Management of Mild Pulmonary Hyperexpansion to Assess for Reactive Airway Disease

Diagnostic Algorithm

The European Respiratory Society recommends obtaining baseline spirometry measuring FEV1 and forced vital capacity (FVC) to quantify the degree of airflow obstruction and establish whether hyperexpansion correlates with obstructive physiology 1, 2
Administer bronchodilator testing with β2-agonists and/or anticholinergics and repeat spirometry to assess reversibility, as suggested by the European Respiratory Society 1, 2
Peak flow diurnal variation >15% over 2 weeks, calculated as: (highest PEF of day - lowest PEF) / mean of highest and lowest PEF, is a criterion for reactive airway disease, according to the European Respiratory Society 1, 2
PC20 (provocative concentration causing 20% fall in FEV1) <2 mg/mL on histamine or methacholine bronchial challenge testing is another criterion for reactive airway disease, as recommended by the European Respiratory Society 1, 2

If reactive airway disease is confirmed, initiate inhaled corticosteroids as the primary anti-inflammatory therapy, particularly if there is evidence of rapid FEV1 decline (>50 mL/year), as suggested by the European Respiratory Society 1, 2
Use large-volume spacer or dry-powder system for doses ≥1,000 μg/day of inhaled corticosteroids to optimize delivery and minimize systemic absorption, according to the European Respiratory Society 1, 2
If COPD pattern predominates, start with as-needed inhaled β-agonist or anticholinergic bronchodilator delivered via appropriate inhaler device, as recommended by the Thorax journal 3
Discontinue bronchodilators if ineffective after adequate trial, as continued use provides no benefit in non-responders, according to the Thorax journal 3

Reassess FEV1 and vital capacity at follow-up visits to determine treatment efficacy, as suggested by the European Respiratory Society 1, 2
Check inhaler technique, symptom relief, and medication adherence at each review, according to the European Respiratory Society 1, 2
Assess exercise capacity to identify patients who might benefit from pulmonary rehabilitation, as recommended by the European Respiratory Society 1, 2