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(Chest. 1999;115:1533-1538.)
© 1999 American College of Chest Physicians

Effects of a ß2-Agonist on Airway Hyperreactivity in Subjects With Cervical Spinal Cord Injury*

Richard V. DeLuca , MD; David R. Grimm , EdD; Marvin Lesser , MD; William A. Bauman , MD and Peter L. Almenoff , MD, FCCP

* From the Spinal Cord Damage Research Center, Veterans Affairs Medical Center, Bronx, NY, and The Mount Sinai School of Medicine, Mount Sinai Medical Center, New York.


   Abstract
TOP
 Abstract
Introduction
 Materials and Methods
 Results
 Discussion
 References
 
Study objective: Aerosolized ipratropium bromide or orally administered baclofen or oxybutynin chloride (Ditropan) block methacholine-associated airway hyperreactivity in subjects with chronic cervical spinal cord injury (SCI), whereas these agents do not inhibit airway hyperreactivity associated with the inhalation of histamine. The present study was performed to determine whether pretreatment with a ß2-agonist attenuates airway hyperresponsiveness in these subjects.

Participants: Subjects with chronic cervical SCI previously demonstrating airway hyperreactivity were challenged with methacholine (n = 9) or histamine (n = 16) alone and, on a separate day, 25 min following inhalation of nebulized metaproterenol sulfate.

Results: Inhalation of the ß2-agonist was associated with an increase in provocative concentration causing a 20% decrease in FEV1 (PC20) values (geometric mean) from 1.01 ± 2.76 to 20.54 ± 6.24 mg/mL for methacholine and from 2.29 ± 2.26 to 19.82 ± 5.93 mg/mL for histamine. No correlation was found between specific PC20 values for individual subjects and percentage improvement in FEV1 (liter) following inhalation of metaproterenol sulfate and between PC20 values and baseline FEV1 percent.

Conclusion: These data, combined with findings that patients with chronic high cervical SCI experience increased breathlessness following exposure to exogenous agents, suggest that long-term prophylactic ß2-agonist therapy may reduce respiratory symptoms associated with airway hyperreactivity in these patients.

Key Words: ß2-agonist • bronchial hyperresponsiveness • histamine • methacholine • quadriplegia • spinal cord injury


   Introduction
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 Abstract
 Introduction
Materials and Methods
 Results
 Discussion
 References
 
A significant number of otherwise healthy subjects with chronic cervical spinal cord injury (SCI) and normal FEV1/FVC ratios demonstrate improvement in FEV1 and/or FVC following inhalation of metaproterenol sulfate or ipratropium bromide.1 ,2 In addition, approximately 80% of such individuals demonstrate airway hyperresponsiveness to aerosolized methacholine or histamine.3 ,4 ,5 These findings, combined with further observations that 73% and 58% of subjects with high quadriplegia (C5 and above not requiring mechanical ventilation) or low quadriplegia (C6-C8), respectively, report breathlessness at rest or with exertion, and that breathlessness among subjects with high quadriplegia is significantly increased following exposure to hot air or passive cigarette smoke,6 suggest potential clinical benefits associated with administration of an exogenous agent that causes bronchodilatation and/or reduces bronchial hyperreactivity. However, although systemic administration of baclofen, a gamma-aminobutyric acid-B agonist, or oxybutynin chloride (Ditropan), a potent musculotropic antispasmodic agent, attenuated or completely blocked the bronchoconstrictive effects of aerosolized methacholine, these agents did not decrease responsiveness to aerosolized histamine.7 ,8 Likewise, although pretreatment of subjects with ipratropium bromide blocked the effects of methacholine, the agent did not reduce histamine-associated airway hyperreactivity.5 The objective of the current study was, therefore, to determine whether pretreatment of subjects with chronic cervical SCI with a ß2-agonist, an agent that relaxes airway smooth muscle in subjects with asthma irrespective of the inciting contractile agent,9 altered the response to inhaled methacholine or histamine.


   Materials and Methods
TOP
 Abstract
 Introduction
 Materials and Methods
Results
 Discussion
 References
 
Healthy male subjects with chronic cervical SCI (C4-C7 not requiring mechanical ventilation) recruited from the patient population followed by the Spinal Cord Injury Service at the Veterans Affairs Medical Center, Bronx, NY, participated in the study. All subjects denied a history of asthma or allergies, and none reported recent respiratory tract infections or other acute pulmonary symptoms. The Institutional Review Board for human studies of the Bronx Veterans Affairs Medical Center granted approval for the study. Informed consent of each subject was obtained prior to the investigation.

Spirometry was performed while subjects were seated in their wheelchairs using an automated pulmonary function laboratory (SensorMedics model 2200; Yorba Linda, Calif). Spirometry parameters were obtained for each subject in compliance with current American Thoracic Society recommendations.10 Results were expressed as absolute values and percent predicted based on spirometry standards established by Morris et al.11

Subjects who had previously demonstrated airway hyperreactivity to methacholine or histamine were selected for study. Because of initial findings that baclofen or oxybutynin inhibits methacholine-associated hyperresponsiveness, but not that associated with aerosolized histamine,7 ,8 subjects receiving these long-term therapies were not challenged with methacholine. On the day of study, by methods previously used in subjects with chronic cervical SCI,3 ,4 ,7 each subject performed five slow inhalations of aerosolized normal saline solution from functional residual capacity (FRC) to total lung capacity (TLC). All subjects were instructed not to hold their breath at TLC and to exhale slowly. Normal saline solution was administered via a nebulizer (Salter 8900 Nebulizer; Asthmakit, Diemolding Healthcare Division; Canastota, NY) containing 4 mL of solution driven by air at a flow rate of 8 L/min with an output of 0.35 mL/min. On initiation of each breath, nebulization was achieved by manual occlusion of a thumbport for approximately 5 s. Subsequently, by use of the same methods, nonresponders to normal saline solution were given increasing concentrations of methacholine or histamine by use of the logarithmic method (0.025, 0.25, 2.5, 10, and 25 mg/mL).

Spirometry was performed 2 min after each challenge, or sooner if subjects experienced cough or chest tightness. The PC20 was defined as the concentration of methacholine or histamine that caused a 20% decrease in the FEV1. The study was terminated when either the PC20 or maximal concentration of methacholine or histamine was reached. A PC20 of <= 8 mg/mL was considered indicative of airway hyperresponsiveness. Previously, we demonstrated that results obtained by administration of methacholine or histamine in logarithmic increases are comparable to those obtained by the doubling-dose method.8 ,12 More recently, we have measured in individuals with cervical SCI similar PC20 values using three different bronchoprovocational challenge methods: continuous inhalation of aerosol using tidal volume breathing, fixed number of dosimeter-regulated breaths, and by the method described herein (unpublished data).

Subjects returned to the laboratory within 2 weeks of the initial study and were rechallenged by use of the same methods following administration of the ß2-agonist metaproterenol sulfate. Subjects received 2.5 mL of a 0.6% solution of the agent via a nebulizer (Salter 8900) (flow rate of 8 L/min) and were challenged 25 min later with either methacholine or histamine. Twenty minutes after administration of metaproterenol sulfate, spirometry was performed to quantitate changes in FEV1 induced by the agent.

Statistical Analysis
All spirometry results are reported as mean ± SD. PC20 values for all subjects were calculated as geometric mean ± SD. An unpaired Student's t test was applied to determine whether spirometry and PC20 values differed between groups, and a paired t test was used to assess differences between the initial histamine and methacholine bronchoprovocations and challenges following administration of metaproterenol sulfate. A Pearson correlation coefficient (r) was calculated to assess linear relationships between the bronchoconstrictor response to either methacholine or histamine and baseline FEV1 percent, and the bronchodilator response to metaproterenol sulfate. The level of significance was set at p < 0.05.


   Results
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
Discussion
 References
 
Level of lesion, completeness of injury, duration of injury, and age of the subjects, along with smoking status and medications, are shown (Table 1 ). Among the 25 responders recruited for the study, 9 were challenged with methacholine and 16 were challenged with histamine. Subjects 1 and 4 in the methacholine group and subjects 13, 15, and 16 in the histamine group had FEV1/FVC ratios < 70%. Among those challenged with methacholine, baseline FVC (3.12 L), FVC percent (60.44), FEV1 (2.38 L), FEV1 percent (59.89), and FEV1/FVC ratio (77%) did not differ significantly compared with values obtained on the day of return before the subjects were given the ß2-agonist (Tables 2 and 3). Similarly, among subjects challenged with histamine, baseline values obtained at the time of the two study days did not differ significantly (Tables 2 and 3 ).


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  		Table 1. Subject Characteristics*

 

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  		Table 2. Results From Individual Spirometry and PC20 Values

 

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  		Table 3. Results From Individual Spirometry and PC20 Values

 
Overall, following pretreatment with metaproterenol, PC20 values for methacholine increased significantly (geometric mean) from 1.01 ± 2.76 to 19.34 ± 6.24 mg/mL, and that for histamine increased significantly from 2.29 ± 2.26 to 18.86 ± 5.93 mg/mL (Tables 2 and 3 ). The increases in PC20 values following pretreatment with metaproterenol sulfate were statistically significant (p < 0.05). For individual subjects, responsiveness to methacholine or histamine did not correlate with the degree of bronchodilation induced with the ß2-agonist. Furthermore, no correlation was found between specific PC20 values for individual subjects and baseline FEV1 percent.


   Discussion
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
References
 
We observed that pretreatment of subjects with chronic cervical SCI with aerosolized metaproterenol sulfate markedly reduced airway hyperresponsiveness to inhaled methacholine and histamine. These findings contrast with previous observations among these subjects that the response to methacholine was blocked with baclofen, oxybutynin, or ipratropium bromide, whereas the response to histamine was not affected by these agents.3 ,4 ,7 ,8 Findings of the current study are comparable to those obtained among subjects with asthma or chronic obstructive lung disease, which have shown significant reduction in response to histamine or methacholine within minutes following inhalation of albuterol, fenoterol, or metaproterenol that persists for 4 to 6 h.13 ,14 ,15 ,16 ,17 ,18 Similar attenuation was observed in normal subjects with upper respiratory tract infections,19 or those challenged with carbachol or inert dust particles.20 The protective effects of ß2-agonists are attributed to interaction of the agent with ß2-receptors, which are widely distributed on airway smooth muscle, thereby causing functional relaxation irrespective of the bronchoconstrictor stimulus.9 ,21 Studies performed in vitro have demonstrated that activation of ß2-receptors on cholinergic and sensory nerves inhibits release of acetylcholine and neuropeptides,22 ,23 which suggests a potential indirect mechanism of bronchodilation since methacholine acts directly on airway smooth muscle through interaction with muscarinic receptors.9 Among subjects with cervical SCI, the effects of histamine were attributed to direct action on H1 receptors;5 therefore, the protective effect of metaproterenol in the current study is ascribed to a direct smooth muscle effect.

Findings from the current study confirm that most subjects with chronic cervical SCI consistently demonstrate airway hyperresponsiveness to aerosolized methacholine and histamine.3 ,4 ,5 Similarly, a significant number of subjects with asthma exhibit amplified bronchoconstriction in response to a variety of physical, physicochemical, chemical, and pharmacologic agents.24 Although the mechanisms of airway hyperreactivity among subjects with SCI or asthma remain unclear, recent findings in healthy control subjects and subjects with asthma that the response to methacholine was similar in both groups when the modulating effect of an increase in lung volume by deep inspiration in control subjects was voluntarily suppressed suggest that airway hyperresponsiveness in asthma may be due to limited smooth muscle relaxation with deep inspiration.25 Also, among control subjects, the bronchoconstrictor response to methacholine was enhanced when subjects inhaled the agent at 0.5 L below FRC and reduced when the study was performed at 0.5 L above FRC, suggesting that lung volume is a major determinant of the bronchoconstrictor response to methacholine in such subjects.26 This may be due to changes in lung volume that act to alter the forces of interdependence between airways and parenchyma that oppose airway smooth muscle contraction. As a result of respiratory muscle paralysis, subjects with cervical SCI have reduced FVC, FEV1, and TLC.27 ,28 It seems unlikely, however, that reduced volumes are the sole explanation for hyperresponsiveness in subjects with cervical SCI because of the absence of correlation between histamine or methacholine PC20 values and baseline FVC percent or FEV1 percent. Furthermore, some subjects with paraplegia have comparable spirometry values without demonstrating hyperresponsiveness to either agent.4

Increased airway responsiveness to bronchoconstrictor stimuli in subjects with asthma may be due to smaller resting airway caliber.29 With preexisting airway narrowing, a small further reduction in caliber would produce a large increase in resistance.29 ,30 ,31 In support, a number of investigators have observed increased responsiveness to histamine or methacholine in control subjects and in subjects with asthma or chronic obstructive bronchitis with lower baseline FEV1, FEV1 percent, FEV1/FVC, or specific airway conductance,32 ,33 ,34 ,35 ,36 ,37 even after adjustment for confounding factors of age, area of residence, smoking habits, and the presence of respiratory symptoms.38 Furthermore, among patients with airway obstruction, those who demonstrated the greatest bronchoconstrictor response to histamine also had the greatest bronchodilatory response to isoproterenol hydrochloride (Isoprenaline), when measured by changes in specific airway conductance.39

In contrast, the current study found no correlation between the bronchodilator response to metaproterenol sulfate and the bronchoconstrictor response to methacholine or histamine, suggesting that hyperresponsiveness to the two provocative agents in subjects with cervical SCI is dissociated from the level of resting airway tone. Findings, however, that a significant number of subjects with cervical SCI experience bronchodilation following inhalation of meta-proterenol or ipratropium bromide1 ,2 suggest that resting airway tone is increased in these subjects, although to our knowledge, no detailed studies have been performed using plethysmography to assess baseline airway resistance. A reduction in compliance in these subjects, with less reduction in specific lung compliance, suggests that the changes in lung compliance are due partly to reduced lung volumes and partly to altered mechanical properties of the lung,40 which has been attributed to possible terminal airspace closure and atelectasis28 ,41 in addition to altered mechanical properties, possibly because of altered surfactant.40

Because in the current study aerosolized metaproterenol decreased airway hyperreactivity in all subjects challenged with histamine or methacholine, long-term administration of the agent may provide subjective or objective improvement in respiratory parameters. In a detailed survey of respiratory symptoms, 68% of subjects with chronic SCI (n = 180) reported one or more respiratory symptom, with breathlessness being reported by 73% of subjects with high quadriplegia (C5 and above not requiring mechanical ventilation) and 58% of those with low quadriplegia (C6-8).6 Breathlessness occurred significantly more often in the group with high quadriplegia following exposure to exogenous agents. A prospective study will be needed to assess possible therapeutic benefit from an aerosolized ß2-agonist in individuals with chronic quadriplegia, while also examining the possibility that long-term administration reduces airway hyperresponsiveness to histamine or methacholine.


   Footnotes
 
Correspondence to: Marvin Lesser, MD, Spinal Cord Damage Research, RM 1E-02, 130 West Kingsbridge Road, Bronx, NY 10468

Abbreviations:FRC = functional residual capacity; PC20 = provocative concentration causing a 20% decrease in FEV1; SCI = spinal cord injury; TLC = total lung capacity

Received for publication August 25, 1997. Accepted for publication January 21, 1998.


   References
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 References
 

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