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Bronchoprovocation tests in asthma: direct versus indirect challenges

Leuppi, Jörg D.

Current Opinion in Pulmonary Medicine: January 2014 - Volume 20 - Issue 1 - p 31–36
doi: 10.1097/MCP.0000000000000009
ASTHMA: Edited by Nicola A. Hanania and Zuzana Diamant

Purpose of review This review describes different bronchoprovocation tests and their merits in diagnosing asthma.

Recent findings A new indirect challenge test using dry powder mannitol has been made available and has been systematically validated and tested in different populations.

Summary Airway hyperresponsiveness (AHR) is a characteristic feature of asthma, and its measurement using direct inhalation challenges, particularly with inhaled methacholine or histamine, or indirect challenges using stimuli such as exercise, dry air hyperpnea, distilled water, hypertonic saline and mannitol, and the pharmacological agent adenosine monophosphate is important in establishing a correct diagnosis. Direct challenge tests are sensitive and have a high negative predictive value to exclude asthma. This is particularly true in excluding asthma as a diagnosis in patients with symptoms that suggest asthma, but are caused by another condition. Indirect AHR correlates better with eosinophilic airway inflammation. Therefore, indirect challenge tests are seen as more specific. A newer indirect challenge test that uses a kit containing prepacked capsules of dry powder mannitol in different doses is safe and efficient to use. Indirect challenge tests are superior to direct challenge tests to confirm the presence of asthma.

Medical University Clinic, Canton Hospital Baselland, Liestal, Switzerland

Correspondence to Professor Jörg D. Leuppi, MD, PhD, Professor of Internal Medicine, University of Basel, Head, Medical University Clinic, Canton Hospital Baselland, Rheinstrasse 26, CH-4410 Liestal, Switzerland. Tel: +41 61 925 21 80; fax: +41 61 925 28 04; e-mail:

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