Asthma Management Handbook

Airway hyperresponsiveness tests for diagnosis in adults

Recommendations

Consider arranging bronchial provocation (challenge) tests for airway hyperresponsiveness if asthma is suspected but initial spirometry does not demonstrate reversible airflow limitation.

Notes:

If challenge testing is needed, consider referring to a respiratory physician for investigation, or discussing with a respiratory physician before selecting which test to order.

Don’t test during a respiratory infection, or initiate inhaled corticosteroid treatment in the few weeks before challenge testing, because these could invalidate the result.

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

Bronchial provocation (challenge) tests should be performed only in accredited respiratory function laboratories.

Note: A list of accredited laboratories is available from the Australian and New Zealand Society of Respiratory Science

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

Do not routinely order tests for airway hyperresponsiveness (challenge tests) for all patients with suspected asthma. It is not necessary to demonstrate airway hyperresponsiveness if the patient shows clinical features of asthma and there is a high probability that these are not due to another cause.

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

More information

Bronchial provocation (challenge) tests in adults and older adolescents

The main roles of bronchial provocation tests of airway hyperresponsiveness (airway hyperreactivity) in adults are to exclude asthma as the cause of current symptoms, and to confirm the presence of exercise-induced bronchoconstriction.123

Bronchial provocation tests for hyperresponsiveness are performed in accredited lung function testing laboratories. These tests involve repeated spirometry tests.

Bronchial provocation tests of airway hyperresponsiveness include:

  • direct challenge tests (e.g. methacholine challenge test)3
  • indirect challenge tests (e.g. exercise challenge test, eucapnic voluntary hyperpnea, hypertonic (4.5%) saline, mannitol challenge test)4
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Challenge tests for exercise-induced bronchoconstriction

Role of challenge tests

Self-reported symptoms are not sensitive enough to detect exercise-induced bronchoconstriction reliably or specific enough to rule out other conditions, particularly in elite athletes.567 Single office FEV1 readings or peak expiratory flow measurement are not adequate to demonstrate exercise-induced bronchoconstriction.8

Standardised, objective bronchial provocation (challenge) tests using spirometry are necessary for the investigation of suspected exercise-induced bronchoconstriction in elite athletes. These tests involve serial spirometry measurements after challenge with exercise (or exercise surrogates e.g. dry powder mannitol, eucapnic voluntary hyperpnoea or hyperventilation, or hyperosmolar aerosols such as 4.5% saline).58, 910 Severity of exercise-induced bronchoconstriction is assessed by percentage fall in FEV1 after challenge.8

Challenge testing is mandated by sports governing bodies before the athlete is given permission to use some asthma medicines, and the required testing protocol varies between specific sports. The latest information is available from the Australian Sports Anti-Doping Authority (ASADA) and the World Anti-Doping Agency (WADA).

Challenge tests are also used in the investigation of exercise-related symptoms in recreational and non-athletes, when objective demonstration of exercise-induced bronchoconstriction is needed to guide management decisions.

Choice of challenge test

There is no single challenge test that will identify all individuals with exercise-induced bronchoconstriction.5 The most appropriate test or tests for an individual depend on clinical and individual factors:

  • The eucapnic voluntary hyperpnoea test can provoke a severe response.5 For safety reasons, the eucapnic voluntary hyperpnoea test should only be used in adults who regularly exercise at high intensity (e.g. elite athletes).5 It should not be used in children.
  • When an exercise challenge test is used, inhalation of dry air is recommended to diagnose or exclude exercise-induced bronchoconstriction because it increases the sensitivity of the test.5
  • Mannitol challenge can be used as an alternative to exercise provocation testing to investigate suspected exercise-induced bronchoconstriction, 5, 11, 12 including in children.13, 14
  • For safety reasons, exercise challenge in dry air should be avoided in patients with FEV1 <70% predicted5

Referral

If challenge testing is needed, consider referring to a respiratory physician for investigation, or discussing with a respiratory physician before selecting which test to order. Do not test during a respiratory infection, or initiate inhaled corticosteroid treatment in the few weeks before challenge testing, because these could invalidate the result.

A list of accredited respiratory function laboratories is available from the Australian and New Zealand Society of Respiratory Science.

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References

  1. Anderson SD. Indirect challenge tests: Airway hyperresponsiveness in asthma: its measurement and clinical significance. Chest. 2010; 138(2 Suppl): 25S-30S. Available from: http://journal.publications.chestnet.org/article.aspx?articleid=1086636
  2. Anderson SD. Bronchial challenge tests: usefulness, availability and challenges. Breathe. 2011; 8: 53-60. Available from: http://www.ers-education.org
  3. Cockcroft DW. Direct challenge tests: airway hyperresponsiveness in asthma: its measurement and clinical significance. Chest. 2010; 138(2 Suppl): 18S-24S. Available from: http://journal.publications.chestnet.org/article.aspx?articleid=1086632
  4. Anderson SD, Pearlman DS, Rundell KW, et al. Reproducibility of the airway response to an exercise protocol standardized for intensity, duration, and inspired air conditions, in subjects with symptoms suggestive of asthma. Respir Res. 2010; Sept 1: 120. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2939602/
  5. Weiler JM, Anderson SD, Randolph C, et al. Pathogenesis, prevalence, diagnosis, and management of exercise-induced bronchoconstriction: a practice parameter. Ann Allergy Asthma Immunol. 2010; 105: S1-47. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21167465
  6. Rundell KW, Im J, Mayers LB, et al. Self-reported symptoms and exercise-induced asthma in the elite athlete. Med Sci Sports Exerc. 2001; 33: 208-13. Available from: http://www.ncbi.nlm.nih.gov/pubmed/11224807
  7. Holzer K, Anderson SD, Douglass J. Exercise in elite summer athletes: Challenges for diagnosis. J Allergy Clin Immunol. 2002; 110: 374-80. Available from: http://www.ncbi.nlm.nih.gov/pubmed/12209082
  8. Parsons JP, Hallstrand TS, Mastronarde JG, et al. An official American Thoracic Society clinical practice guideline: exercise-induced bronchoconstriction. Am J Respir Crit Care Med. 2013; 187: 1016-27. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23634861
  9. Fitch KD, Sue-Chu M, Anderson SD, et al. Asthma and the elite athlete: Summary of the International Olympic Committee's Consensus Conference, Lausanne, Switzerland, January 22-24, 2008. J Allergy Clin Immunol. 2008; 122: 254-260. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18678340
  10. Anderson SD, Kippelen P. Assessment and prevention of exercise-induced bronchoconstriction. Br J Sports Med. 2012; 46: 391-6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22247297
  11. Brannan JD, Koskela H, Anderson SD, Chew N. Responsiveness to mannitol in asthmatic subjects with exercise- and hyperventilation-induced asthma. Am J Respir Crit Care Med. 1998; 158: 1120-6. Available from: http://www.atsjournals.org/doi/full/10.1164/ajrccm.158.4.9802087
  12. Holzer K, Anderson SD, Chan HK, Douglass J. Mannitol as a challenge test to identify exercise-induced bronchoconstriction in elite athletes. Am J Respir Crit Care Med. 2003; 167: 534-7. Available from: http://www.atsjournals.org/doi/full/10.1164/rccm.200208-916OC
  13. Kersten ET, Driessen JM, van der Berg JD, Thio BJ. Mannitol and exercise challenge tests in asthmatic children. Pediatr Pulmonol. 2009; 44: 655-661. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19499571
  14. Barben J, Kuehni CE, Strippoli MP, et al. Mannitol dry powder challenge in comparison with exercise testing in children. Pediatr Pulmonol. 2011; 46: 842-8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21465681