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Eur Respir J 2004; 24:332-333
Copyright ©ERS Journals Ltd 2004

From the Editor

P.J. Sterk

Leiden, The Netherlands

From the Editor:

I appreciate D. Lee's comments regarding my editorial on the usage of postbronchodilator spirometry in the Global Initiative for Chronic Obstructive Lung Disease (GOLD) and American Thoracic Society/European Respiratory Society criteria for the definition and classification of patients with chronic obstructive pulmonary disease (COPD) 1. Will it be meaningful to add prebronchodilator values and reversibility to those criteria? It sounds plausible, but I believe it is not justified. The reason for this is that we should distinguish the criteria for the disease from potentially relevant information on the disease.

We all seem to agree that COPD is a disease in which airflow limitation is not fully reversible. The latter points to residual airflow limitation after giving an adequate dose of abronchodilator: in other words, a lowered ceiling (postbronchodilator value) of spirometry. Would it be helpful to include the reversibility as such? Apart from the different ways of expressing reversibility 2, it appears that the response to a bronchodilator has hardly any diagnostic value for COPD 3, whilst being very poorly reproducible 4. As indicated in my editorial, this is not unexpected since the prebronchodilator value of forced expiratory volume in one second and, thereby, its reversibility towards the postbronchodilator ceiling value is modulated by variable degrees of smooth muscle contraction. Therefore, the prebronchodilator value, as well as the reversibility, does not seem to be an adequate criterion as to whether airflow limitation is "not fully reversible".

Does this mean that reversibility is a useless index? No, certainly not. The degree of reversibility may point towards clinically and pathophysiologically relevant phenotypes ofCOPD. What are the determinants of smooth muscle contraction in this disease? We don't know, but there is recent evidence that patients with a substantial degree of reversibility of their airflow limitation (notwithstanding their abnormal postbronchodilator value) do have certain specific characteristics, such as elevated levels of exhaled nitric oxide and sputum eosinophilia 5, together with blood eosinophilia and reduced levels of neutrophil activation 6. Hence, indeed, there is a message that needs to be taken seriously in measuring reversibility, despite its poor reproducibility 4.

Taken together, when distinguishing the strict criteria for the definition and classification of chronic obstructive pulmonary disease from other potentially useful information on the clinical phenotype of the disease, D. Lee and myself do seem to agree. I thank him for his comments.

References

  1. Sterk PJ. Let's not forget: the GOLD criteria for COPD are based on post-bronchodilator FEV1. Eur Respir J 2004;23:497–498.[Free Full Text]
  2. Brand PLP, Quanjer PH, Postma DS, et al. Interpretation of bronchodilator response in patients with obstructive airways disease. The Dutch Chronic Non-Specific Lung Disease (CNSLD) study group. Thorax 1992;47:429–436.[Abstract]
  3. Meslier N, Racineux JL, Six P, Lockhart A. Diagnostic value of reversibility of chronic airway obstruction to separate asthma from chronic bronchitis: a statistical approach. Eur Respir J 1989;2:497–505.[Abstract]
  4. Calverley PMA, Burge PS, Spencer S, Anderson JA, Jones PW. Bronchodilator reversibility testing in chronic obstructive pulmonary disease. Thorax 2003;58:659–664.[Abstract/Free Full Text]
  5. Papi A, Romagnoli M, Baraldo S, et al. Partial reversibility of airflow limitation and increased exhaled NO and sputum eosinophilia in chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2000;162:1773–1777.[Abstract/Free Full Text]
  6. Sitkauskiene B, Sakalauskas R, Malakauskas K, Lötvall J. Reversibility to a beta2-agonist in COPD: relationship to atopy and neutrophil activation. Respir Med 2003;97:591–598.[CrossRef][ISI][Medline] [Order article via Infotrieve]




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