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Deviation from ATS/ERS recommendations for spirometry

An unambiguous bronchodilator response according to the ECCS and ERS (ref. 1) is one in which the FEV1 and/or VC increase by both more than 12% of the predicted value and more than 200 mL. In a more recent ATS/ERS recommendation (ref. 8) the predicted value has been replaced by the initial value. Below are some comments that the users might wish to keep in mind.

200 mL criterion FEV1
  Of 4343 patients who performed spirometric tests before and after administration of a bronchodilator drug at Dijkzigt Academic Hospital, in 126 patients the FEV1 increased by >12% of the predicted value. In one case only was the increase <200 mL, and this occurred in an elderly lady who was very short (85 yr, 154 cm) in whom the predicted value was very low (1200 mL). Therefore, if FEV1 increases 12% or more of the predicted value, the >200 mL requirement is superfluous. However, an increase of >200 mL is larger than the spontaneous variability in patients (ref. 3), and can therefore be regarded as mild bronchodilatation even if it is less than 12% of the predicted FEV1.
   
9% criterion FEV1
  An increase in FEV1 of >9% is regarded as significant bronchodilation in recommendations for general practitioners in the Netherlands. There is evidence in support of this in the literature (ref. 4). On that account an increase in FEV1 of 9-12% of the predicted value is regarded as evidence of mild bronchodilatation, and of >12% of the predicted FEV1 as unequivocal (marked) bronchodilation.
   
(F)VC criterion
  A response to a bronchodilator drug in FEV1 is usually accompanied by an increase in the VC. It is not obvious, however, whether a clear-cut increase in VC without a material change in FEV1 signifies bronchodilatation. According to the literature this is open to doubt (ref. 5), as an isolated increase in the (F)VC may be due to an increase in expiratory time; according to one author the phenomenon signifies a technical artifact (ref. 6). Based on the literature an isolated increase in the VC (>12% predicted and/or >340 mL) is therefore occasionally reported if FEV1 increases by <12% predicted and <200 mL and FEV1%(F)VC has increased, remained unchanged or fell by a maximum of 2%.
It has been suggested (ref. 7) to regard a larger increase in (F)VC than in FEV1 in asthma patients as a bronchodilator response (volume versus flow responders). This would signify slight opening of hitherto occluded small airways; this would allow more complete emptying of lung compartments even though the contribution to increased expiratory flow would be small.
   
200 mL criterion (F)VC
  A significant change in VC in patients according to the literature (3 authors (ref. 7)) should exceed 330, 340 and 380 mL, respectively; the latter two figures derive from rather small series of patients. The 200 mL criterion recommended by ECCS and ERS, and more recently by ATS/ERS (ref. 8), therefore appears to be too low; a weighted average of the three studies comes to 350 mL. In fact, in severe COPD a volume response in FVC without an improvement in FEV1 is accompanied by improvement in dyspnea and exercise tolerance, and should therefore be regarded as a positive bronchodilator response.

See also:
Reference values for all ages


Ref. 1 - ECCS and ERS
  In the revised 1993 version of the 1983 report (ref. 2) of the European Community for Coal and Steel (ECCS) published in 1993 predicted values of lung indices were unchanged. They are almost universally applied in Europe. The 1993 report was officially adopted by the European Respiratory Society (ERS).
The following chapter deals with spirometry, predicted values and bronchodilator responsiveness:
Quanjer PhH, Tammeling GJ, Cotes JE, Pedersen OF, Peslin R, Yernault JC. Lung volumes and forced ventilatory flows. Eur Respir J 1993; 6 suppl. 16: 5-40. Erratum Eur Respir J 1995; 8: 1629.
 
Ref. 2 - ECCS 1983
  Quanjer PhH (ed.) Standardized lung function testing. Bull Eur Physiopathol Respir 1983; 19 suppl. 5: 45-51.
 
Ref. 3 - Variability in patients
  Tweeddale PM, Alexander F, McHardy GJR. Short term variability in FEV1 and bronchodilator responsiveness in patients with obstructive ventilatory defects. Thorax 1987; 42: 487-490.
  Sourk RL, Nugent KM. Bronchodilator testing: confidence intervals derived from placebo inhalations. Am Rev Respir Dis 1983; 128: 153-157.
  Rozas CJ, Goldman AL. Daily spirometric variability. Normal subjects and subjects with chronic bronchitis with and without airflow obstruction. Arch Intern Med 1982; 142: 1287-1291.
 
Ref. 4 - Literature on bronchodilatation
  Sourk RL, Nugent: Bronchodilator testing: confidence intervals derived from placebo inhalations. Am Rev Respir Dis 1983; 128: 153-157.
  Tweeddale PM, Alexander F, McHardy GJR. Short term variability in FEV1 and bronchodilator responsiveness in patients with obstructive ventilatory defects. Thorax 1987; 42: 487-490.
  Eliasson O, Degraff AC. The use of criteria for reversibility and obstruction to define patient groups for bronchodilator trials. Influence of clinical diagnosis, spirometric, and anthropometric variables. Am Rev Respir Dis 1985; 132: 858-864.
  Meslier N, Racineux JL. Tests of reversibility of airflow obstruction. Eur Respir Rev 1991; 1: 34-40.
  Quanjer PhH, Tammeling GJ, Cotes JE, Pedersen OF, Peslin R, Yernault JC. Lung volumes and forced ventilatory flows. Eur Respir J 1993; 6 suppl. 16: 5-40. Erratum Eur Respir J 1995; 8: 1629.
  Brand PLP, Quanjer PhH, Postma DS, Kerstjens HAM, Koëter GH, Dekhuyzen PNR, Sluiter HJ, Dutch CNSLD Study Group. Interpretation of bronchodilator response in patients with obstructive airway disease. Thorax 1992; 47: 429-436.
  Waalkens HJ, Merkus PJFM, van Essen-Zandvliet EEM, Brand PLP, Gerritsen J, Duiverman EJ, Kerrebijn KF, Knol K, Quanjer PhH. Dutch CNSLD Study Group. Assessment of bronchodilator response in children with asthma. Eur Respir J 1993; 6: 645-651.
  Casan P, Roca J, Sanchis J: Spirometric response to a bronchodialtor. Reference values for healthy children and adolescents. Bull Europ Physiopath Resp 1983; 19: 567-569.
  Pardos Martinez C, Fuertes Fernández-Espinar J, Nerín de la Puerta I, González Pérez-Yarza E: Cuándo se considera positivo el test de broncodilatación. Anales Españoles de Pediatria 2002; 57: 5-11.
  Dales RE, Spitzer WO, Tousignat P, Schechter M, Suissa S: Clinical interpretation of airway response to a bronchodilator. Epidemiologic considerations. Am Rev Respir Dis 1988; 138: 317-320.
 
Ref. 5 - Isolated improvement in the VC
  Ramsdell JW, Tisi GM. Determination of bronchodilatation in the clinical pulmonary function laboratory: role of change in static lung volumes. Chest 1979; 76: 622-628.
  Girard WM, Light RW. Should the FVC be considered in evaluating response to bronchodilator? Chest 1983; 84: 87-89.
  Tweeddale PM, Alexander F, McHardy GJR. Short term variability in FEV1 and bronchodilator responsiveness in patients with obstructive ventilatory defects. Thorax 1987; 42: 487-490.
  Miller WF, Scacci R, Gast LR. Laboratory evaluation of pulmonary function (p. 276). JB Lippincott, Philadelphia, 1987. SBN 0-397-50574-4
  Enright PL, Hyatt RE. Office spirometry (p. 191). Lea & Febiger, Philadelphia, 1987. ISBN 0-8121-1075-7
  Berger R, Smith D. Acute postbronchodilator changes in pulmonary function parameters in patients with chronic airways obstruction. Chest 1988; 93: 541-546.
Ref. 6 - Isolated increase in FVC: artifact?
  Berger R, Smith D. Acute postbronchodilator changes in pulmonary function parameters in patients with chronic airways obstruction. Chest 1988; 93: 541-546.
Ref. 7 - Flow versus volume responders
  Woolcock AJ, Read J. Improvement in bronchial asthma not reflected in forced expiratory volume. Lancet 1965; 1323-1325.
  Ramsdell JW, Tisi GM. Determination of bronchodilation in the clinical pulmonary function laboratory. Role of changes in static lung volumes. Chest 1979; 76: 622-628.
  Paré PD, Lawson LM, Brooks LA. Patterns of response to inhaled bronchodilators in asthmatics. Am Rev Respir Dis 1983; 127: 680-685.
   
Ref. 8 - Flow versus volume responders
8 Pellegrino R, Viegi G, Brusasco V, et al. Interpretative strategies for lung function tests. ATS/ERS Task Force: Standardization of Lung Function Testing. Eur Respir J 2005; 26: 948-968.
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