2005049

“Reactive Airways Disease”
A Lazy Term of Uncertain Meaning That Should Be Abandoned
JOHN V. FAHY and PAUL M. O’BYRNE
Department of Medicine and the Cardiovascular Research Institute, University of California, San Francisco, California; and the Department of Medicine, McMaster University, Hamilton, Ontario, Canada The terms “reactive airways” and “reactive airways disease” disorder is currently recognized as distinct by the American have crept into the clinical lexicon in recent years. They are Thoracic Society and the American College of Chest Physi- being used as synonyms for asthma. The terms are widely used in case presentations involving outpatients and inpatients, and Airway hyperreactivity is also a specific term that means even patients in intensive care units. They are in particular that the airways are hyperreactive to a variety of stimuli in- commonly used in the pediatric setting. The problem is that cluding methacholine, histamine, hypertonic saline, distilled “reactive airways” and “reactive airways disease” are highly water, exercise, or eucapnic hyperventilation (4). Hyperreac- nonspecific terms that have no clinical meaning. As such, we tivity in this context means a bronchoconstrictor response at view these terms as unhelpful and potentially harmful, and we “doses” that normally have no bronchoconstrictor effect. Air- way hyerreactivity actually encompasses both airway sensitiv- Patients are usually labeled with “reactive airways” if they ity (the dose of agonist at which the FEV1 begins to fall) and have a history of cough, sputum production, wheeze, or dys- airway hyperresponsiveness (the slope of the dose–response pnea. Sometimes, however, the only prompt for a diagnosis of curve thereafter). Airway hyperreactivity is a characteristic of “reactive airways disease” is the possession by the patient of asthma and to a lesser extent of chronic obstructive pulmo- an inhaler of some sort. Most often, physicians who use the nary disease (COPD) (5), but has also been described in pa- terms do not have pulmonary function test results for the tients with allergic rhinitis (6), but no asthma, in cystic fibrosis patient. Certainly, it is very rare that patients have had mea- (7), and even in irritable bowel disease (8). Thus, although air- surement of airway reactivity to methacholine, histamine, or way hyperreactivity is a highly specific term with definite mean- hypertonic saline. Therefore, armed only with symptoms re- ing, it is not a disease diagnosis; rather it represents a physio- ferable to the airway, or with a history of inhaler use, the doc- logical abnormality of the airway. It is, however, an important tor will present on rounds or write in the chart, in letters, or in component of the diagnostic criteria for asthma.
discharge summaries that the patient has “reactive airways The use of the term “reactive airways disease” in part re- disease.” Unfortunately, this diagnosis often goes unchal- flects the difficulty with establishing a diagnosis of asthma in lenged. In fact, increasingly the term is being commonly used some situations. In the pediatric setting, especially in very among specialists in pulmonary medicine.
young children, the diagnosis of asthma may be problematic The term “reactive airways disease” needs to be distin- because the history is difficult to obtain, because good quality guished from reactive airways dysfunction syndrome (RADS) pulmonary function tests cannot be obtained, or because and from airway hyperreactivity—two terms that have value asthma is a diagnosis that carries a negative connotation for and meaning in pulmonary medicine. RADS is a specific term the patients. Thus, the term “reactive airways disease” may be coined by Brooks and coworkers (1) in 1985 to describe an used as a nonspecific term in clinical contexts ranging from asthma-like illness developing after a single exposure to high asthma, to wheezy bronchitis, to viral bronchiolitis, or even to levels of an irritating vapor, fume, or smoke. Patients with pneumonia. In adult medicine, we suspect that the term is RADS have methacholine airway hyperreactivity, but other popular because of instances in which physicians obtain a his- pulmonary function tests may or may not be abnormal. Symp- tory of wheeze, sputum production, or inhaler use, but a for- toms and airway hyperreactivity can persist for years after mal diagnosis of asthma is not in the patient record. A formal the incriminating exposure. RADS differs from occupational diagnosis of asthma requires documentation of reversible air- asthma in that it typically occurs after a single exposure with- way obstruction or airway hyperreactvity in the setting of a out a preceding period of sensitization. It should be noted that typical history of asthma. Frequently, the physiological infor- not all experts agree that RADS is a real clinical syndrome mation is missing or elements of a typical asthma history are (2), arguing that the entity is based on case reports that lack missing. In the absence of these findings, physicians will pro- control groups and that usually lack preexposure pulmonary vide a label of “reactive airways disease” to convey that the function assessment. However, the weight of current scientific patient has some sort of airway problem.
evidence supports RADS as a distinct clinical entity, and the The problem with the term reactive airways or reactive air- ways disease is not just that they represent an annoyance topurists of terminology. The problem is that using the terms (Received in original form May 15, 2000 and in revised form October 27, 2000) may provide physicians with a false sense of diagnosis security.
Supported by RO1 HL61662 from the National Institutes of Health (J.V.F.). P.M.
Ascribing a label of reactive airways to a patient may be harm- O’Byrne is a Senior Scientist of MRC, Canada.
ful in this context, because it may prevent work-up of the Correspondence and requests for reprints should be addressed to John V. Fahy, cause of the symptom complex that led to the diagnosis of re- M.D., Box 0111, University of California, San Francisco, 505 Parnassus Avenue,San Francisco, CA 94143. E-mail: [email protected] active airways disease in the first place. These patients may ac- Am J Respir Crit Care Med
Vol 163. pp 822–823, 2001
tually have asthma, chronic bronchitis, emphysema, or even Internet address: www.atsjournals.org
pneumonia. Treatment usually prescribed for these specific diseases may or may not be prescribed if the diagnosis is “re- References
active airways disease.” Overtreatment may also be a side ef- 1. Brooks SM, Weiss MA, Bernstein IL. Reactive airways dysfunction syn- fect of this diagnosis. We suspect that many patients with a di- drome (RADS): persistent asthma syndrome after high level irritant agnosis of “reactive airways disease” receive treatment with exposures. Chest 1985;88:376–384.
inhaled ␤-agonists or with inhaled corticosteroids. However, if 2. Kern DG, Sherman CB. What is this thing called RADS? Chest 1994; the patient does not have asthma there is no evidence that 3. Alberts WM, do Pico GA. Reactive airways dysfunction syndrome. Chest these treatments benefit the patient.
Finally, the terms “reactive airways” and “reactive airways 4. Boushey HA, Holtzman MJ, Sheller JR, Nadel JA. State of the art: disease” are now making their way from the clinical lexicon to bronchial hyperreactivity. Am Rev Respir Dis 1980;121:389–413.
the clinical literature. Two recent publications have used the 5. Ramsdale EH, Morris MM, Roberts RS, Hargreave FE. Bronchial re- term “reactive airway disease” (9, 10). In one instance reactive sponsiveness to methacholine in chronic bronchitis: relationship to air- airway disease was used as a summary term to describe pa- flow obstruction and cold air responsiveness. Thorax 1984;39:912–918.
6. Ramsdale EH, Morris MM, Roberts RS, Hargreave FE. Asymptomatic tients with asthma and/or COPD; in the other it was used syn- bronchial hyperresponsiveness in rhinitis. J Allergy Clin Immunol 1985; onymously with airway hyperreactivity (10). We find this trend troubling because many patients considered to have “re- 7. van Haren EH, Lammers JW, Festen J, Heijerman HG, Groot CA, van active airways disease” do not have asthma, and the vast ma- Herwaarden L. The effects of the inhaled corticosteroid budesonide jority of patients with reactive airways have never had their on lung function and bronchial hyperresponsiveness in adult patients airway reactivity measured. We believe it essential to preserve with cystic fibrosis. Respir Med 1995;89:209–214.
8. Whtie AM, Stevens WH, Upton AR, O’Byrne PM, Collins SM. Airway the integrity of asthma and airway hyperactivity as diagnostic responsiveness to inhaled methacholine in patients with irritable bowel terms in the clinical literature. In fact, in the context of clinical syndrome. Gastroenterology 1991;89:209–214.
research, we believe the use of the terms “reactive airways” 9. Tierney WM, Murray MD, Gaskins DL, Zhou XH. Using computer- and “reactive airways disease” will complicate research on based medical records to predict mortality for inner-city patients with asthma, especially for clinical epidemiologists who are investi- reactive airways disease. J Am Med Informatics Assoc 1997;4:313–321.
gating the current worldwide epidemic of asthma.
10. Moudgil GC. The patient with reactive airways disease. Can J Anaesth In summary, at best the diagnostic label “reactive airways dis- ease” is an annoyance to those of us who want to maintain diag-nostic clarity in our discipline. At worst, the term represents aform of diagnostic laziness that may case harm to patients.

Source: http://wwwappskc.lonestar.edu/programs/respcare/FIONA/RSPT2210/RAD.pdf