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Background: The most recognizable phenotype of severe asthma comprises people who are blood eosinophil and FeNO-high, driven by type-2 (T2) cytokine biology which responds to targeted biological therapies. However, in many people with severe asthma, these T2 biomarkers are suppressed but poorly controlled asthma persists. The mechanisms driving asthma in the absence of T2 biology are poorly understood. Objectives: To explore airway pathology in T2 biomarker-high and -low severe asthma. Methods: T2 biomarker-high severe asthma (T2-high, n=17) was compared to biomarker-intermediate (T2-intermediate, n=21) and biomarker-low (T2-low, n=20) severe asthma, and healthy controls (n=28). Bronchoscopy samples were processed for immunohistochemistry, and sputum for cytokines, PGD2 and LTE4 measurements. Results: Tissue eosinophil, neutrophil and mast cell counts were similar across severe asthma phenotypes and not increased when compared to healthy controls. In contrast, the remodeling features of airway smooth muscle mass and MUC5AC expression were increased in all asthma groups compared to health, but similar across asthma subgroups. Submucosal glands were increased in T2-intermediate and T2-low asthma. In spite of similar tissue cellular inflammation, sputum IL-4, IL-5, and CCL26 were increased in T2-high versus T2-low asthma, and several further T2-associated cytokines, PGD2 and LTE4, were increased in T2-high and T2-intermediate asthma compared to healthy controls. Conclusions: Eosinophilic tissue inflammation within proximal airways is suppressed in T2 biomarker-high and T2-low severe asthma, but inflammatory and structural cell activation is present, with sputum T2-associated cytokines highest in T2 biomarker-high patients. Airway remodeling persists, and may be important for residual disease expression beyond eosinophilic exacerbations.

A 56-year-old man has difficult-to-control asthma and a history of four exacerbations in the prior 12 months despite high-dose inhaled corticosteroids (ICS) and additional controller therapies. Is he suitable for more advanced therapeutic options? To address this query, we herein review the clinical assessment of a patient with suspected severe asthma and discuss factors contributing to poor asthma control and how biomarkers assist in disease investigation and stratification. The key components of our multidisciplinary approach are to confirm an asthma diagnosis and adherence to treatment, to assess any contributing comorbidities or confounding factors, and to stratify what type of asthma the patient has. The combination of spirometry and repeated measures of key biomarkers of type 2 airway inflammation-the blood eosinophil count and fractional exhaled nitric oxide-identifies whether poor disease control is driven by uncontrolled, ICS-resistant type 2 airway inflammation or ongoing airflow obstruction. A failure to elicit evidence of either suggests an alternative driver for the patient's symptoms, including chronic airway infection and non-asthma causes. Each phenotype represents a treatable trait that requires a specific targeted approach. Critically, steroids can cause harm, and their use should be guided by objective evidence of inflammation rather than symptoms alone. To conclude, after assessment of treatment adherence and exclusion of relevant comorbidities, the patient was found to have severe asthma with ICS-resistant type 2 airway inflammation. We will consider additional treatment options at our next appointment in part 2/2 of this How I Do It series.

IntroductionThe reduction of the risk of asthma attacks is a major goal of guidelines. The fact that type-2 inflammatory biomarkers identify a higher risk, anti-inflammatory responsive phenotype is potentially relevant to this goal. We aim to quantify the relation between blood eosinophils, exhaled nitric oxide (FeNO) and the risk of severe asthma attacks.Methods and analysisA systematic review of randomised controlled trials (RCTs) will be conducted by searching MEDLINE from January 1993 to April 2021. We will include RCTs that investigated the effect of fixed treatment(s) regimen(s) on severe asthma exacerbation rates over at least 24 weeks and reported a baseline value for blood eosinophils and FeNO. Study selection will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, and the methodological appraisal of the studies will be assessed by the Cochrane Risk-of-Bias Tool for RCTs. Study authors will be contacted to request anonymised individual participant data (IPD) for patients randomised to the trial’s control arm. An IPD meta-analysis will be performed for multivariable prognostic modelling with performance assessment (calibration plots and the c-statistic) in a cross-validation by study procedure. The outcome to predict is the absolute number of severe asthma attacks to occur in the following 12 months if anti-inflammatory therapy is not changed (ie, annualised number of attacks requiring ≥3 days of systemic corticosteroids and/or hospitalisation if the patient was randomised to the control arm of an RCT). A summary prognostic equation and risk stratification chart will be reported as a basis for further analyses of individualised treatment benefit.Ethics and disseminationThe protocol has been reviewed by the relevant Oxford academic ethics committee and found to comprise fully anonymised data not requiring further ethical approbation. Results will be communicated in an international meeting and submitted to a peer-reviewed journal.PROSPERO registration numberCRD42021245337.

The controversy surrounding short-acting β2-agonist (SABA) monotherapy for very mild and mild asthma continues in guidelines despite increasing evidence in favor of combined inhaled corticosteroid/reliever therapy. We herein briefly review the findings from two high-quality randomized controlled trials and other safety data to conclude that the efficacy and safety of SABA monotherapy have been overstated, especially in type-2 high or allergic disease.

Aim To update obstetric care providers about asthma management. Summary Asthma is the most frequent comorbid chronic illness in pregnancy. Convincing evidence shows that uncontrolled asthma magnifies the risk of maternal, fetal and neonate complications. Unfortunately, one in four women take no inhaler during pregnancy, and it is likely that decreased adherence, rather than changes in pathology, explains uncontrolled maternal asthma. Patient surveys reveal a need for information and reassurance. Although some molecules are preferred in pregnancy, there is currently no basis to withhold any asthma medication – old or new. Biomarkers such as blood eosinophils and fractional exhaled nitric oxide are an effective way to assess the risk of asthma attacks and the likelihood of responding to inhaled steroids. Furthermore, practice-changing trials in mild asthma show that switching reliever-only regimens to as-needed ‘controller-and-reliever’ therapy is effective. We suggest that applying these changes can alleviate women’s concerns and improve outcomes.

Background Published methods to describe and visualize Care Trajectories (CTs) as patterns of healthcare use are very sparse, often incomplete, and not intuitive for non-experts. Our objectives are to propose a typology of CTs one year after a first hospitalization for Chronic Obstructive Pulmonary Disease (COPD), and describe CT types and compare patients’ characteristics for each CT type. Methods This is an observational cohort study extracted from Quebec’s medico-administrative data of patients aged 40 to 84 years hospitalized for COPD in 2013 (index date). The cohort included patients hospitalized for the first time over a 3-year period before the index date and who survived over the follow-up period. The CTs consisted of sequences of healthcare use (e.g. ED-hospital-home-GP-respiratory therapists, etc.) over a one-year period. The main variable was a CT typology, which was generated by a ‘tailored’ multidimensional State Sequence Analysis, based on the “6W” model of Care Trajectories. Three dimensions were considered: the care setting (“where”), the reason for consultation (“why”), and the speciality of care providers (“which”). Patients were grouped into specific CT types, which were compared in terms of care use attributes and patients’ characteristics using the usual descriptive statistics. Results The 2581 patients were grouped into five distinct and homogeneous CT types: Type 1 (n = 1351, 52.3%) and Type 2 (n = 748, 29.0%) with low healthcare and moderate healthcare use respectively; Type 3 (n = 216, 8.4%) with high healthcare use, mainly for respiratory reasons, with the highest number of urgent in-hospital days, seen by pulmonologists and respiratory therapists at primary care settings; Type 4 (n = 100, 3.9%) with high healthcare use, mainly cardiovascular, high ED visits, and mostly seen by nurses in community-based primary care; Type 5 (n = 166, 6.4%) with high healthcare use, high ED visits and non-urgent hospitalisations, and with consultations at outpatient clinics and primary care settings, mainly for other reasons than respiratory or cardiovascular. Patients in the 3 highest utilization CT types were older, and had more comorbidities and more severe condition at index hospitalization. Conclusions The proposed method allows for a better representation of the sequences of healthcare use in the real world, supporting data-driven decision making.

The prototype ORACLE scale based on two simple measures of type 2 airway inflammation (blood eosinophils and FENO) quantifies the excess risk conferred by raised biomarkers that is removed by type-2 anti-inflammatory treatment in trial populations

Rationale Patients with severe asthma, raised fractional exhaled nitric oxide (FeNO) and high blood eosinophil (Eos) counts are at increased risk of asthma attacks. Objective To investigate this relationship by correlating FeNO and blood Eos to inflammatory mediators in the airway and peripheral blood in severe asthma. Methods Induced sputum Eos and 11 sputum supernatant plus 9 serum inflammatory proteins were analyzed by electrochemiluminescence or ELISA in a pooled cross-sectional analysis of patients with severe asthma and healthy controls. We recruited patients in whom we had a high degree of confidence in treatment adherence to high-dose inhaled corticosteroids (ICS) and/or systemic corticosteroids. Spearman correlations were computed between FeNO, blood Eos and sputum/serum analytes plus clinical measurements, controlling for a false discovery rate (FDR) Results Correlation of FeNO and sputum/serum analytes in 74 patients with severe asthma showed significant correlations with sputum Eos (r=0.51), interleukin (IL)-4 (r=0.48), IL-5 (r=0.47), IL-33 (r=0.35), thymic stromal lymphopoietin (TSLP: r=0.41), eotaxin-3 (CCL26: r=0.55), thymus associated regulated cytokine (TARC or CCL17: r=0.32), and asthma attacks in the previous year (r=0.25). Blood Eos correlated with serum IL-5 (r=0.41). In effect, FeNO non-suppression was associated with higher sputum Eos (fold-difference in median values, FeNO Conclusion Raised FeNO despite adherence to high-dose ICS identifies corticosteroid-resistant airway type-2 cytokine (IL-4, -5), chemokine (eotaxin-3, TARC), alarmin (IL-33, TSLP) and sputum eosinophilia, while blood eosinophils correlate with systemic IL-5. These biomarkers provide complementary information on distinct immunological compartments. Please refer to page A190 for declarations of interest related to this abstract.

Background: Non-suppression of fractional exhaled nitric oxide (FeNO) during remotely monitored inhaled corticosteroid (ICS) therapy is associated with persistent symptoms and blood eosinophilia. To provide mechanistic insight, we assessed sputum type 2 cytokines and chemokines before and after a FeNO suppression test. Methods: FeNO suppression was performed in 44 patients with severe asthma and FeNO > 40 ppb. FeNO was monitored for 7 days of 1000μg of fluticasone propionate delivered via an INCATM device, with clinical and sputum sampling on days 0 and 7. FeNO suppression was defined as a 42% reduction in FeNO. Sputum supernatant was analyzed in 15 paired samples by ELISA (Prostaglandin D2, Leukotriene E4) and MSD assays (IL-4,-5,-13,-25,-33, CCL26, TSLP). Results: Suppressors (n=21) vs non-suppressors had a greater drop in ACQ-5 (mean∆: -1.2 vs -0.3, p Conclusion: Failure to suppress FeNO during ICS treatment was associated with steroid-unresponsive sputum PGD2 and LTE4 levels.

Reduction of the risk of asthma attacks is a major goal of current asthma management. We propose to derive a risk scale predicting asthma attacks based on the blood eosinophil count and exhaled nitric oxide (FeNO). Biomarker-stratified trial-level attack rates were extracted and pooled from the control arms of the Novel START, CAPTAIN, QUEST, Benralizumab Phase 2b, PATHWAY, STRATOS 1–2 and DREAM trials (n=3051). These were used to derive rate ratios and the predicted asthma attack rate for different patient groups. The resultant prototype risk scale shows potential to predict asthma attacks, which may be prevented by anti-inflammatory treatment.

Purpose The impacts of high blood eosinophil count (HBEC) at admission for COPD exacerbation on posthospitalization outcomes are still unclear. Previous studies have focused on its associations with first readmission rates; yet, its impacts on longitudinal outcomes such as subsequent readmissions still have to be explored. The main objective of this study is to investigate outcomes associated with HBEC following a first hospitalization for COPD exacerbation. Patients and methods This is an observational cohort study design. We retrospectively analyzed data of patients with a first hospitalization within 5 years for COPD exacerbation between April 2006 and March 2013. Patients were stratified into the HBEC group if the blood eosinophil count at admission was ≥200 cells/µL and/or ≥2% of the total white blood cells. With information on exact dates of subsequent hospitalizations and death, we modeled readmissions and death as states in a multi-state Markov model and estimated transition probabilities to the next states. Sensitivity analyses were performed by varying thresholds for the definition of HBEC (≥300 cells/µL and/or ≥3%). Results A total of 479 patients were included, of which 173 had HBEC. The transition probabilities for a first readmission was 74% (95% CI, 66%-83%) for patients with HBEC vs 70% (95% CI, 63%-77%) for patients with normal blood eosinophil count (NBEC). The transition probabilities for a second readmission were 91% (95% CI, 84%-100%) for HBEC patients in contrast with 83% (95% CI, 74%-92%) for NBEC patients. Meanwhile, transition probability for death was lower in patients with HBEC. The differences enlarged in sensitivity analyses with higher cutoff. Conclusion Greater blood eosinophil cell counts during a first hospitalization for COPD predict increased susceptibility to up to two readmissions. These patients may however have a lower risk of death.

Background: Prednisolone is widely used to treat acute exacerbations of airway disease. There is evidence that they act by depleting circulating eosinophils within hours of the first dose. Potentially the anti-IL-5 biologics may be a safer and longer-lasting alternative, although whether they deplete blood eosinophils as quickly as prednisolone is unclear. Methods: We assessed blood eosinophil counts at baseline and, 2, 4, 6, 8, 24 and 96 h, or until blood eosinophils Results: Groups did not differ significantly in demographics, inhaled corticosteroid dose, lung function and baseline blood eosinophil count. The mean(SD) time for blood eosinophil level to decrease 50% from baseline was 25.8(14.3), 1.7(0.7) and 2.5(0.4) hours on mepolizumab, benralizumab and prednisolone respectively (p≤0.001 for both benralizumab and prednisolone compared to mepolizumab) (Fig. 1). Conclusion: Benralizumab depletes blood eosinophils as rapidly as prednisolone and may therefore be an alternative treatment for acute eosinophilic asthma exacerbations. Larger studies comparing this approach to current treatment are awaited.

People with severe corticosteroid-dependent asthma have greater morbidity, mortality and corticosteroid side effects than any other people with asthma. Just as type-2 inflammation and recurrent asthma attacks remodel airways, we propose the concept of ‘people remodelling’ to represent the utter disruption of people’s lives by the consequences of severe asthma and its associated corticosteroid treatments. To tackle this important problem, three biologics targeting type-2 inflammation – mepolizumab, benralizumab and dupilumab – have shown efficacy in tapering corticosteroids in dedicated phase III trials. We herein review the literature and propose an evidence-based, dose- and agent-specific corticosteroid weaning protocol for busy clinicians looking to achieve the best outcomes possible for their patients: independence from corticosteroids and reversal of people remodelling.

Au début des années 1960 au Québec, un mouvement indépendantiste de gauche commence à prendre forme autour d’initiatives comme la revue Parti pris, le RIN et le FLQ. Après son emprisonnement et la publication de Nègres blancs d’Amérique en 1968, Pierre Vallières devient une figure incontournable de ce mouvement. Aujourd’hui, le livre de Vallières est devenu un classique de la littérature québécoise, et cet article veut démontrer que les thèses historiques qui l’informent reconduisent essentiellement le discours sur l’identité du Canada français tel qu’il se développe dans l’historiographie canadienne-anglaise entre le milieu du XIXe siècle et les années 1960, qu’en un certain sens, ce classique qui dénonce le colonialisme en est également un témoignage.

Background A subset of patients with COPD demonstrates eosinophilic inflammation either in their sputum or blood. Previous studies regarding the association between increased blood eosinophil levels and poor readmission outcomes are conflicting. The goal of this study was to investigate outcomes following severe COPD exacerbations in patients with higher blood eosinophil levels. Methods With an observational study design, data on hospitalizations for severe COPD exacerbation were retrospectively gathered. Patient health data previous to and up to 1 year following the index hospitalization were included. Patients were stratified into the eosinophilic group if the blood eosinophil level on admission was ≥ 200 cells/μL and/or ≥ 2% of the total WBC count. Clinical outcomes were 12-month COPD-related readmission, 12-month all-cause readmission, length of stay, and time to COPD-related readmission. These outcomes were analyzed by using logistic, negative binomial, and Cox regression models. Results A total of 167 patients were included; 55 had eosinophilia. Eosinophilia was associated with an increased risk of 12-month COPD-related readmission (OR, 3.59 [95% CI, 1.65-7.82]; P = .0013), an increased risk of 12-month all-cause readmission (2.32 [95% CI, 1.10-4.92]; P = .0277), and a shorter time to first COPD-related readmission (hazard ratio, 2.74 [1.56-4.83]; P = .0005). The length of stay was not statistically different between eosinophilic and noneosinophilic patients. Sensitivity analyses using different eosinophilia definitions revealed a proportional increase in effect size with increasing eosinophil cell count definitions for predicting 12-month readmissions. Conclusions Blood eosinophil levels can be used as a biomarker in severe COPD exacerbations for predicting higher readmission rates.

Purpose The impacts of high blood eosinophil count (HBEC) at admission for COPD exacerbation on posthospitalization outcomes are still unclear. Previous studies have focused on its associations with first readmission rates; yet, its impacts on longitudinal outcomes such as subsequent readmissions still have to be explored. The main objective of this study is to investigate outcomes associated with HBEC following a first hospitalization for COPD exacerbation. Patients and methods This is an observational cohort study design. We retrospectively analyzed data of patients with a first hospitalization within 5 years for COPD exacerbation between April 2006 and March 2013. Patients were stratified into the HBEC group if the blood eosinophil count at admission was ≥200 cells/µL and/or ≥2% of the total white blood cells. With information on exact dates of subsequent hospitalizations and death, we modeled readmissions and death as states in a multi-state Markov model and estimated transition probabilities to the next states. Sensitivity analyses were performed by varying thresholds for the definition of HBEC (≥300 cells/µL and/or ≥3%). Results A total of 479 patients were included, of which 173 had HBEC. The transition probabilities for a first readmission was 74% (95% CI, 66%–83%) for patients with HBEC vs 70% (95% CI, 63%–77%) for patients with normal blood eosinophil count (NBEC). The transition probabilities for a second readmission were 91% (95% CI, 84%–100%) for HBEC patients in contrast with 83% (95% CI, 74%–92%) for NBEC patients. Meanwhile, transition probability for death was lower in patients with HBEC. The differences enlarged in sensitivity analyses with higher cutoff. Conclusion Greater blood eosinophil cell counts during a first hospitalization for COPD predict increased susceptibility to up to two readmissions. These patients may however have a lower risk of death.

Maryse Bélanger,1,2 Simon Couillard,1,2 Josiane Courteau,1 Pierre Larivée,1,2 Thomas G Poder,1,3,4 Nathalie Carrier,1 Kim Girard,1 Felix-Antoine Vézina,1,2 Alain Vanasse1,4 1Research Center, Centre hospitalier universitaire de Sherbrooke, Sherbrooke, QC, Canada; 2Respirology Service, Department of Medicine, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, QC, Canada; 3Health Technology Assessment Unit, UETMIS, CIUSSS de l’Estrie – CHUS, Sherbrooke, QC, Canada; 4Department of Family Medicine and Emergency Medicine, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, QC, Canada Purpose: Current evidence suggests that a higher blood eosinophil cell count at admission for acute exacerbation of COPD (AECOPD) is associated with a favorable response to systemic steroids. However, the impact of blood eosinophil counts at admission on post-hospitalization outcomes is still unclear. The main objective of this study is to investigate readmission outcomes associated with blood eosinophilia following severe COPD exacerbation in patients with infrequent COPD hospitalizations. Patients and methods: This is an observational cohort study design. We retrospectively analyzed data of patients with a first hospitalization within 5years for COPD exacerbation between April 2006 and March 2013. Patients were stratified into the eosinophilic group if the blood eosinophil count on admission was ≥200 cells/µL and/or ≥2% of the total white blood cell (WBC) count. The primary outcome was 1-year COPD-related readmission. Secondary outcomes included 1-year all-cause mortality, 1-year all-cause readmission, length of stay, time to COPD-related readmission, and number of 1-year COPD-associated emergency department (ED) and ambulatory visits. Results: A total of 479 patients were included. Of whom, 173 were stratified into the eosinophilic group. Higher blood eosinophil cell count was associated with an increased risk of 1-year COPD-related readmission (OR, 1.83 [95% CI, 1.16–2.89]; P

Thomas G Poder1–3 Nathalie Carrier,1 Maryse Bélanger,1,4 Simon Couillard,1,4 Josiane Courteau,1 Pierre Larivée,1,4 Alain Vanasse1,3 1Research Center, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC, Canada; 2Health Technology Assessment Unit, UETMIS, CIUSSS de l’Estrie – CHUS, Sherbrooke, QC, Canada; 3Department of Family Medicine and Emergency Medicine, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, QC, Canada; 4Respirology Service Department of Medicine, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, QC, Canada Background: Exacerbations explain much of the cost of COPD. Higher blood eosinophil cell counts at admission for acute exacerbation of COPD increase the risk of subsequent exacerbations and hospitalizations. However, there is no literature on the economic burden of patients with this inflammatory profile. The objective of this study is to assess the cost of health-care service utilization according to different counts of blood eosinophils.Methods: The observational retrospective cohort included all first hospitalizations for COPD exacerbation between April 2006 and March 2013. The eosinophilic group was defined by blood eosinophil counts on admission ≥200 cells/µL and/or ≥2% of the total white blood cell count. Study outcomes were: total costs (2016 Canadian dollars) (index hospitalization and 1-year follow-up), total index hospitalization costs, total 1-year costs (all-cause readmissions, ambulatory and emergency service use), and 1-year COPD-related costs (only cost for COPD after initial discharge). Sensitivity analyses were conducted to evaluate the impact of different eosinophil cut-offs on outcomes.Results: In total, 479 patients were included, 173 in the eosinophilic group (92 in the higher cut-off). The average total cost was $18,263 ($6,706 for the index hospitalization), without significant difference between groups (P=0.3). The average 1-year COPD-related cost was higher in the eosinophilic group ($3,667 vs $2,472, P=0.006), with an adjusted mean difference of $1,416. Analysis of data using the higher cut-off of ≥400 cells or ≥3% was associated with a slightly larger difference in 1-year COPD-related costs between groups ($4,060 vs $2,629, P=0.003), with an adjusted mean difference of $1,640.Conclusion: A higher blood eosinophil cell count at admission for a first hospitalization is associated with an increase in total 1-year COPD-related costs. Keywords: chronic obstructive pulmonary disease, exacerbations, health-care utilization, cohort study, Canada, Quebec

CASE/IMAGERY DESCRIPTION: A 56-year-old immunocompetent male consulted for one month of relapsing fever, moderate dyspnea, nonproductive cough, headaches, and myalgias. Past medical history...

Several authors have studied predictors of outcomes following a hospitalization for chronic obstructive pulmonary disease (COPD); however, few have reported outcomes following a first hospitalization for COPD. The objective is to develop a predictive mortality risk model in patients surviving a first hospitalization for COPD. This is a retrospective cohort study using linked administrative and clinical data. The cohort included 1129 patients of 40-84 years, discharged alive from a hospitalization for COPD in a regional hospital (Sherbrooke, Canada) between 04/2006 and 03/2013 and to whom were prescribed at least two COPD drugs during their hospitalization. One-year mortality was analysed using logistic regression on a derivation sample and validated on a testing sample. In total, 141 (12.5%) patients died within one year from discharge of their first hospitalization for COPD. Predictors were: older age (OR (95% CI): 1.055 (1.026-1.085)), male sex (OR (95% CI): 1.474 (0.921-2.358)), having a severe COPD exacerbation (OR (95% CI): 2.548 (1.571-4.132)), higher hospital length of stay (OR (95% CI): 1.024 (0.996-1.053)), higher Charlson co-morbidity index (OR (95% CI): 1.262 (1.099-1.449)), being diagnosed of cancer (OR (95% CI): 2.928 (1.456-5.885)), the number of prior all-cause hospitalizations (OR (95% CI): 1.323 (1.097-1.595)), and a COPD duration exceeding 3 years (OR (95% CI): 1.710 (1.058-2.763)). A simple clinical prognosis tool is proposed and shows good discrimination in both the derivation and validation cohorts (c-statistic0.78). One over eight patients discharged alive from a first COPD hospitalization will die the following year. It is thus important to identify higher-risk patients in order to plan and manage appropriate treatment.

International audience; Objective: Self-reported respiratory symptoms are poor predictors of exercise-induced bronchoconstriction (EIB) in athletes. The objective of this study was to determine whether athletes have an inadequate perception of bronchoconstriction.Methods: One hundred thirty athletes and 32 nonathletes completed a standardized questionnaire and underwent eucapnic voluntary hyperpnea (EVH) and methacholine inhalation test. Perception scores were quoted on a modified Borg scale before each spirometry measurement for cough, breathlessness, chest tightness, and wheezing. Perception slope values were also obtained by plotting the variation of perception scores before and after the challenges against the fall in FEV1 expressed as a percentage of the initial value [(perception scores after - before)/FEV1].Results: Up to 76% of athletes and 68% of nonathletes had a perception score of ≤0.5 at 20% fall in FEV1 following methacholine. Athletes with EIB/airway hyperresponsiveness (AHR) had lower perception slopes to methacholine than nonathletes with asthma for breathlessness only (P=.02). Among athletes, those with EIB/AHR had a greater perception slope to EVH for breathlessness and wheezing (P=.02). Female athletes had a higher perception slope for breathlessness after EVH and cough after methacholine compared with men (P