Breathing Trouble
The Walrus|September/October 2021
Tens of thousands of Canadians who have received asthma diagnoses don’t actually have it
RENÉE PELLERIN

FOLLOWING a bout of pneumonia in 2014, Becky Hollingsworth experienced a persistent cough and shortness of breath. Her doctor diagnosed asthma and prescribed two inhalers plus an oral medication. They eased her cough, but Hollings worth wasn’t convinced that asthma was what she had. Her symptoms weren’t severe enough, she thought. So, months later, when she received an automated phone call inviting her into an asthma study, she leaped at the opportunity.

The study was led by Shawn Aaron, chief of respirology at the University of Ottawa and The Ottawa Hospital. His research was inspired by what he was seeing among patients referred to him because their asthma medications weren’t working. Asthma is a common disease of the airways that comes with symptoms, such as wheezing and chest tightness, also seen in other lung conditions. But, when Aaron tested the referred patients, he found many for whom the diagnosis was simply wrong. He’d already done several smaller studies; this new project was ambitious, involving 613 adults in ten locations across the country.

Hollingsworth, a retired nurse, was an eager recruit, willing to undergo repeated tests in Ottawa, an hour-long drive from her home. The first test was spirometry, one she’d not had before.

Wearing nose clips, patients exhale into a tube connected to a spirometer, a device that measures airflow, as fast and hard as they can for five seconds. After three blows, they inhale a bronchodilator —  medication that relaxes muscles around the airways — wait fifteen minutes, and do three more blows. If the machine registers improvement in airflow, the diagnosis is asthma.

In Hollingsworth’s case, the bronchodilator made no difference, indicating she might not have the disease. But asthma symptoms can come and go. On a good day, a patient can do well on spirometry but still have the condition. Aaron therefore submitted all study participants who appeared asthma-free to a second test: the methacholine challenge. Methacholine is a chemical that causes the airways to get twitchy and irritable. During the test, patients inhale increasing doses of methacholine and blow into a spirometer after each increase. A person with asthma will react badly and be hyperresponsive to low doses of the chemical.

In day-to-day practice, it’s too costly to give everyone who passes a spirometry test the methacholine challenge; it is typically reserved for the most difficult cases. But Aaron needed to be precise in determining how many in the study had received incorrect diagnoses. For even greater certainty, he instructed participants who passed the methacholine challenge to wean off their medications over several weeks and then get re-tested. Those who consistently showed no indication of asthma were then assessed by a pulmonologist to determine what they actually had.

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