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Comparison of methacholine and mannitol challenges: importance of method of methacholine inhalation.
Allergy, Asthma & Clinical Immunology ( IF 2.7 ) Pub Date : 2020-02-11 , DOI: 10.1186/s13223-020-0410-x
Donald W Cockcroft 1, 2 , Beth E Davis 1 , Christianne M Blais 1
Affiliation  

Background Direct inhalation challenges (e.g. methacholine) are stated to be more sensitive and less specific for a diagnosis of asthma than are indirect challenges (e.g. exercise, non-isotonic aerosols, mannitol, etc.). However, data surrounding comparative sensitivity and specificity for methacholine compared to mannitol challenges are conflicting. When methacholine is inhaled by deep total lung capacity (TLC) inhalations, deep inhalation inhibition of bronchoconstriction leads to a marked loss of diagnostic sensitivity when compared to tidal breathing (TB) inhalation methods. We hypothesized that deep inhalation methacholine methods with resulting bronchoprotection may be the explanation for conflicting sensitivity/specificity data. Methods We reviewed 27 studies in which methacholine and mannitol challenges were performed in largely the same individuals. Methacholine was inhaled by dosimeter TLC methods in 13 studies and by tidal breathing in 14 studies. We compared the rates of positive methacholine (stratified by inhalation method) and mannitol challenges in both asthmatics and non-asthmatics. Results When methacholine was inhaled by TLC inhalations the prevalence of positive tests in asthmatics, 60.2% (548/910), was similar to mannitol, 58.9% (537/912). By contrast, when methacholine was inhaled by tidal breathing the prevalence of positive tests in asthmatics 83.1% (343/413) was more than double that of mannitol, 41.5% (146/351). In non-asthmatics, the two methacholine methods resulted in positive tests in 18.8% (142/756) and 16.2% (27/166) by TLC and TB inhalations respectively. This compares to an overall 8.3% (n = 76) positive rate for mannitol in 913 non-asthmatics. Conclusion These data support the hypothesis that the conflicting data comparing methacholine and mannitol sensitivity and specificity are due to the method of methacholine inhalation. Tidal breathing methacholine methods have a substantially greater sensitivity for a diagnosis of asthma than either TLC dosimeter methacholine challenge methods or mannitol challenge. Methacholine challenges should be performed by tidal breathing as per recent guideline recommendations. Methacholine (more sensitive) and mannitol (more specific) will thus have complementary diagnostic features.

中文翻译:

乙酰甲胆碱和甘露醇挑战的比较:乙酰甲胆碱吸入方法的重要性。

背景 直接吸入挑战(例如乙酰甲胆碱)被认为比间接吸入挑战(例如运动、非等渗气雾剂、甘露醇等)更敏感且特异性更低。然而,与甘露醇挑战相比,乙酰甲胆碱的相对敏感性和特异性的数据是相互矛盾的。当通过深部总肺活量 (TLC) 吸入法吸入乙酰甲胆碱时,与潮式呼吸 (TB) 吸入法相比,支气管收缩的深部吸入抑制会导致诊断灵敏度显着下降。我们假设具有支气管保护作用的深度吸入乙酰甲胆碱方法可能是敏感性/特异性数据相互矛盾的原因。方法 我们回顾了 27 项研究,其中乙酰甲胆碱和甘露醇攻击在大部分相同的个体中进行。在 13 项研究中通过剂量计 TLC 方法吸入乙酰甲胆碱,在 14 项研究中通过潮汐呼吸法吸入乙酰甲胆碱。我们比较了哮喘患者和非哮喘患者的乙酰甲胆碱阳性率(通过吸入法分层)和甘露醇激发率。结果 当通过 TLC 吸入法吸入乙酰甲胆碱时,哮喘患者的阳性检测率为 60.2% (548/910),与甘露醇相似,为 58.9% (537/912)。相比之下,当通过潮式呼吸吸入乙酰甲胆碱时,哮喘患者的阳性检测率为 83.1% (343/413),是甘露醇 41.5% (146/351) 的两倍多。在非哮喘患者中,两种乙酰甲胆碱方法导致 18.8% (142/756) 和 16 的阳性检测结果。TLC 和 TB 吸入分别为 2% (27/166)。相比之下,913 名非哮喘患者的甘露醇阳性率为 8.3%(n = 76)。结论 这些数据支持这样的假设,即比较乙酰甲胆碱和甘露醇敏感性和特异性的相互矛盾的数据是由于乙酰甲胆碱吸入方法造成的。潮式呼吸乙酰甲胆碱法对哮喘诊断的敏感性明显高于 TLC 剂量计乙酰甲胆碱激发法或甘露醇激发法。根据最近的指南建议,应通过潮式呼吸进行乙酰甲胆碱挑战。因此,乙酰甲胆碱(更敏感)和甘露醇(更特异)将具有互补的诊断特征。结论 这些数据支持这样的假设,即比较乙酰甲胆碱和甘露醇敏感性和特异性的相互矛盾的数据是由于乙酰甲胆碱吸入方法造成的。潮式呼吸乙酰甲胆碱法对哮喘诊断的敏感性明显高于 TLC 剂量计乙酰甲胆碱激发法或甘露醇激发法。根据最近的指南建议,应通过潮式呼吸进行乙酰甲胆碱挑战。因此,乙酰甲胆碱(更敏感)和甘露醇(更特异)将具有互补的诊断特征。结论 这些数据支持这样的假设,即比较乙酰甲胆碱和甘露醇敏感性和特异性的相互矛盾的数据是由于乙酰甲胆碱吸入方法造成的。潮式呼吸乙酰甲胆碱法对哮喘诊断的敏感性明显高于 TLC 剂量计乙酰甲胆碱激发法或甘露醇激发法。根据最近的指南建议,应通过潮式呼吸进行乙酰甲胆碱挑战。因此,乙酰甲胆碱(更敏感)和甘露醇(更特异)将具有互补的诊断特征。潮式呼吸乙酰甲胆碱法对哮喘诊断的敏感性明显高于 TLC 剂量计乙酰甲胆碱激发法或甘露醇激发法。根据最近的指南建议,应通过潮式呼吸进行乙酰甲胆碱挑战。因此,乙酰甲胆碱(更敏感)和甘露醇(更特异)将具有互补的诊断特征。潮式呼吸乙酰甲胆碱法对哮喘诊断的敏感性明显高于 TLC 剂量计乙酰甲胆碱激发法或甘露醇激发法。根据最近的指南建议,应通过潮式呼吸进行乙酰甲胆碱挑战。因此,乙酰甲胆碱(更敏感)和甘露醇(更特异)将具有互补的诊断特征。
更新日期:2020-04-22
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