El asma en las personas mayores también existe / Asthma Exists in Older People too

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[Translated article] Asthma Exists in Older People too / El asma en las personas mayores también existe

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[Consensus document for severe asthma in adults. 2022 update]. / Documento de consenso de asma grave en adultos. Actualización 2022.

Severe asthma is a heterogeneous syndrome with several clinical variants and often represents a complex disease requiring a specialized and multidisciplinary approach, as well as the use of multiple drugs. The prevalence of severe asthma varies from one country to another, and it is estimated that 50% of these patients present a poor control of their disease. For the best management of the patient, it is necessary a correct diagnosis, an adequate follow-up and undoubtedly to offer the best available treatment, including biologic treatments with monoclonal antibodies. With this objective, this consensus process was born, which began in its first version in 2018, whose goal is to offer the patient the best possible management of their disease in order to minimize their symptomatology. For this 2020 consensus update, a literature review was conducted by the authors. Subsequently, through a two-round interactive Delphi process, a broad panel of asthma experts from SEPAR and the regional pulmonology societies proposed the recommendations and conclusions contained in this document.

Normativa sobre asma grave no controlada / Guidelines for Severe Uncontrolled Asthma

Desde la publicación, hace ya 9 años, de la última normativa de la Sociedad Española de Neumología y Cirugía Torácica (SEPAR) sobre asma de control difícil(ACD), se han producido avances en los conocimientos de la enfermedad asmática, que hacen necesario realizar una puesta al día de los datos disponibles e incorporarlos tras su análisis en el nivel de evidencia y recomendación más adecuado. Recientemente han aparecido documentos de consenso y guías de práctica clínica (GPC) que abordan este problema. En esta normativa se hará mención explícita a lo que la previa guía de ACD definía como «verdadera asma de control difícil»; es decir, al asma que tras haber verificado su diagnóstico, realizado un abordaje sistematizado para descartar factores ajenos a la propia enfermedad que conducen a un mal control de la misma («falsa asma de control difícil»), y realizar una estrategia de tratamiento adecuado (escalones 5 y 6 de la Guía española para el manejo del asma [GEMA]), no se consigue alcanzar el control: «asma grave no controlada» (AGNC). En esta línea la normativa propone una revisión de la definición, un intento de clasificación de las diferentes manifestaciones de este tipo de asma, una propuesta del abordaje diagnóstico por pasos y un tratamiento dirigido según fenotipo, conjuntamente con un apartado específico sobre este arquetipo de asma en la infancia, con el objetivo de que pueda servir de ayuda a los profesionales sanitarios y repercutir en el cuidado de estos pacientes

Since the publication, 9 years ago, of the latest SEPAR (Spanish Society of Pulmonology and Thoracic Surgery) Guidelines on Difficult-to-Control Asthma (DCA), much progress has been made in the understanding of asthmatic disease. These new data need to be reviewed, analyzed and incorporated into the guidelines according to their level of evidence and recommendation. Recently, consensus documents and clinical practice guidelines (CPG) addressing this issue have been published. In these guidelines, specific mention will be made of what the previous DCA guidelines defined as «true difficult-to-control asthma». This is asthma that remains uncontrolled after diagnosis and a systematic evaluation to rule out factors unrelated to the disease itself that lead to poor control («false difficult-to-control asthma»), and despite an appropriate treatment strategy (Spanish Guidelines for the Management of Asthma [GEMA] steps 5 and 6): severe uncontrolled asthma. In this respect, the guidelines propose a revised definition, an attempt to classify the various manifestations of this type of asthma, a proposal for a stepwise diagnostic procedure, and phenotype-targeted treatment. A specific section has also been included on DCA in childhood, aimed at assisting healthcare professionals to improve the care of these patients

Guidelines for severe uncontrolled asthma.

Since the publication, 9 years ago, of the latest SEPAR (Spanish Society of Pulmonology and Thoracic Surgery) Guidelines on Difficult-to-Control Asthma (DCA), much progress has been made in the understanding of asthmatic disease. These new data need to be reviewed, analyzed and incorporated into the guidelines according to their level of evidence and recommendation. Recently, consensus documents and clinical practice guidelines (CPG) addressing this issue have been published. In these guidelines, specific mention will be made of what the previous DCA guidelines defined as "true difficult-to-control asthma". This is asthma that remains uncontrolled after diagnosis and a systematic evaluation to rule out factors unrelated to the disease itself that lead to poor control ("false difficult-to-control asthma"), and despite an appropriate treatment strategy (Spanish Guidelines for the Management of Asthma [GEMA] steps 5 and 6): severe uncontrolled asthma. In this respect, the guidelines propose a revised definition, an attempt to classify the various manifestations of this type of asthma, a proposal for a stepwise diagnostic procedure, and phenotype-targeted treatment. A specific section has also been included on DCA in childhood, aimed at assisting healthcare professionals to improve the care of these patients.

Normativa sobre el estudio de la hiperrespuesta bronquial inespecífica en el asma / Guidelines for the Study of Nonspecific Bronchial Hyperresponsiveness in Asthma

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Factors associated with bronchiectasis in patients with COPD.

BACKGROUND: Previous studies have shown a high prevalence of bronchiectasis in patients with moderate to severe COPD. However, the factors associated with bronchiectasis remain unknown in these patients. The objective of this study is to identify the factors associated with bronchiectasis in patients with moderate to severe COPD. METHODS: Consecutive patients with moderate (50% < FEV(1) ≤ 70%) or severe (FEV(1) ≤ 50%) COPD were included prospectively. All subjects filled out a clinical questionnaire, including information about exacerbations. Peripheral blood samples were obtained, and lung function tests were performed in all patients. Sputum samples were provided for monthly microbiologic analysis for 6 months. All the tests were performed in a stable phase for at least 6 weeks. High-resolution CT scans of the chest were used to diagnose bronchiectasis. RESULTS: Ninety-two patients, 51 with severe COPD, were included. Bronchiectasis was present in 53 patients (57.6%). The variables independently associated with the presence of bronchiectasis were severe airflow obstruction (OR, 3.87; 95% CI, 1.38-10.5; P = .001), isolation of a potentially pathogenic microorganism (PPM) (OR, 3.59; 95% CI, 1.3-9.9; P = .014), and at least one hospital admission due to COPD exacerbations in the previous year (OR, 3.07; 95% CI, 1.07-8.77; P = .037). CONCLUSION: We found an elevated prevalence of bronchiectasis in patients with moderate to severe COPD, and this was associated with severe airflow obstruction, isolation of a PPM from sputum, and at least one hospital admission for exacerbations in the previous year.

¿Por qué miramos el asma a través del ojo de la cerradura? / Why do We Look at Asthma through the Keyhole?

Al igual que sucede con el resto de la patología, el estudio del asma se ha venido realizando tradicionalmente desde los postulados marcados por la ciencia reduccionista. Ese modelo sigue aportando respuestas a las preguntas teóricas y prácticas que las enfermedades plantean pero no nos ofrece una visión completa de su complejidad y multidimensionalidad. Para superar esta limitación surge la medicina orientada hacia sistemas basada en la aplicación de los conceptos y herramientas de la biología de sistemas. La biología de sistemas es una estrategia analítica transdisciplinar que, a partir de los datos generados por las ciencias ómicas, permite relacionar los elementos de un organismo o sistema biológico, comprender las propiedades emergentes del mismo y generar modelos matemáticos capaces de predecir su comportamiento dinámico. La aplicación de la biología de sistemas al asma comienza a dar ya los primeros pasos. Hoy el reto principal es comprender la necesidad del cambio de enfoque. El punto de partida pasa por abandonar la idea del asma como enfermedad exclusiva de la vía aérea considerando que en su patogénia participa todo el pulmón y, aún más, que posiblemente se trate, al menos en parte, de un proceso sistémico. Vistas nuestras limitaciones actuales, entender el asma y diseñar estrategias terapéuticas personalizadas para cada paciente, exige pensar en medicina de sistemas(AU)

As happens with the rest of pathology, the study of asthma has been traditionally conducted from postulates set by reductionist science. That model still provides answers to theoretical and practical questions that establish diseases, but does not offer us a complete view of their complexity and multidimensionality. To overcome this limitation has emerged medicine directed towards systems based on the application of biological systems concepts and tools. Biological systems is a cross-disciplinary strategy which, from the data generated by the “-omic” sciences, helps to relate the elements of an organism or biological system, to understand the properties arising from the same and to generate mathematical models capable of predicting their dynamic behaviour. The application of biological systems to asthma starts is starting to make ground. The main challenge today is to understand the need to change focus. The starting point is to abandon the idea that asthma is exclusively an airways disease and considering that the whole lung is involved and, even more, the possibility that it is, at least in part, a systemic process. In view of our current limitations, to understand asthma and design personalised treatment strategies for each patient, requires thinking of systems medicine(AU)

[Why do we look at asthma through the keyhole?]. / Por qué miramos el asma a través del ojo de la cerradura?

As happens with the rest of pathology, the study of asthma has been traditionally conducted from postulates set by reductionist science. That model still provides answers to theoretical and practical questions that establish diseases, but does not offer us a complete view of their complexity and multidimensionality. To overcome this limitation has emerged medicine directed towards systems based on the application of biological systems concepts and tools. Biological systems is a cross-disciplinary strategy which, from the data generated by the "-omic" sciences, helps to relate the elements of an organism or biological system, to understand the properties arising from the same and to generate mathematical models capable of predicting their dynamic behaviour. The application of biological systems to asthma starts is starting to make ground. The main challenge today is to understand the need to change focus. The starting point is to abandon the idea that asthma is exclusively an airways disease and considering that the whole lung is involved and, even more, the possibility that it is, at least in part, a systemic process. In view of our current limitations, to understand asthma and design personalised treatment strategies for each patient, requires thinking of systems medicine.

La complejidad en el asma: inflamación y redes libres de escala / Complexity in Asthma: Inflammation and Scale-Free Networks

Tradicionalmente la interpretación del asma se ha fundamentado en relaciones deterministas directas del tipo estímulo-inflamación-hiperrespuesta bronquial-obstrucción-síntomas, olvidando, sin embargo, que en esta enfermedad no es infrecuente detectar circunstancias que no guardan linealidad. Por tal motivo algunos autores postulan que el abordaje de su patogenia debería comenzar a realizarse desde la óptica de los sistemas complejos que adoptan una topología libre de escala. La teoría de los impactos inflamatorios múltiples, propuesta por el grupo de Pavord, representa, en su sentido más amplio, una aportación adicional a esta línea de pensamiento. De acuerdo con ella, en el asma la coexistencia de estímulos inflamatorios adicionales, de localización pulmonar o extrapulmonar, agravan la evolución del proceso respiratorio. Los efectos de esos estímulos pueden ser aditivos o actuar de manera sinérgica con la propia inflamación asmática. Más allá de su interés práctico, la hipótesis viene a recordarnos que el organismo es un constructo conformado a partir de conjuntos interconectados, y que el asma incluye en su patogenia elementos de naturaleza diversa entrelazados. Si esto es así, el planteamiento futuro tendría que comenzar a centrarse en la búsqueda de los hubs de esa red llamada asma integrando la información aportada por la genómica, la proteómica y la metabolómica(AU)

Our understanding of asthma has traditionally been based on linear deterministic relationships of the type stimulus-bronchial hyperresponsiveness-obstruction-symptoms. This notion however neglects the fact that nonlinear relationships may be present. To better define the disease, some authors therefore suggest that we should think in terms of complex systems with a scale-free topology. The idea of multiple inflammatory hits proposed by the group of Pavord is in its broadest sense a further contribution to this line of thought. According to this theory, the coexistence of additional inflammatory stimuli, which may or may not be localized to the lungs, are responsible for deteriorating lung function. The effects of these stimuli may be additive or act in synergy with the underlying inflammation of asthma itself. In addition to the practical implications, this hypothesis serves as a reminder that the body is made up of interconnected parts and that the pathogenesis of asthma includes distinct elements linked together. If this hypothesis proves valid, future approaches should start to look for the hubs in this network that constitutes asthma, and attempt to integrate information from genomics, proteomics, and metabolomics(AU)

[Complexity in asthma: inflammation and scale-free networks]. / La complejidad en el asma: inflamación y redes libres de escala.

Our understanding of asthma has traditionally been based on linear deterministic relationships of the type stimulus-bronchial hyperresponsiveness-obstruction-symptoms. This notion however neglects the fact that nonlinear relationships may be present. To better define the disease, some authors therefore suggest that we should think in terms of complex systems with a scale-free topology. The idea of multiple inflammatory hits proposed by the group of Pavord is in its broadest sense a further contribution to this line of thought. According to this theory, the coexistence of additional inflammatory stimuli, which may or may not be localized to the lungs, are responsible for deteriorating lung function. The effects of these stimuli may be additive or act in synergy with the underlying inflammation of asthma itself. In addition to the practical implications, this hypothesis serves as a reminder that the body is made up of interconnected parts and that the pathogenesis of asthma includes distinct elements linked together. If this hypothesis proves valid, future approaches should start to look for the hubs in this network that constitutes asthma, and attempt to integrate information from genomics, proteomics, and metabolomics.

Creencias sobre la salud y los medicamentos en la población asmática española. Validación de 2 instrumentos para su medida / Spanish Asthma Patients’ Beliefs About Health and Medicines: Validation of 2 Questionnaires

Introducción: Se ha procedido a la traducción, validación y aplicación en población asmática española del Cuestionario de Creencias sobre la Salud (CCS; 19 ítems en 6 dominios) y el Cuestionario de Creencias sobre los Medicamentos (CCM; 18 ítems en 2 subescalas: genérico y específico).Pacientes y métodos: El trabajo se llevó a cabo, durante 2 sesiones, en 126 pacientes con asma estable y diferentes grados de gravedad. En la primera se practicó una espirometría forzada y se recogieron además características sociodemográficas y datos de historia clínica. En la segunda, los pacientes rellenaron cuestionarios de ansiedad (STAI) y depresión (Beck), así como las versiones españolas del CCS y CCM (previo proceso de traducción y retrotraducción).Resultados: El CCM presentó una consistencia interna y una validez de contenido adecuadas. En cambio, el CCS no reprodujo la estructura original de 6 factores, sino que se obtuvieron únicamente 4 (CCS-reformulado: variancia explicada: 48%; alfa de Cronbach: 0,63–0,75). El CCM y el CCS-reformulado presentaron las siguientes interacciones: a) creencias negativas sobre los medicamentos y la propia enfermedad, y b) conciencia de necesitar medicación, confianza en el médico y pesimismo. Las creencias negativas se asociaron, a su vez, con ansiedad y depresión, mientras que el ser consciente de necesitar medicación se asoció con la gravedad. El bajo nivel de estudios, el sexo (mujer) y una mayor duración del asma se relacionaron con creencias fatalistas sobre el control de la enfermedad.Conclusiones: El CCS-reformulado y el CCM poseen propiedades métricas satisfactorias y evalúan aspectos similares pero no idénticos sobre las creencias y juicios de valor de los asmáticos sobre su salud y los medicamentos. Estos juicios se asocian de manera diferente con las facetas clínicas, sociodemográficas y psicológicas estudiadas(AU)

Objective: We translated 2 health beliefs questionnaires—an instrument based on the health belief model (HBM) containing 19 items in 6 domains and the Beliefs About Medicines Questionnaire (BMQ) containing 18 items divided into a general and a specific section—and then administered and validated them in a group of Spanish patients with asthma.Patients and Methods: In 2 clinical visits data were collected on 126 patients with stable asthma of different levels of severity. At the first visit, the patients underwent spirometry and were asked questions about sociodemographic factors and clinical history. At the second visit, they completed the State-Trait Anxiety Inventory, the Beck Depression Inventory, and the Spanish versions of the HBM and BMQ, which had been previously translated and backtranslated.Results: The BMQ had adequate internal consistency and content validity but the HBM replicated just 4 of the 6 domains present in the original questionnaire. The reformulated HBM (measuring 4 domains) accounted for 48% of the variance and had Cronbach #a levels ranging from 0.63 to 0.75. The 2 questionnaires showed interactions between a) negative beliefs about medicines and asthma and b) awareness of the need for medication and trust in physician and pessimism. Correlations were also found between negative beliefs and anxiety and depression and between awareness of the need for medication and disease severity. Finally, low educational level, female sex, and greater duration of asthma were correlated with beliefs that disease control was driven by chance.Conclusions: The reformulated HBM and the BMQ have satisfactory measurement properties and assess similar but not identical aspects of beliefs and value judgments about health and medicine in individuals with asthma. These beliefs were correlated to different degrees with the clinical, sociodemographic, and psychologic variables studied(AU)

[Spanish asthma patients' beliefs about health and medicines: validation of 2 questionnaires]. / Creencias sobre la salud y los medicamentos en la población asmática española. Validación de 2 instrumentos para su medida.

OBJECTIVE: We translated 2 health beliefs questionnaires-an instrument based on the health belief model (HBM) containing 19 items in 6 domains and the Beliefs About Medicines Questionnaire (BMQ) containing 18 items divided into a general and a specific section-and then administered and validated them in a group of Spanish patients with asthma. PATIENTS AND METHODS: In 2 clinical visits data were collected on 126 patients with stable asthma of different levels of severity. At the first visit, the patients underwent spirometry and were asked questions about sociodemographic factors and clinical history. At the second visit, they completed the State-Trait Anxiety Inventory, the Beck Depression Inventory, and the Spanish versions of the HBM and BMQ, which had been previously translated and backtranslated. RESULTS: The BMQ had adequate internal consistency and content validity but the HBM replicated just 4 of the 6 domains present in the original questionnaire. The reformulated HBM (measuring 4 domains) accounted for 48% of the variance and had Cronbach #a levels ranging from 0.63 to 0.75. The 2 questionnaires showed interactions between a) negative beliefs about medicines and asthma and b) awareness of the need for medication and trust in physician and pessimism. Correlations were also found between negative beliefs and anxiety and depression and between awareness of the need for medication and disease severity. Finally, low educational level, female sex, and greater duration of asthma were correlated with beliefs that disease control was driven by chance. CONCLUSIONS: The reformulated HBM and the BMQ have satisfactory measurement properties and assess similar but not identical aspects of beliefs and value judgments about health and medicine in individuals with asthma. These beliefs were correlated to different degrees with the clinical, sociodemographic, and psychologic variables studied.

[Contribution of exhaled nitric oxide measurements to abbreviated bronchial challenge test protocols]. / Aportaciones del óxido nítrico exhalado a los procedimientos abreviados de las pruebas de provocación bronquial.

OBJECTIVE: The bronchial challenge test is commonly used to diagnose asthma but it is a tedious, time-consuming procedure. Although in recent years, several shortened methods have been proposed, it has been shown that they can give rise to exaggerated bronchoconstriction. The aims of the present study were a) to determine the frequency of exaggerated bronchoconstriction in patients with asthma following the application of a shortened bronchial challenge test, and b) to determine if the fraction of exhaled nitric oxide (FENO) can be used to predict the onset of exaggerated bronchoconstriction. PATIENTS AND METHODS: We performed a prospective study of 210 patients with asthma in whom FENO levels were measured in accordance with the abbreviated protocol recommended by the European Respiratory Society (ERS). Exaggerated bronchoconstriction was defined as a decrease of more than 20% in forced expiratory volume in 1 second after the first challenge, after a skipped dose, or after administration of saline. A receiver operating characteristic (ROC) curve was generated to determine the best FENO cutoff value for predicting exaggerated bronchoconstriction. The pretest probability of developing exaggerated bronchoconstriction was also calculated using Bayes' theorem. RESULTS: The frequency of exaggerated bronchoconstriction in our series was 30%. Patients who developed exaggerated bronchoconstriction had significantly higher FENO levels than those who did not (32.6 vs 16.2 parts per billion [ppb]). The chosen FENO cutoff of 19.5 ppb had a sensitivity of 80%, a specificity of 77%, and a negative predictive value of 88%. The area under the ROC curve was 0.83 (95% confidence interval, 0.77-0.89). CONCLUSIONS: The abbreviated bronchial challenge test recommended by the ERS led to exaggerated bronchoconstriction in 30% of the patients studied. FENO measurements could possibly be used to identify patients at increased risk of exaggerated bronchoconstriction. The shortened challenge test can be performed safely in individuals with a FENO of <19.5 ppb.

[Assessment of patient satisfaction and preferences with inhalers in asthma with the FSI-10 Questionnaire]. / Satisfacción y preferencia del paciente asmático por los dispositivos de inhalación. Aplicación del FSI-10.

BACKGROUND AND OBJECTIVE: Lack of adherence to inhaled corticosteroid therapy is common in patients with asthma, and it has been suggested that allowing patients to choose their own inhalers would resolve this problem. The FSI-10 (Feeling of Satisfaction with Inhaler) is a self-completed questionnaire to assess patient opinions regarding ease or difficulty of use, portability, and usability of devices for delivery of inhaled corticosteroids. The aim of this study was to define the measurement properties of the FSI-10 questionnaire and to use this inventory to compare satisfaction and preferences of patients with asthma regarding 3 different devices for delivery of inhaled corticosteroids: Turbuhaler, Accuhaler, and Novolizer. PATIENTS AND METHODS: We performed a multicenter, prospective, observational study in 112 stable asthmatic patients (64 women; mean [SD] age, 37 [22] years) treated on a regular basis with inhaled corticosteroids. The use of the devices was explained to the patients and the order in which they should be used in each case was randomly assigned. The devices were used for 7-day periods and at the end of each the FSI-10 questionnaire was completed for the device used. Once the protocol was completed, patients stated their preference for the different devices used. RESULTS: The FSI-10 was easily understood and rapidly completed, and it exhibited acceptable measurement properties. Factor analysis showed that the measure was unidimensional. Although acceptance of all 3 devices assessed was reasonable, the FSI-10 questionnaire detected significant differences between them: Turbuhaler and Novolizer scored higher than Accuhaler on a number of questions. This preference is partly explained by Turbuhaler having been the device that was commonly used by the patients prior to the study. However, the highest scoring and most often preferred inhaler in patients under 16 years of age was the Novolizer, even though the Turbuhaler had also usually been used by those patients prior to the study. CONCLUSIONS: The FSI-10 is a useful instrument for assessing the degree of satisfaction of asthmatic patients regarding available inhalation devices. It is easy to understand and complete, and able to identify differences in patient satisfaction with the different inhalers.

Aportaciones del óxido nítrico exhalado a los procedimientos abreviados de las pruebas de provocación bronquial / Contribution of exhaled nitric oxide measurements to abbreviated bronchial challenge test protocols

OBJETIVO: La prueba de provocación bronquial es un procedimiento habitual en el diagnóstico del asma, pero su realización resulta larga y tediosa. Por ello se han propuesto métodos que acortan su duración. Sin embargo, en los últimos años se ha señalado que dichos métodos pueden dar lugar a broncoconstricciones excesivas (BE). Los objetivos del presente estudio han sido: a) determinar la frecuencia de BE en pacientes con asma tras la aplicación del método abreviado de la prueba de provocación bronquial, y b) cuantificar si la determinación de óxido nítrico en aire exhalado (ONE) puede predecir la aparición de BE. PACIENTES Y MÉTODOS: Se ha realizado un estudio prospectivo sobre 210 asmáticos a quienes se determinó el ONE y se realizó una prueba de provocación bronquial siguiendo el protocolo abreviado de la European Respiratory Society (ERS). Se definió BE como una caída superior al 20% del volumen espiratorio forzado en el primer segundo tras la primera dosis, después de suprimir una dosis o tras el diluyente. Se construyó una curva de eficacia diagnóstica para determinar el mejor punto de corte del ONE para predecir BE y se calculó la probabilidad preprueba de presentar BE, siguiendo el teorema de Bayes. RESULTADOS: La frecuencia de BE en nuestra serie fue del 30%. Hubo diferencias significativas en el ONE, siendo la concentración más elevada en el grupo que presentó BE (32,6 frente a 16,2 ppb). El punto de corte de ONE elegido fue 19,5 ppb, con una sensibilidad del 80%, especificidad del 77% y valor predictivo negativo del 88%. El área bajo la curva de eficacia diagnóstica fue de 0,83 (intervalo de confianza del 95%, 0,77-0,89). CONCLUSIONES: La prueba de provocación bronquial abreviada que recomienda la ERS da lugar a un 30% de BE. La determinación de ONE podría identificar a los pacientes con mayor probabilidad de presentar BE. Una concentración de ONE inferior a 19,5 ppb permite realizar la prueba de provocación bronquial abreviada con seguridad

OBJECTIVE: The bronchial challenge test is commonly used to diagnose asthma but it is a tedious, time-consuming procedure. Although in recent years, several shortened methods have been proposed, it has been shown that they can give rise to exaggerated bronchoconstriction. The aims of the present study were a) to determine the frequency of exaggerated bronchoconstriction in patients with asthma following the application of a shortened bronchial challenge test, and b) to determine if the fraction of exhaled nitric oxide (FENO) can be used to predict the onset of exaggerated bronchoconstriction. PATIENTS AND METHODS: We performed a prospective study of 210 patients with asthma in whom FENO levels were measured in accordance with the abbreviated protocol recommended by the European Respiratory Society (ERS). Exaggerated bronchoconstriction was defined as a decrease of more than 20% in forced expiratory volume in 1 second after the first challenge, after a skipped dose, or after administration of saline. A receiver operating characteristic (ROC) curve was generated to determine the best FENO cutoff value for predicting exaggerated bronchoconstriction. The pretest probability of developing exaggerated bronchoconstriction was also calculated using Bayes' theorem. RESULTS: The frequency of exaggerated bronchoconstriction in our series was 30%. Patients who developed exaggerated bronchoconstriction had significantly higher FENO levels than those who did not (32.6 vs 16.2 parts per billion [ppb]). The chosen FENO cutoff of 19.5 ppb had a sensitivity of 80%, a specificity of 77%, and a negative predictive value of 88%. The area under the ROC curve was 0.83 (95% confidence interval, 0.77-0.89). CONCLUSIONS: The abbreviated bronchial challenge test recommended by the ERS led to exaggerated bronchoconstriction in 30% of the patients studied. FENO measurements could possibly be used to identify patients at increased risk of exaggerated bronchoconstriction. The shortened challenge test can be performed safely in individuals with a FENO of <19.5 ppb