Vocal cord dysfunction (VCD), a condition that frequently mimics or confounds asthma, is characterized by a paradoxical adduction of the vocal cords on inspiration. The apposition of the vocal cords produces airflow obstruction sufficient to cause wheezing, chest tightness, shortness of breath, and cough. Misdiagnosis as asthma has led to inappropriate treatment, most notably with high-dose corticosteroids. Herein we report two cases of VCD who presented with chronic cough and episodic breathlessness, respectively. Flow-volume loops on spirometry were abnormal, with evidence of variable extrathoracic airway obstruction, manifested as flat or truncated inspiratory loops. Laryngoscopy or bronchoscopy demonstrated paradoxical adduction with posterior "chinking" of the vocal cords on inspiration. One case also had asthma and depressive illness. After the diagnosis of VCD, the clinical manifestations resolved with speech therapy and/or psychotherapy. VCD should be suspected in patients with asthma-like symptoms. An early diagnosis avoids unnecessary aggressive management.
Adrenal Cortex Hormones ; Airway Obstruction ; Asthma ; Bronchoscopy ; Cough ; Diagnosis ; Diagnostic Errors ; Dyspnea ; Early Diagnosis ; Humans ; Laryngoscopy ; Psychotherapy ; Respiratory Sounds ; Speech Therapy ; Spirometry ; Thorax ; Vocal Cord Dysfunction* ; Vocal Cords*

BACKGROUND: Several investigators have demonstrated a considerable disagreement between FEV1 and PEFR to assess the severity of airflow obstruction. The purpose of this study was to examine whether the discrepancy between the two measurements affects the assessment in the severity of acute asthma. METHODS: Thirty-five consecutive asthma patients measured both FEV1 and PEFR at 0, 1hr, 1, 3, 5, 7 days of an emergency room admission using a spirometer and a Ferraris PEFR meter. The degree of discrepancy between FEV1 and PEFR expressed as % predicted values was determined. RESULTS: When predictive equations that recommended by the instrument manufacturers were used, PEFR measured with the PEFR meter (f-PEFR) was significantly higher than FEV1 at all time points, with 16.1% mean difference and unacceptable wide limits of agreement (-20.0~52.3%). The classification in severity was significantly different between FEV1 and f-PEFR (p < 0.001). The discrepancy was inter-instrumental in large part because f-PEFR was 10.1% higher than spirometric PEFR. Different predictive equations altered the degree of the differences but could not completely correct it. CONCLUSION: These results indicate that f-PEFR values underestimate the severity of airflow obstruction in acute asthma despite using recommended predictive equations. Therefore, these confounding factors should be considered when the severity of airflow obstruction is assessed with PEFR.
Acute Disease ; Adult ; Aged ; Airway Obstruction/diagnosis/*physiopathology ; Asthma/*physiopathology ; Comparative Study ; Female ; Forced Expiratory Volume/physiology ; Human ; Male ; Middle Age ; Peak Expiratory Flow Rate/*physiology ; Predictive Value of Tests

Bacillus Calmette-Guerin (BCG) is reported to suppress Th2 response and asthmatic reaction. Dendritic cells (DCs), the major antigen-presenting cells, infections with BCG are known to result in inducing various cytokines. Thus, DCs are likely to play a role in the effects of BCG on asthma. This study aims at investigating that cytokine milieu secreted by BCG-treated DCs directly enhances allergen-specific Th1 response and/or suppresses Th2 response in allergic asthma. DCs and CD3+ T cells were generated from Dermatophagoides farinae-sensitive asthmatics. DCs were cultured with and without BCG and subjected to flow cytometric analysis. IL-12 and IL-10 were determined from the culture supernatants. Some DCs were cocultured with T cells in the presence of D. farinae extracts after adding the culture supernatants from BCG-treated DCs, and IL-5 and IFN-gamma were determined. BCG-treated DCs enhanced significantly the expressions of CD80, CD86, and CD40, and the productions of IL-12 and IL-10. Addition of culture supernatants from BCG-treated DCs up-regulated production of IFN-gamma by T cells stimulated by DCs and D. farinae extracts (p<0.05), but did not down-regulate production of IL-5 (p>0.05). The cytokine milieu secreted by BCG-treated DCs directly enhanced allergen-specific Th1 response, although did not suppress Th2 response.
Antigens, Dermatophagoides/*immunology ; Asthma/*immunology ; Cells, Cultured ; Coculture Techniques ; Culture Media ; Cytokines/*immunology/secretion ; Dendritic Cells/cytology/*immunology/secretion ; Humans ; Hypersensitivity/immunology ; Interferon Type II/immunology/secretion ; Interleukin-10/immunology/secretion ; Interleukin-12/immunology/secretion ; Interleukin-5/immunology/secretion ; Lymphocyte Activation/immunology ; Mycobacterium bovis/*immunology ; Research Support, Non-U.S. Gov't ; Th2 Cells/cytology/immunology/secretion ; Up-Regulation/immunology

The role of lung mast cells in exercise-induced asthma (EIA) is controversial. To investigate whether the skin mast cell releasability is increased after exercise in EIA, 49 young atopic men with or without asthma took part in a free-running test for 6 min and were given skin prick tests using morphine, a mast cell secretagogue, before and after the exercise. The mean diameters of the wheal induced by morphine in patients with EIA were not significantly different from those in patients without EIA before exercise, although the baseline lung function was significantly lower and the airway hyperresponsiveness, the peripheral blood eosinophil count, and the size of the wheal in response to Dermatophagoides pteronyssinus were significantly higher in patients with EIA. However, the differences of the morphine-induced wheal diameter between patients with EIA and those without EIA became significant at 120 min after exercise (p<0.05), while the responses to histamine were not significantly different. These results suggest that exercise increases the releasability of skin mast cells in EIA patients whose asthma/allergy are relatively severe.
Adolescent ; Adult ; Analgesics, Opioid/diagnostic use ; Asthma/*immunology/physiopathology ; *Exercise ; Histamine/diagnostic use ; Humans ; Male ; Mast Cells/drug effects/*immunology ; Morphine/diagnostic use ; Skin/cytology/*immunology ; Skin Tests

It has been suggested that dendritic cells (DCs) are critical antigen presenting cells for eosinophilic airway inflammation in a mouse model of asthma, and cysteinyl leukotrienes may play a role in DC trafficking in asthmatics. We investigated whether the number of DCs is increased in the induced sputum of both atopic and nonatopic asthmatics and is related to activated eosinophil count in the sputum. Sputum was induced by inhalation of hypertonic saline in 9 atopic and 12 nonatopic asthmatics and 10 nonatopic normal controls, and differential cell counts were performed. DCs and activated eosinophils were identified by immunocytochemistry with monoclonal antibodies (anti-CD1a and EG2, respectively). There were significantly higher percentages of eosinophils, EG2+ cells, and CD1a+ DC in the sputum of atopic and nonatopic asthmatics compared with normal controls, respectively. In asthmatics, the percentage of CD1a+ DC was significantly correlated with that of EG2+ cells (Rs=0.62, p=0.004). We demonstrated that the increased number of DCs was evident in the induced sputum of both atopic and nonatopic asthmatics, and the DC number was related to the activated eosinophil count, which suggests that DCs may contribute to the ongoing eosinophilic inflammation in asthmatic airways, and vice versa.
Adult ; Aged ; Antigens, CD1/analysis ; Asthma/*immunology/pathology ; Comparative Study ; Dendritic Cells/*immunology ; Eosinophil Granule Proteins/analysis ; Eosinophils/cytology/*immunology ; Female ; Humans ; Immunohistochemistry ; Leukocyte Count ; Male ; Middle Aged ; Research Support, Non-U.S. Gov't ; Sputum/cytology/*immunology

BACKGROUND: It has been sugested that excessive airway narrowing in asthma may be detected by a decrease in forced vital capacity (FVC). A volume differrence between slow vital capacity (SVC) and FVC may be used as a surrogate index of airway collapse. OBJECTIVE: To investigate the relationship between an airway collapsibility index (CI) and airflow limitation or airway hyperresponsiveness in asthma. METHODS: Forty-six patients with suspected asthma and 21 normal control subjects were enrolled. CI was defined as a difference between SVC and FVC, and measured before and after a methacholine (MCh) bronchoprovocation test. Positive response to MCh was defined as a fall of FEV1 by more than 12%. RESULTS: CI significantly increased from 1.10+/-3.86% to 5.52+/-7.91% after MCh in the positive MCh group (n=19, p<0.01). Not only FVC but also SVC was significantly decreased after MCh. One-fifth of the decrease in FVC was caused by the increase in CI. Both FVC and SVC were significantly related to baseline FEV1 values and in percent change after MCh. Although CI was also significantly related to FEV1 in percent change after MCh. CI was significantly higher in the positive MCh group than in the control and was not significantly related to baseline FEV1 values. Furthermore, the relationship of CI values between before and after MCh was significant (r=0.622, p<0.01). CI was not significantly different according to the severity of MCh-PC20. CONCLUSION: Because the relationship between CI and the severity of airflow limitation or MCh-PC20 was less significant. CI may be better than FVC to represent the characteristic of excessive airway narrowing in asthma.
Asthma* ; Humans ; Methacholine Chloride ; Vital Capacity

BACKGROUND: Wheezing is one of the characteristics of asthma, Intensity of wheezing is correlated with the severity of airway obstruction. However, some asthmatic patients may show wheezing despite normal ventilatory function. OBJECTIVE: To determine the cause of wheezing in asthmatic patients with normal ventilatory function. METHODS: Thirty-eight consecutive asthmatic patients with wheezing despite FEV1> or =80% of predicted value were retrospectively examined for clinical data. RESULTS: Twenty-seven patients (71.1%) were women. Sixteen patients (42.1%) showed airway obstruction based on the Intermountain Thoracic Society criteria. Patients with airway obstruction had significantly lower FEF50% than did those without it (P<.001). When the patients with no wheezing were re-examined by the pulmonary function test. 14 patients (48.3%) showed a significant bronchodilation. In patients without airway obstruction, FEF50/FIF50 was significantly higher than in those with it (P<.01), and FEF50/FIF50 >1 suggesting upper airway obstruction was observed in 7 of 16 (43.8%) patients. Associated diseases were rhinitis in 21 (55.3%) patients, sinusitis in 18 (47.4%), and postnasal drip syndrome in 3 (7.9%). CONCLUSIONS: Wheezing despite normal ventilatory function in asthma occurs more often in women. It may be related to reversible airway obstruction in nearly half patients and to upper airway obstruction such as rhinitis. in considerable numbers of the remaining patients.
Airway Obstruction ; Asthma* ; Female ; Humans ; Respiratory Function Tests ; Respiratory Sounds* ; Retrospective Studies ; Rhinitis ; Sinusitis

The objective of this study is to investigate whether BCG infection before, during or after sensitization suppresses allergen-induced airway hyperresponsiveness and eosinophilic inflammation in allergic asthma rats, and to determine the required dose of BCG to induce such an inhibition. Eighty-seven Sprague-Dawley (SD) rats were sensitized and provoked with ovalbumin (OA). A pretreatment of 6 x 10(4) or 6 x 10(5) colony forming units (CFUs) of BCG or saline was done at four different times: 3 days before sensitization, at sensitization, 3 days before provocation, or at provocation. The assessment of tracheal smooth muscle (TSM) responsiveness to electrical field stimulation or acetylcholine (ACh) and bronchoalveolar lavage (BAL) were performed 1 day after OA provocation. Doses of 6 x 10(4) CFUs inhibited TSM sensitivity of rats infected 3 days before sensitization or at sensitization, but not 3 days before provocation or at provocation. However, doses of 6 x 10(5) CFUs significantly inhibited not only the airway eosinophilia of rats infected 3 days before sensitization or at sensitization, but also the TSM sensitivity of rats infected 3 days before provocation or at provocation. In conclusion, BCG infection suppresses the development of sensitivity of airway smooth muscle and airway eosinophilic inflammation in allergic asthma rats. Furthermore, a relatively high dose of BCG infection inhibits airway sensitivity, even after allergen sensitization.
Animal ; Asthma/immunology* ; BCG Vaccine/immunology* ; Disease Models, Animal ; Disease Models, Animal ; Eosinophils/immunology ; Leukocyte Count ; Lung/immunology* ; Male ; Muscle, Smooth, Vascular/immunology ; Rats ; Rats, Sprague-Dawley ; Time Factors ; Vaccination

The objective of this study is to investigate whether BCG infection before, during or after sensitization suppresses allergen-induced airway hyperresponsiveness and eosinophilic inflammation in allergic asthma rats, and to determine the required dose of BCG to induce such an inhibition. Eighty-seven Sprague-Dawley (SD) rats were sensitized and provoked with ovalbumin (OA). A pretreatment of 6 x 10(4) or 6 x 10(5) colony forming units (CFUs) of BCG or saline was done at four different times: 3 days before sensitization, at sensitization, 3 days before provocation, or at provocation. The assessment of tracheal smooth muscle (TSM) responsiveness to electrical field stimulation or acetylcholine (ACh) and bronchoalveolar lavage (BAL) were performed 1 day after OA provocation. Doses of 6 x 10(4) CFUs inhibited TSM sensitivity of rats infected 3 days before sensitization or at sensitization, but not 3 days before provocation or at provocation. However, doses of 6 x 10(5) CFUs significantly inhibited not only the airway eosinophilia of rats infected 3 days before sensitization or at sensitization, but also the TSM sensitivity of rats infected 3 days before provocation or at provocation. In conclusion, BCG infection suppresses the development of sensitivity of airway smooth muscle and airway eosinophilic inflammation in allergic asthma rats. Furthermore, a relatively high dose of BCG infection inhibits airway sensitivity, even after allergen sensitization.
Animal ; Asthma/immunology* ; BCG Vaccine/immunology* ; Disease Models, Animal ; Disease Models, Animal ; Eosinophils/immunology ; Leukocyte Count ; Lung/immunology* ; Male ; Muscle, Smooth, Vascular/immunology ; Rats ; Rats, Sprague-Dawley ; Time Factors ; Vaccination

BACKGROUND: Upper airway diseases, such as vocal cord dysfunction (VCD), masquerade as asthma. Bronchial hyperresponsiveness (BHR) to methacholine (MCh) has been demonstrated in only part of suspected asthma patients. Investigators have shown upper airway hyperresponsi- veness (UHR) in patients with VCD. OBJECTIVE: To determine the clinical importance of UHR and to evaluate the usefulness of UHR test in patients with suspected asthma. METHODS: Thirty-six consecutive patients with suspected asthma underwent a MCh inhalation challenge. BHR was determined with PC20 < 8 mg/ml, UHR with a decrease in MIF50 > 25% from the baseline, and upper airway obstruction (UAO) with MEF50/MIF50 > 1. RESULTS: Only 17 patients (47.2%) showed BHR. Also, the same proportion of subjects showed UHR, and the each combination of BHR/UHR was nearly equal in distribution (9 BHR+/UHR-, 8 BHR+/UHR+, 9 BHR-/UHR+, and 10 BHR-/UHR-). Patients with BHR-/UHR+ had significantly lower serum total IgE level than those with BHR-/UHR-. Eight patients with UHR and UAO showed significantly shorter duration of disease (p < 0.05), smaller numbers of atopy family history (p < 0.05), and lower serum total IgE level than the others (p < 0.05). CONCLUSION: Many patients with suspected asthma showed UHR, and about half of patients with negative MCh-BHR showed UHR that might be related to non-asthmatic diseases including VCD. Therefore, a routine UHR test may be warranted in detecting upper airway diseases in suspected asthma.
Airway Obstruction ; Asthma* ; Humans ; Immunoglobulin E ; Inhalation ; Methacholine Chloride* ; Research Personnel ; Vocal Cord Dysfunction