Bronchial provocation testing: the futureAnderson, Sandra D; Brannan, John DCurrent Opinion in Allergy and Clinical Immunology: February 2011 - Volume 11 - Issue 1 - p 46–52 doi: 10.1097/ACI.0b013e3283423183 Mechanisms of allergy and adult asthma: Edited by Stephen T. Holgate and J. Andrew Grant Abstract Author Information Purpose of review Performing a bronchial provocation test (BPT) using a direct or indirect stimulus to identify bronchial hyper-responsiveness (BHR) reduces the possibility of over and under-diagnosis of asthma based on history and symptoms. This review discusses some long-held beliefs of BPTs to include or exclude a diagnosis of asthma or exercise-induced bronchoconstriction (EIB). Recent findings A high frequency of negative methacholine tests has been reported in 240 patients given a diagnosis of asthma at the end of the study, many of whom had documented EIB. This suggests that a negative methacholine test should not be relied upon to rule out asthma. Further, a positive methacholine test alone should be interpreted with caution as it may reflect airway injury rather than asthma or EIB. Mannitol, an indirect stimulus, identified a similar prevalence of BHR to methacholine and identified more patients than a single exercise test in three studies. However, neither mannitol nor methacholine identified all patients with EIB. Mannitol has a higher specificity for a physician diagnosis of asthma than methacholine. Summary It is likely that both a direct test and an indirect test result may be required in some patients in order to confirm or exclude a diagnosis of asthma with certainty. Department of Respiratory & Sleep Medicine, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia Correspondence to Dr Sandra D. Anderson, 11 West, Department of Respiratory & Sleep Medicine, Royal Prince Alfred Hospital, Missenden Road, Camperdown, NSW 2050, Australia Tel: +61 2 9515 6017; e-mail: firstname.lastname@example.org Copyright © 2011 Wolters Kluwer Health, Inc. All rights reserved.