ARTICLE IN PRESS

Respiratory Medicine (2007) 101, 272–276

Restrictive impairment in patients with asthma$

Albert Miller, Agnes Palecki

Pulmonary Division, Department of Medicine, St. Vincent Catholic Medical Centers-Queens Division,
Mary Immaculate Hospital, 88-25 153rd Street, Suite 3J, Jamaica, NY 11432, USA

Received 20 January 2006; accepted 11 May 2006

KEYWORDS Summary
Pulmonary function Background: Patients with asthma have intermittent or persistent airflow obstruc-
testing; tion, most often manifested spirometrically by reduced forced expiratory volume in
Spirometric 1 s (FEV1) and FEV1/vital capacity (VC) ratio. In some patients, the VC may be
impairment; reduced by air trapping, with an increase in functional residual capacity (FRC) and
Restriction; residual volume (RV) (pseudorestriction). We have reported 12 asthmatic patients
Adult asthma 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 FEV1/FVC ratio. Patients with
any clinical finding consistent with restriction, including a decreased diffusing
capacity (DL) or obesity (BMI 430) 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.

$
Disclosure: No financial support or financial interest.
Corresponding author. Tel.: +1 718 558 7227; fax: +1 718 558 7203.
E-mail address: almiller@svcmcny.org (A. Miller).

0954-6111/$ - see front matter & 2006 Elsevier Ltd. All rights reserved.
doi:10.1016/j.rmed.2006.05.008
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Restrictive impairment in asthma 273

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.
& 2006 Elsevier Ltd. All rights reserved.

Introduction Methods and definitions

Asthma is a disorder characterized by increased The PFTs were performed according to American
reactivity of the airways. Patients with asthma Thoracic Society (ATS) specifications2,3 using Sen-
have recurrent or persistent airflow obstruction, somedics Vmax 22 for spirometry and diffusing
which is reversible either spontaneously or with capacity for carbon monoxide (DLCO) and model V
appropriate therapy. An obstructive pattern is most for plethysmographic FRC; FRC was measured in all
often present, recognized by reduced forced patients who could enter and tolerate the body
expiratory volume in 1 s (FEV1), and FEV1 to forced box; fewer than 20% were unable to do so for
vital capacity (FEV1/FVC) or FEV1/vital capacity orthopedic or psychologic reasons.
(VC) ratio. Patients may have normal spirometry Forced exhalation time (FET) 100% X6 s or an
between attacks. In some patients, the FVC may be expiratory plateau was required of all spirometric
reduced due to air trapping, resulting in pseudo- efforts accepted. Consistent with practice in the
restriction on spirometry in the presence of United States and with the predicted values, forced
increased or normal total lung capacity (TLC), VC (FVC) was reported, although a separately
increased functional residual capacity (FRC) and performed slow VC was used to calculate lung
increased residual volume (RV). volumes if it was larger than the FVC. Reference
Several years ago, we reported on 12 asthmatics, values for spirometric4 and for static lung volumes5
observed in a 2 years interval at a medium-sized were race adjusted for people of African origin2 and
inner city teaching hospital, whose impairment on those for DLCO6 were adjusted for smoking. The
pulmonary function testing was restrictive1; those lower 95% confidence interval was used to define
with any other reason for restriction, including abnormality.
many who were obese, were excluded. The The diagnosis of asthma was accepted when the
diagnosis of asthma in these patients was often following criteria were met:
called into question because of the report of
restrictive impairment and appropriate therapy
1. Physician diagnosis of asthma with intermittent
cancelled or delayed. The nature of this series did
or persistent symptoms of shortness of breath,
not permit us to estimate the frequency of this
wheezing and/or chest tightness.
finding in the asthmatic population. We therefore
2. Confirmation by one of the following pulmonary
undertook a prospective review of pulmonary
functional findings:
function in all asthmatic adults during a subsequent
(a) Repeated variability in well-performed
45-month interval, to confirm the observation of
spirometic values (increase in FEV1 or FVC).
restrictive impairment, to estimate its frequency
(b) Positive bronchodilator (BD) responses (in-
and to consider its mechanisms.
crease in FEV1 or FVC X12% and 200 mL from
baseline).
(c) Positive methacholine challenge (20% fall in
Methods FEV1 at a dose p8 mg/mL).

Study design Restriction was defined as all of the following:

We reviewed the pulmonary function tests (PFTs)
and clinical and demographic features of all post- 1. Decrease in TLC or decrease in VC with no
pubertal patients diagnosed as asthma between increase in FRC. FRC was preferred to RV
January 2000 and September 2003 at the St. because it is directly measured, and because of
Vincent Catholic Medical Center 184 bed Mary the difficulty in measuring ERV especially in
Immaculate Hospital (MIH) division, Jamaica, obese patients.
Queens, New York. 2. Normal or high FEV1/FVC ratio.
 ARTICLE IN PRESS
274 A. Miller, A. Palecki

Patients with another significant respiratory BMI. These 11 were added to the 21 with normal
diagnosis, congestive heart failure, radiographic BMI and DL since their initial restrictive impairment
findings of interstitial lung disease (ILD), neuro- could not be attributed to obesity.
muscular disorder or skeletal deformity were True restrictive impairment was thus noted in at
excluded. Those with decreased DL and/or least 32 of 413 asthmatics (8%). All 32 had normal
BMI430 were placed in separate categories. DL and of the 25 measured, 22 (88%) had normal or
decreased plethysmographic FRC. It is likely that
restriction was similarly attributable to asthma in
Results some of the 32 patients who had restriction and
decreased DL with no clinical or radiographic
As seen in Table 1, of 413 patients with asthma, 107 evidence of ILD.
(26%) had spirometric results within the normal Age range of the 32 asthmatics with restrictive
range, 180 (44%) were obstructed (decreased FEV1, impairment and no other explanation was 21–64; 24
decreased FEV1/FVC, normal FVC) and an addi- (75%) were female, 18 (56%) were never-smokers, 3
tional 26 (6%) showed spirometric mixed obstruc- (9%) former smokers; and 11 (34%) current smokers.
tive-restrictive impairment (decreased FEV1, By ethnicity, 10 were Black, 8 Asian, 7 White, 6
decreased FEV1/FVC with decreased FVC). Of the Hispanic and one Amerindian.
100 asthmatic patients (24% of the total) with
spirometric restriction alone, plethysmographic
FRC was measured in 81 and was increased in only Discussion
seven. That FRC was not increased ruled out
‘‘pseudorestriction’’ secondary to air trapping. Of The findings in these 32 asthmatic patients with
these 100 patients with restriction, 63 had a BMI restriction mirror the 12 previously reported from
430 (including 17 who also had a decreased DL) this hospital1 after the same process of exclusion in
and 16 had a decreased DL with a normal BMI. both series. We rigidly ruled out other conditions
There were 21 patients with restriction who had which could contribute to restrictive impairment. It
both DL and BMI within the normal range. is likely that in certain asthmatic patients with
Of the 46 patients with an increased BMI and restrictive impairment who were excluded, their
normal DL, 11 normalized their FVC post-BD or restrictive impairment was similarly caused or
within 4 weeks on treatment with no decrease in contributed to by their asthma.

Table 1 Distribution of pulmonary function impairments in 413 patients with asthma.

All patients with asthma

413
k
Normal pulmonary function
107 (26%)
k
Obstruction
180 (44%)
k
Mixed obstruction—restriction
26 (6%)
k
Restriction
100 (24%)
k

k k k k
Nl BMI, Nl DL mBMI, Nl DL mBMI,kDL Nl BMI,kDL
21 (5%) 46 (10%) 17 (5%) 16 (4%)
k
Nl FVCpRx
11 (3%)
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Restrictive impairment in asthma 275

Restriction in asthma was reported in two review.16,17 In a 2000 Centers for Disease Control
patients by Colp and Williams,7 and attributed to and Prevention survey of almost 200,000 adults in
reversible closure of the airways. Hudgel and co- all 50 states, odds ratios for both lifetime and
workers8 reported a young woman with sponta- current asthma were increased in the obese (1.54
neous and exercise-induced dyspnea. During a and 1.65, respectively), more so in women.18
typical episode, lung volumes decreased markedly
(TLC from 5.3 to 2.6 L, VC from 3.8 to 1.2 L), and
FEV1 fell from 3.0 to 1.0 L while FEV1/FVC ratio Conclusion
increased (from 0.78 to 0.85) and specific airways
conductance and flow rates measured at absolute True restrictive impairment was noted in at least 32
lung volume increased. Static compliance de- of 413 asthmatics (8%), consistent with previous
creased and elastic recoil increased. The authors observations in asthma and reactive airways dys-
attributed these changes to muscular contraction function syndrome. This finding is not widely
of small airways. Dawson cites closure of the recognized and should not preclude the diagnosis
airways in young patients with seemingly mild of asthma, BD testing or appropriate therapy for
bronchospasm; FVC decreases and obstruction is asthma.
not detected because flow may be preserved in
other airways.9
One of the present authors (A.M.) reported
restrictive impairment in 21 patients with asthma Acknowledgment
over a 4-year period in a part-time pulmonary
practice10; patients with other causes for restric- The authors acknowledge the contributions of the
tion were excluded, as in the present study. Full Chief Technician of the Pulmonary Function La-
lung volumes were generally not available to rule boratory, Mohammed Mashriqi, whose patience and
out pseudorestriction. persistence provided and retrieved the test results
True restrictive impairment with decreased FRC reported.
and TLC and positive BD response has been described
in reactive airways dysfunction syndrome,11 most
recently as a result of exposure at Ground Zero References
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