Paradoxical Bronchospasm in Us Military Veterans With Copd or Asthma at a Tertiary Va Medical Center

Abstract

Inhaled short-acting b2-adrenergic agonists (SABA) can rarely elicit paradoxical bronchospasm (PB), which may be life threatening. Prior studies have shown PB to be associated with significantly worse respiratory outcomes, including greater frequency of COPD exacerbations.Among U.S. military veterans, COPD has been reported to be of higher prevalence but the prevalence of PB is not known in this population. The purpose of our study was to determine whether paradoxical bronchospasm is recognized and reported in spirometry test results of U.S. military veterans with COPD and asthma at our tertiary care VA medical center. METHODS:We performed a retrospective review of 1,150 adequately performed pre-and post-bronchodilator spirometry test reports between years 2017 to 2020. PB was defined as at least 12%-and 200-mL decrease in forced expiratory volume in one second (FEV1) and/or forced vital capacity (FVC) from baseline after inhalation of albuterol. In addition, to pertinent demographics and comorbidities, spirometry data including pre-and post-bronchodilator FEV1 and FVC was obtained and analyzed.RESULTS: Eighteen reports were identified with post bronchodilator PB (1.5%), 12 with COPD, 4 with asthma and 2 with asthma/COPD. Noreport alluded to post-bronchodilator PB. This included 17 males and one female, 14 African Americans, 3 Caucasian and one Latinx, aged 67AE8 years (meanAESD) with BMI 28AE5 kg/m2. Thirteen were ex-tobacco smokers, 4 current smokers and one never smoked. Chest CT revealed emphysema in 8 veterans with COPD and bronchial wall thickening in 3.Chest radiographs of 4 veterans with asthma were unremarkable. All veterans were treated with inhaled b2-adrenergic agonists.Five were treated with cardioselective beta 1 blockers and 10 for gastroesophageal reflux disease (GERD). Eleven veterans were diagnosed with obstructive sleep apnea. In 12 veterans, inhaled albuterol (4 actuations)-induced decrease in FEV1 was 22AE8% and 367AE167 mL from baseline. In 6 veterans, only FVC decreased significantly from baseline (14AE3% and 448AE179 mL). No veteran reported respiratory symptoms during or after spirometry testing. Two veterans died during follow-up.CONCLUSIONS: PB displayed during spirometry testing of veterans, albeit rare, is not recognized nor reported in test results. Most identified cases of PB had history of smoking (current or prior), underlying GERD and obstructive sleep apnea history. CLINICAL IMPLICATIONS: Two large studies that investigated the prevalence of PB displayed during spirometry testing in the U.S. did not include U.S. military veterans with COPD and asthma. To the best of our knowledge, our study is the first to report PB in this population who underwent spirometry testing according to ATS/ERS guidelines. Paradoxical bronchospasm can represent a rare unrecognized phenotype of patients with COPD and asthma and should be readily recognized and reported..