Are asthma-like symptoms due to bronchial or extrathoracic airway dysfunction?

• Published in: The Lancet (British edition) 1995-09, Vol.346 (8978), p.791-795
• Main Authors: Bucca, C, Rolla, G, Brussino, L, De Rose, V, Bugiani, M
• Format: Article
• Language: English
• Subjects: Adult; Airway Obstruction - diagnosis; Asthma; Asthma - diagnosis; Bronchial Diseases - diagnosis; Bronchial Hyperreactivity - diagnosis; Bronchial Hyperreactivity - physiopathology; Bronchial Provocation Tests; Chronic Disease; Cough; Cough - diagnosis; Diagnosis, Differential; Diseases; Dyspnea; Dyspnea - diagnosis; Female; Forced Expiratory Volume - drug effects; Histamine; Histamine - pharmacology; Humans; Laryngitis; Laryngitis - diagnosis; Male; Maximal Midexpiratory Flow Rate - drug effects; Medical research; Nose Diseases - diagnosis; Patients; Pharyngitis; Pharyngitis - diagnosis; Probability; Respiration; Respiratory Sounds - diagnosis; Respiratory system; Respiratory tract; Respiratory tract diseases; Signs and symptoms; Sinusitis; Sinusitis - diagnosis; Throat
• ISSN: 0140-6736; 1474-547X
• DOI: 10.1016/S0140-6736(95)91617-2

Summary Patients with asthma-like symptoms may not have asthma but obstruction of the extrathoracic airway (EA). To evaluate if dysfunction of the EA causes asthma-like symptoms, we assessed bronchial and EA responsiveness to inhaled histamine in 441 patients who presented with at least one of three key symptoms—cough, wheeze, dyspnoea—but had neither documented asthma nor bronchial obstruction. The histamine concentrations causing a 20% fall in forced expiratory volume in 1 s (PC20FEV1) and a 25% fall in maximal mid-inspiratory flow (PC25MIF50) were used as respective thresholds of bronchial and EA responsiveness. Values 8 mg/mL or less indicated bronchial (B-HR) or EA hyper-responsiveness (EA-HR). The influence of concurrent upper respiratory tract diseases, such as post-nasal drip (PND), pharnygitis, laryngitis and sinusitis, was also assessed. We found four response patterns to the histamine challenge: EA-HR in 26·5% of the patients, B-HR in 11·1%, combined EA-HR and B-HR in 40·6%, and no-HR in 21·8%. Cough was reported by 79% of the patients, wheeze by 53%, and dyspnoea by 40%. Patients with cough as the sole presenting symptom (34·2%), as compared with those with wheeze and/or dyspnoea (20%), had significantly greater probability of having EA-HR (OR 5·35, 95% Cl 3·25-8·82) and lower probability of having B-HR (OR 0·45, Cl 0·28-0·70); patients with cough plus wheeze and/or dyspnoea (45·8%) had significantly greater probability of having both EA-HR and B-HR than either those with cough alone (OR 2·48, Cl 1·49-4·13), or those with wheeze and/or dyspnoea but not cough (OR 1·74, Cl 1·36-2·22). EA-HR alone or combined with B-HR was strongly associated with EA diseases, particularly pharyngitis and PND. Cough was significantly associated with PND, either when it was the sole symptom (OR 2·16, Cl 1·14-4·09) or when it was combined with wheeze and/or dyspnoea (OR 3·53, Cl 1·97-6·33). Our results suggest that extrathoracic airway dysfunction may account for asthma-like symptoms, particularly chronic cough. This abnormality seems to be sustained by chronic diseases of the upper respiratory tract.