THE JOURNAL

OF

ALLERGY AND

CLINICAL VOLUME

IMMUNOLOGY NUMBER

64

6, PART 2

Editorial Richard

R. Rosenthal,

M.D.* Baltimore,

The concept of bronchial challenge, the willful provocation of hyperactive human airways with an inhaled substance, or with exercise, is not new .im4 In the past several years, during which time the technique has been standardized and equipment has become more available, we have seen an increased interest in these procedures.5 The variety of scientific persuasions represented by the workshop participants attests to the relevance of bronchoprovocation techniques to a growing number of clinical interests. Pediatric and adult specialists, in both allergy and pulmonary medicine, are using bronchoprovocation for clinical investigation as well as a diagnostic adjunct. Physiologists are looking to such techniques to study the fundamental processes of reversible obstructive airway disease, and pharmacologists, recognizing the value of a laboratory model of asthma, have used bronchoprovocation to study drug efficacy. Epidemiologic studies by Britt et al.6 have shown there may be a risk factor for the development of chronic obstructive pulmonary disease associated with methacholine sensitivity, and the armed services are presently using exercise challenge, when appropriate, to assess the suitability of active duty assignments for personnel. The separate studies of Butcher,’ Gerblich et al. ,8 and Chester et al. ,g described in this issue, not only validate the use of inhalation provocation for documentation of work-related disability, but

Md.

raise the issue of cholinergic hyperreactivity as an industrial risk factor as well. As interest grows and the technique becomes more available, there is concern regarding the proper utilization and the potential for abuse. Unlike many other clinical techniques, bronchoprovocation has not been “sold” to the medical community as a state-of-the-art tool necessary for diagnostics. Indeed, the indications herein should help add perspective to the role of challenge procedures in the clinical armamentarium. As with any technique, the benefits of the information gained from challenge should be weighed against the risks to the patient, the cost, and the diagnostic alternatives. Undoubtedly, the role of challenge procedures will continue to expand. Even now, whether these may be new compensable tests to be used as a clinical screen is questioned. It is important that the selection of these techniques for use in diagnosis or clinical investigation conform always to the principles of good medical practice. The appropriate selection of patients and the proper conduct of trials, both discussed in this issue, should help to prevent indiscriminate use. It is hoped that a thoughtful analysis of principles and our collective experience will help each of us to decide when and how to use these techniques. Anything less constitutes a threat to our credibility as physicians. REFERENCES

From Division of Allergy and Clinical Immunology, Johns Hopkins School of Medicine. Reprint requests to: Richard R. Rosenthal, M.D., The Johns Hopkins School of Medicine at Good Samaritan Hospital, 5601 Loch Raven Blvd., Baltimore, MD 21239. *Chairman, Bronchoprovocation Committee, American Academy of Allergy. 0091-6749/79/l

30561+02$00.20/0

0 1979 The C. V. Mosby

1, Citron KM, Frankland AW, Sinclair JD: Inhalation test of bronchial hypersensitivity in pollen asthma Thorax 13:229, 1958. 2. ltkin I II, Anand S, Yau M, Middlebrook G: Quantitative inhalation challenge in allergic asthma. J ALLERGY 34~97, 1963. 3. Popa V, Teculescu D, Stanescu D, Gavrilescu N: The value of inhalation challenge tests in perennial bronchial asthma. J ALLERGY 42:130, 1968. Co.

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4. Bernstein L. Kreindler A, Sugeman D: Direct bronchial testing in allergy: Preliminary results concerning utility, validity, and safety of the technique in treated and untreated asthmatic patients. Ann Allergy 22~4, 1969. 5. Chai H, Farr RS, Froehlich LA, Mathison DA, McLean JA. Rosenthal RR, Sheffer AL II, Spector SL, Townley RG: Standardization of bronchial inhalation challenge procedures. J ALI ERGY CLIN IhlMUNOI. 56:323, 1975. 6. Britt J, Cohen B. Menkea H. Bleecker E, Rosenthal R, and Norman P: Airways reactivity and functional deterioration in relatives of COPD patients. 22nd Aspen Lung Conference, Chest. (In press.)

J. ALLERGY

CLIN. IMMUNOL. DECEMBER 1979

7. Butcher BT: Inhalation testing with toluene diisocyanate. J ALLERGY CLIN IMMUNOL 64(suppl.):655. 1979. 8. Gerblich AA, Horowitz J, Chester EH. Schwartz HJ, Fleming GM: A proposed standardized method for bronchoprovocation tests in toluene diisocyanate-induced asthma. J ALL~RCY CLIN IMMUNOL 64(suppl.):658, 1979. 9. Chester EH, Martinez-Catinchi F, Schwartz HJ. Horowitz J, Fleming GM, Gerblich AA, McDonald EW, Brethauer R: Patterns of airway reactivity to asthma produced by exposure to toluene di-isocyanate. Chest 7583229. 1979.

Bronchial challenge.

THE JOURNAL OF ALLERGY AND CLINICAL VOLUME IMMUNOLOGY NUMBER 64 6, PART 2 Editorial Richard R. Rosenthal, M.D.* Baltimore, The concept of br...
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