivity and to confirm this with a challenge test of bronchoconstriction.

Exercise-induced bronchoconstriction

Spirometry Objective testing should begin with spirometry at rest. In true exercise-induced bronchoconstriction, the results should be within normal limits. Should resting values be abnormal, then asthma, or some other chronic lung condition, is present. There is, of course, no reason why asthma and exercise-induced bronchoconstriction should not co-exist but the distinction is important because without successful treatment of underlying asthma, treatment of an exercise component will likely be unsuccessful. If baseline testing is normal, some form of exercise or pharmacologic stress will be required, either on the sideline or practice venue, or in the laboratory. Exercise testing Treadmill or ergometer-based testing in lung function laboratories are effective methods for diagnosing exercise-induced bronchoconstriction, but may result in false negatives if the exercise stimulus is not intense enough.

[USEFULNESS OF THE FORCED OSCILLATION TECHNIQUE IN THE DIAGNOSIS OF COUGH VARIANT ASTHMA WITH PROLONGED OR CHRONIC COUGH].

Usefulness of carrying out the reversibility test after inhaling bronchodilator by forced oscillation technique (FOT) in addition to spirometry was investigated in the diagnosis of bronchial asthma (BA), cough variant asthma (CVA) and allergic rhinitis (AR) with prolonged or chronic cough. The subjects were the 622 patients at Idaimaeminamiyojo Clinic in Sapporo who complained cough over three weeks, and underwent bronchial reversibility test with salbutamol by using spirometry and FOT. We divided them into 5 groups; BA, BA+AR, CVA, CVA+AR, AR, and examined their lung functions. The mean of improvement of FEV1 after inhalation of salbutamol was significantly different (p<0.001); 465ml (26%) of BA, 136ml (5.5%) of CVA, and 44ml (1.6%) of AR. However, in CVA, the mean reversibility value was not over the diagnostic criteria of BA; 200ml (12%). Improvement of respiratory resistant at 5Hz (R5) using FOT in BA/CVA were 25.7%/24.1%, and significantly higher (p<0.001) than that in AR, and these results were alike even in cases accompanied by AR; BA+AR, CVA+AR, and AR. AUC value in the ROC curve for diagnosis of CVA from AR with R5 was 0.870, and highest among with R5, R20, R35 and Fres. When the cut off value of R5 improvement was 15%, sensitivity was 74% and specificity was 81%. It was suggested that the additional bronchial reversibility test using FOT may be useful especially in the diagnosis of cough variant asthma where the reversibility in spirometry alone is not sufficient.

[Bronchial adenoid cystic carcinoma masquerading as bronchial asthma: a case report].

Here we reported a case of bronchial adenoid cystic carcinoma from Peking University Third Hospital. A 40-year-old female presented with dry cough for 1 year and nocturnal paroxysmal attacks of wheezing for 4 months. She was a non-smoker, and did not have past histories of asthma or allergy. On physical examination, no stridor, wheezing and cyanosis were present and the general appearance was good. The results of the laboratory analysis, including blood eosinophils count, immunoglobulin E level and chest X-ray were normal. Spirometry revealed reversible airflow obstruction, and post-bronchodilator forced expiratory volume in one second (FEV1) showed an increase of 12% and 230 mL from baseline. Bronchial asthma was diagnosed, however, she responded poorly despite the adequate anti-asthma therapy including high dose inhaled corticosteroid plus long-acting beta2-agonist, theophylline and montelukast. Then chest computed tomography (CT) was performed which showed a polypoid mass occupying the lumen of left main bronchus. Then the bronchoscopy revealed a polypoid endo-bronchial mass arising from the left main bronchus, causing subtotal obstruction of the lumen. Biopsy was carried out through the bronchoscopy, the pathological findings showed characteristic cribriform and tubular pattern which was formed by two-layered cells with ductal and myoepithelial phenotypes, which were consistent with adenoid cystic carcinoma. Re-examining the patient, the lung was clear without any wheeze when she was seated. However, inspiratory wheeze was heard in her left upper lung when she was supine, and disappeared after sitting up again. Subsequently the patient underwent a resection surgery. At the operational site, the tumor was seen on the anterolateral wall of the left main bronchus, without submucosally expanding histologically. Therefore, a sleeve resection surgery of the left main bronchus was performed. Following surgery, chest CT scan revealed complete resolution of the tumor. Her symptoms improved significantly, as did her pulmonary function tests, although all the medicines for asthma were stopped. Now, two years after the operation, the patient remained asymptomatic, and spirometry was performed again which showed normal completely. The presenting case report emphasizes the fact that not all wheezes and reversible airflow obstruction are asthma. It is critical to bear in mind that if a "difficult asthma" patient does not respond to appropriate anti-asthma therapy; localized obstructions should be differentiated.

The value of inhalation challenge testing as an office procedure.

One hundred seventy-three bronchial challenge tests were performed as an outpatient procedure on 35 selected clinic patients. The incidence of positive tests was sufficiently high and the procedure tolerated well enough to suggest this as a practical office procedure if carefully done in properly chosen patients.

Post bronchodilator test

Procedure An initial spirometry is performed to assess the patient's native respiratory status. You will be asked to take a deep breath and then blow into the mouthpiece of the spirometer as hard as you can. This is a baseline measurement. A dose of bronchodilator medication is administered by means of inhaler or nebulizer (such as 400mcg of salbutamol (also known as albuterol)). You will wait about 15 minutes and then the spirometry is repeated. An increase in FEV1 (or forced expiratory volume in the first second of a forced exhalation) of >200ml is considered a positive result. Bear in mind, however, that this number does not apply to children, and that it can differ depending on the patient's native result; small patient's with pulmonary fibrosis, restrictive lung disease etc. will have a measurably lower FEV1 than healthy average-sized adults. This can give a false positive result of the test. References Pulmonary function testing