title: Radiological correlates and clinical implications of the paradoxical lung function response to β₂ agonists: an observational study.
abstract: BACKGROUND
  Bronchodilator response has been noted in a significant proportion of patients with chronic obstructive pulmonary disease (COPD). However, there are also reports of a paradoxical response to β₂ agonists resulting in bronchoconstriction. Asymptomatic bronchoconstriction is likely to be far more common than is symptomatic bronchoconstriction with β₂ agonists, but no systematic studies have been done. We assessed the prevalence of paradoxical response in current and former smokers with and without COPD, and its radiological correlates and clinical implications.
  
  
  METHODS
  Non-Hispanic white and African-American patients (aged 45-80 years) from a large multicentre study COPDGene were classified into two groups on the basis of a paradoxical response, defined as at least a 12% and 200 mL reduction in forced expiratory volume in 1 sec (FEV₁) or forced vital capacity (FVC), or both, after administration of a shortacting β₂ agonist (180 μg salbutamol).
  
  
  RESULTS
  Patients were recruited from January, 2008, to June, 2011. 9986 (96%) of 10,364 patients enrolled in the COPDGene study were included in the analysis population (mean age 59·6 years [SD 9·0]). Paradoxical response was noted in 453 (5%) of 9986 patients and the frequency was similar in patients with COPD (198 [4%] of 4439) and smokers without airflow obstruction (255 [5%] of 5547). Compared with white patients, a paradoxical response was twice as common in African-American patients (227 [7%] of 3282 vs 226 [3%] of 6704; p<0·0001). In the multivariate analyses, African-American ethnic origin (adjusted odds ratio 1·89, 95% CI 1·50-2·39; p<0·0001), less emphysema (0·96, 0·92-0·99; p=0·023), and increased wall-area percentage of the segmental airways (1·04, 1·01-1·08; p=0·023) were independently associated with a paradoxical response. A paradoxical response was independently associated with worse dyspnoea (adjusted β for Modified Medical Research Council Dyspnoea Scale 0·12 [95% CI 0·00 to 0·24]; p=0·05), lower 6 min walk distance (-45·8 [-78·5 to -13·2]; p=0·006), higher Body Mass Index, Airflow Obstruction, Dyspnea, and Exercise Capacity (BODE) index (0·31 [0·19 to 0·43]; p<0·0001), and a greater frequency of severe exacerbations (increased by a factor of 1·35, 1·00-1·81; p=0·048).
  
  
  CONCLUSIONS
  Paradoxical response to β₂ agonists is associated with respiratory morbidity and is more common in African-Americans. These findings might have implications for the use of β2agonists in some patients.
  
  
  BACKGROUND
  National Institutes of Health.
authors.affiliation: Division of Pulmonary, Allergy and Critical Care Medicine, University of Alabama, Birmingham, AL, USA; Lung Health Center, University of Alabama, Birmingham, AL, USA. Electronic address: spbhatt@uab.edu.
authors.forename: Surya P
authors.initials: SP
authors.lastname: Bhatt
authors.affiliation: Division of Pulmonary, Allergy and Critical Care Medicine, University of Alabama, Birmingham, AL, USA; Lung Health Center, University of Alabama, Birmingham, AL, USA.
authors.forename: James M
authors.initials: JM
authors.lastname: Wells
authors.affiliation: Division of Pulmonary and Critical Care, Temple University Hospital, Philadelphia, PA, USA.
authors.forename: Victor
authors.initials: V
authors.lastname: Kim
authors.affiliation: Division of Pulmonary and Critical Care, Temple University Hospital, Philadelphia, PA, USA.
authors.forename: Gerard J
authors.initials: GJ
authors.lastname: Criner
authors.affiliation: Channing Division of Network Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
authors.forename: Craig P
authors.initials: CP
authors.lastname: Hersh
authors.affiliation: Channing Division of Network Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
authors.forename: Megan
authors.initials: M
authors.lastname: Hardin
authors.affiliation: Division of Pulmonary, Allergy and Critical Care Medicine, University of Alabama, Birmingham, AL, USA; Lung Health Center, University of Alabama, Birmingham, AL, USA.
authors.forename: William C
authors.initials: WC
authors.lastname: Bailey
authors.affiliation: Department of Radiology, University of Alabama, Birmingham, AL, USA.
authors.forename: Hrudaya
authors.initials: H
authors.lastname: Nath
authors.affiliation: Department of Preventive Medicine, University of Alabama, Birmingham, AL, USA.
authors.forename: Young-Il
authors.initials: YI
authors.lastname: Kim
authors.affiliation: Morehouse School of Medicine, Atlanta, GA, USA.
authors.forename: Marilyn G
authors.initials: MG
authors.lastname: Foreman
authors.affiliation: Quantitative Imaging Laboratory, National Jewish Health, Denver, CO, USA.
authors.forename: Douglas S
authors.initials: DS
authors.lastname: Stinson
authors.affiliation: Division of Biostatistics and Bioinformatics, National Jewish Health, Denver, CO, USA.
authors.forename: Carla G
authors.initials: CG
authors.lastname: Wilson
authors.affiliation: Division of Pulmonary, Critical Care, Sleep and Allergy, University of Nebraska Medical Center, Omaha, NE, USA.
authors.forename: Stephen I
authors.initials: SI
authors.lastname: Rennard
authors.affiliation: Channing Division of Network Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
authors.forename: Edwin K
authors.initials: EK
authors.lastname: Silverman
authors.affiliation: Division of Pulmonary and Critical Care Medicine, National Jewish Health, Denver, CO, USA.
authors.forename: Barry J
authors.initials: BJ
authors.lastname: Make
authors.affiliation: Division of Pulmonary, Allergy and Critical Care Medicine, University of Alabama, Birmingham, AL, USA; Lung Health Center, University of Alabama, Birmingham, AL, USA.
authors.forename: Mark T
authors.initials: MT
authors.lastname: Dransfield
mesh_terms: D058666:Adrenergic beta-2 Receptor Agonists / Q000009:adverse effects*; D001741:Black or African American / Q000706:statistics & numerical data; D000368:Aged; D000420:Albuterol / Q000009:adverse effects*; D015992:Body Mass Index; D018450:Disease Progression; D004417:Dyspnea / Q000209:etiology; D017079:Exercise Tolerance / Q000502:physiology; D005260:Female; D005541:Forced Expiratory Volume / Q000187:drug effects; D006801:Humans; D008297:Male; D008875:Middle Aged; D029424:Pulmonary Disease, Chronic Obstructive / Q000150:complications / Q000000981:diagnostic imaging* / Q000188:drug therapy*; D011656:Pulmonary Emphysema / Q000150:complications / Q000000981:diagnostic imaging; D011859:Radiography; D012720:Severity of Illness Index; D014797:Vital Capacity / Q000187:drug effects; D016138:Walking / Q000502:physiology; D044465:White People / Q000706:statistics & numerical data
chemical_list: D058666:Adrenergic beta-2 Receptor Agonists; D000420:Albuterol