Small-airways dysfunction associates with respiratory symptoms and clinical features of asthma: A systematic review Erica van der Wiel, MD, Nick H.T.

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Small-airways dysfunction associates with respiratory symptoms and clinical features of asthma: A systematic review Erica van der Wiel, MD, Nick H.T. ten Hacken, MD, PhD, Dirkje S. Postma, MD, PhD, Maarten van den Berge, MD, PhD Journal of Allergy and Clinical Immunology Volume 131, Issue 3, Pages 646-657 (March 2013) DOI: 10.1016/j.jaci.2012.12.1567 Copyright © 2013 American Academy of Allergy, Asthma & Immunology Terms and Conditions

Fig 1 Flowchart of the literature search. A PubMed search resulted in 5902 articles using the term “Asthma AND (small airway* OR peripheral airway* OR distal airway* OR distal lung OR impulse oscillometry OR alveolar nitric oxide OR exhaled nitric oxide OR nocturnal OR residual volume OR montelukast OR HFA OR hydrofluoroalkane OR extra fine OR transbronchial OR closing volume OR closing capacity OR air trapping OR hyperinflation OR nitrogen OR HRCT OR high resolution CT OR MRI)” limited to the English language and human subjects. Hand searching of the reference lists of retrieved articles and reviews was also undertaken. Titles and/or abstracts and/or full articles were reviewed during the initial search, and 195 articles were selected according to the following criteria: A, a study population of asthmatic patients; B, measurement of small-airways parameters; C, reporting clinical signs or symptoms. An article was excluded if it met criteria D (ie, no original research [review, editorial, or case report]) or E (ie, a study population with age <4 years to exclude transient wheezing). According to these criteria, the relevance of these 224 articles were reviewed by 2 authors considering whether the relation between small-airways dysfunction and clinical signs or symptoms had appropriately been analyzed (clinical symptoms or severity of symptoms were not based on lung function or steroid use). Discrepancies were resolved by means of open discussion with all authors. Using this method, 80 articles were finally selected for extensive review in this article. The search was conducted in October 2012. Journal of Allergy and Clinical Immunology 2013 131, 646-657DOI: (10.1016/j.jaci.2012.12.1567) Copyright © 2013 American Academy of Allergy, Asthma & Immunology Terms and Conditions

Fig 2 A, Significant correlation between the percent predicted slope of phase III of SBNT (dN2) and the ACQ score (Spearman correlation coefficient: ρ = 0.62, P = .003). B, Significant differences in dN2 values between frequent and infrequent exacerbators (P = .0005). Reproduced with permission from Bourdin et al.21 Journal of Allergy and Clinical Immunology 2013 131, 646-657DOI: (10.1016/j.jaci.2012.12.1567) Copyright © 2013 American Academy of Allergy, Asthma & Immunology Terms and Conditions

Fig 3 Number per volume (Nv) of eosinophils in patients with nonnocturnal asthma (NNA) and nocturnal asthma (NA) is shown in the endobronchial biopsy specimens (EBBX) and transbronchial biopsy specimens (TBBX) at 4 am and 4 pm. The open bars represent the nonnocturnal asthma group (n = 10), and the solid bars represent the nocturnal asthma group (n = 11). Values are expressed as medians with the 25th to 75th interquartile range in parentheses above each bar. #*%P ≤ .05. The transbronchial biopsy specimens of patients with nocturnal asthma show a significant increase in eosinophil numbers overnight. Reprinted with permission from the American Thoracic Society, ©2013, from Kraft et al.40 Journal of Allergy and Clinical Immunology 2013 131, 646-657DOI: (10.1016/j.jaci.2012.12.1567) Copyright © 2013 American Academy of Allergy, Asthma & Immunology Terms and Conditions

Fig 4 Relationship between onset of respiratory symptoms and changes in FEV1 (A) and R5 (B) values. Data are illustrated for the 9 of 33 subjects who developed symptoms with minimal change in FEV1 during the provocation test (mean change, −3.4%). MCT, Methacholine provocation test.. Adapted from Segal et al,47 Disparity between proximal and distal airway reactivity during methacholine challenge, COPD, ©2011, Informa Healthcare. Reproduced with permission from Informa Healthcare. Journal of Allergy and Clinical Immunology 2013 131, 646-657DOI: (10.1016/j.jaci.2012.12.1567) Copyright © 2013 American Academy of Allergy, Asthma & Immunology Terms and Conditions

Fig 5 Correlations between the decrease in FEV1 versus the increasing resistance (R20 [A] and R5-R20 [B]) at 5 minutes after exercise challenge. R5-R20, reflecting resistance of the small airways, is correlated with FEV1 (ρ = −0.375, P = .009), whereas R20, reflecting resistance of the large airways, did not correlate with FEV1 (ρ = −0.104, P = .487). Adapted with permission from Lee et al.68 Journal of Allergy and Clinical Immunology 2013 131, 646-657DOI: (10.1016/j.jaci.2012.12.1567) Copyright © 2013 American Academy of Allergy, Asthma & Immunology Terms and Conditions