Restrictive impairment in patients with asthma

BACKGROUND: Patients with asthma have intermittent or persistent airflow obstruction, most often manifested spirometrically by reduced forced expiratory volume in 1s (FEV(1)) and FEV(1)/vital capacity (VC) ratio. In some patients, the VC may be reduced by air trapping, with an increase in functional residual capacity (FRC) and residual volume (RV) (pseudorestriction). We have reported 12 asthmatic patients with reduced VC and no increase in RV, i.e., a true restrictive impairment [Gill et al. True restrictive impairment in bronchial asthma. Am J Respir Crit Care Med 1999:159:A652]. OBJECTIVES: To confirm previous observations of true restrictive impairment (not attributable to air trapping) in patients with asthma, and to estimate its frequency in an asthmatic population. METHODS: Review of pulmonary function tests and clinical records of all post-pubertal patients diagnosed as asthma between January 2000 and September 2003 in a 184 bed inner city teaching hospital in Jamaica, Queens, New York. The clinical diagnosis of asthma was accepted when one or more of the following pulmonary function criteria were met: Positive bronchodilator response (BD), positive methacholine, repeated variability in spirometric values. Restriction was defined as decrease in total lung capacity (TLC) or decrease in VC with no increase in functional residual capacity (FRC) plus normal or high FEV(1)/FVC ratio. Patients with any clinical finding consistent with restriction, including a decreased diffusing capacity (DL) or obesity (BMI >30) were excluded. RESULTS: A total of 100 of 413 (24%) patients with asthma had restriction; 21 of these met all exclusions (including DL and BMI) and 11 (of 46) patients with an increased BMI and normal DL normalized their FVC on BD therapy, demonstrating that their pre-BD restrictive impairment could not be attributed to obesity. Plethysmographic FRC was measured in 81 of the 100 patients with restriction and was increased in only seven. CONCLUSION: True restrictive impairment was noted in at least 32 of 413 asthmatics (8%), consistent with previous observations in asthma and reactive airways dysfunction syndrome. This finding is not widely recognized and should not preclude the diagnosis of asthma, BD testing or appropriate therapy for asthma.